New York Times and The Atlantic on APRN skill and autonomy
October 24, 2012 -- In recent months a number of commentators have issued pleas for the United States to expand the authority and scope of practice of advanced practice registered nurses (APRNs), which studies show would improve health care and rein in costs, contrary to the claims of some opposing physician groups. Two of these pieces are Tina Rosenberg's excellent article "The Family Doctor, Minus the M.D.", posted today on The New York Times website as part of the paper's "Fixes" series, and physician John Rowe's generally good May 7 post on The Atlantic website, "Why Nurses Need More Authority." Rosenberg's Times piece makes clear that clinics run by nurse practitioners (NPs) provide primary care that is at least as good as physician-run clinics. She cites NP credentials and the research showing how good their care is, and she explains why the nursing practice model is so effective. Rowe's item still betrays some condescension and a mistaken belief that APRNs are suited only for "routine" care and unqualified for more difficult diagnostic and care management tasks. But both items argue forcefully that expanding APRN practice would improve access to care and likely reduce health care costs. Both note that organized medicine opposes these measures, claiming wrongly that APRN care is inferior. And both pieces suggest that the physician groups' opposition appears to be driven more by concerns about lost income and authority than by any well-founded concern for patients. We thank those responsible for these pieces and all who wish to base important health policy decisions on facts rather than fear or bias.
"Why is there so much opposition from physicians?"
The Atlantic item notes that author John Rowe "is a physician and a professor in the department of health policy and management at the Columbia University Mailman School of Public Health." The item does not mention that Rowe was also the CEO of insurance giant Aetna from 2000 to 2006, something that might affect readers' views of his credibility to address these issues, one way or the other. In any case, the piece makes clear that Rowe does not represent the perspective of all physicians on this--the subhead, after noting that allowing nurses to be primary care providers will expand coverage and cut costs, asks "why is there so much opposition from physicians?"
Rowe begins by arguing that the United States faces a "severe shortage of primary care physicians," particularly in view of the expansion of coverage under the Affordable Care Act (Obamacare), as well as the "relatively lower incomes" of these physicians and an increase in the population needing care. He argues that one of the best ways to address that shortage is to expand the scope of practice of APRNs, who are "well-trained registered nurses with specialized qualifications who can make diagnoses, order tests and referrals, and write prescriptions." Rowe notes that the Institute of Medicine of the National Academy of Sciences' "landmark" 2010 report "The Future of Nursing" concluded, based on an exhaustive review of studies, that "properly trained APRNs can independently provide core primary care services as effectively as physicians," specifically that they "can provide wellness and preventive care services, diagnose and manage common, uncomplicated acute illnesses, and help patients manage chronic diseases such as diabetes," and therefore APRNs should be allowed to practice fully.
Rowe explains the problem: "Nurses are only permitted to practice independently to the full extent of their training and competence in 16 states and the District of Columbia." He says regulatory barriers in the remaining states should be removed, but "the turf wars of organized medicine are preventing progress," and he notes that the American Medical Association, the American Osteopathic Association, the American Academy of Pediatrics, and the American Academy of Family Physicians all oppose expanding APRN care. Rowe seems genuinely outraged at the situation in Colorado, where physician groups apparently sued to reverse the former governor's decision to permit nurse anesthetists to provide anesthesia and pain management in rural and "critical access" hospitals. He says this forces patients to travel hundreds of miles unnecessarily and may compel some hospitals to close, a "classic example of doctor-centric care trumping patient-centric care." Rowe suggests that some physicians feel "threatened by some mix of concerns about lost income and their traditional position as 'captain of the ship'"--a remarkably direct analysis of the root of the problem.
Rowe makes a few statements about APRN care that point in the right direction, but are somewhat condescending. Noting that the physician groups "argue that physicians with more years of training under their belts must necessarily know more than an APRN ever could," Rowe says that "of course they know more, but it is well established that they do not know more about providing the core elements of basic primary care." We agree that physicians don't know more about "basic primary care," but physicians also do not "know more" about health care generally simply because they may have more years of formal education. APRNs typically have 6-8 years of university-level education, 4-6 of it in nursing. In addition most APRNs have spent years in clinical practice in between their undergraduate and graduate studies. It's absurd to suggest that four years of medical school and a residency mean a physician knows more than an APRN "ever could." Rowe also asserts that letting APRNs "handle routine care frees up physicians to focus on diagnostic dilemmas and more complex management issues while dramatically reducing waiting times for care," expanding on his earlier reference to APRNs handling "uncomplicated" acute illness. In fact, APRNs--who have a superior holistic practice model and advanced interpersonal skills, who take the time to listen and examine patients with care--are more than capable of handling "diagnostic dilemmas and more complex management issues." Nurses have often made diagnoses that physicians failed to.
Rowe says that expanding APRN practice can also save money, citing RAND estimates that it could save billions in Massachusetts alone, and other studies showing that nurses practicing in retail pharmacy clinics save a lot of money as well. He also notes that nurses can be trained more quickly and cheaply, since "between three and 12 nurses can be educated for the price of one doctor." However, he is presumably assuming that the APRNs get master's degrees rather than the four-year doctorate of nursing practice, which is slated to become the standard professional degree for APRNs, and he may also not be accounting for an APRN residency, so those savings would presumably be reduced to the extent those elements were added. Rowe does not say directly that APRNs can also save money because they are generally paid less than physicians, and he does not suggest that they may actually save money by doing a better job.
Looking forward, Rowe finds "hope" because employers and patients are losing patience with the current situation. And he suggests that the shift "away from fee-for-service and toward accountable care organizations" may increase demand for APRN services. He does not add that many patients simply prefer APRN care, as past reports have shown. Rowe does note that the Federal Trade Commission has found that some states' efforts to restrict APRN practice appear to be anti-competitive and "in some cases [has found] evidence that the restrictive laws protect professional interests rather than consumers," and he suggests that these agency findings may add impetus to the calls for reform. Rowe concludes that the states resisting full APRN care will eventually have to accept reality, and that the "inconsistent, often punitive, and highly politicized regulatory environment surrounding APRNs must recognize the new horizons in medical care in the United States."
On the whole, although Rowe seems to have an incomplete understanding of nursing expertise, this piece is a helpful and remarkably strong argument for the expansion of APRN care in an influential publication.
"There were no measures on which the nurses did worse"
Tina Rosenberg's piece appears in the Times' online "Fixes" feature, which "looks at solutions to social problems and why they work." Her main focus is NP-run health clinics and how they can address the shortage of primary care. Rosenberg begins with a description of the nurse-run Family Health Clinic and an affiliated clinic (right) in Carroll County, Indiana, which are part of Purdue University's School of Nursing. The clinics serve mostly uninsured patients, "most of them farmers or employees of the local pork production plant," who come for "family care, pediatrics, mental health and pregnancy care. Many patients come in for chronic problems: obesity, diabetes, hypertension, depression, alcoholism."
Taking a wider view, Rosenberg says that there are about 250 completely NP-run health clinics in the nation. She explains that NPs have master's degrees and that a "proposal endorsed by the American Association of Colleges of Nursing for 2015 would require nurse practitioners to have a doctorate of nursing practice, which would mean two or three more years of study." She notes that NPs "do everything primary care doctors do, including prescribing, although some states require that a physician provide review," and that "like doctors, of course, nurse practitioners refer patients to specialists or a hospital when needed."
Rosenberg goes on to discuss the coming shortage of primary care physicians, making the same basic points that Rowe did. But she makes some important additional observations. She notes that primary care physicians are not well-distributed, with very few working in rural areas or the poor parts of major cities, treating the underinsured. She attributes this partly to money, specifically the fact that these physicians make less than specialists and "take an even larger financial hit to treat the poor," so they have trouble paying off their medical school debts. In addition, she says, managing poor patients can be "frustrating," because they tend to be sicker and less compliant with "doctor's orders" (an awful misnomer in any context) and to have less education and fewer resources to get better.
Rosenberg addresses head-on the concern that a nurse-run clinic is "second-class primary care," noting flatly that "it is not." First, she says, the actual alternative for residents of places like Carroll County is no primary care at all, because there are so few physicians; residents might eventually end up in the ED, but often much sicker than necessary. Rosenberg continues:
Just as important, while nurses take a different approach to patient care than doctors, it has proven just as effective. It might be particularly useful for treating chronic diseases, where so much depends on the patients' behavioral choices. Doctors are trained to focus on a disease - what is it? How do we make it go away? Nurses are trained to think more holistically. The medical profession is trying to get doctors to ask about their patients' lives, listen more, coach more and lecture less - being "patient-centered" is the term - in order to better understand what ails them.
In other words, though Rosenberg does not say it, the medical profession is trying to get physicians to relate to patients more effectively by asking them to act more like nurses. She does drive the point home by quoting nurse Donna Torrisi, executive director of the Family Practice and Counseling Network clinics in Philadelphia (right), about how nurses' psycho-social focus compares to the approach of many physicians: "While in the hospital you'll often hear doctors refer to a patient as 'the cardiac down the hall.'" Rosenberg suggests that younger physicians are "no doubt" better about this, but it's difficult for them in a fee-for-service system; by contrast, NPs are "salaried," giving them "the luxury of time." Jennifer Coddington, a pediatric NP who is "co-clinical director" at the Carroll County clinics, explains that she spends a lot of time teaching patients and families about how to manage their diseases, mindful of their educational and economic levels. Rosenberg says that a physician might suggest that a patient lose weight or refer her to a nutritionist, but the Carroll County clinics have nutrition counselors who actually sit and discuss specific diet plans and cooking methods with patients. The only concern we have here is that readers may assume from this discussion that NPs are actually not so good at diagnosis; in fact, they excel at that too.
These are all reasons why it would make sense that NP care would be good, but Rosenberg also describes the research showing that is in fact the case:
A review of 118 published studies over 18 years comparing health outcomes and patient satisfaction at doctor-led and nurse practitioner-led clinics found the two groups to be equivalent on most outcomes. The nurses did better at controlling blood glucose and lipid levels, and on many aspects of birthing. There were no measures on which the nurses did worse.
Rosenberg turns to the cost issue. She notes that many nurse-led clinics are cheaper than physician led-ones--Medicare reimburses NPs only 85% of what it pays physicians--but also says that "in some cases, nurse-managed clinics had slightly higher per-patient costs than traditional clinics." Rosenberg explains that nurse-led clinics are often small and unable to provide the "variety of practitioners necessary to keep a clinic running at full capacity," plus they treat "the most difficult and expensive patients." But the big cost savings is that NP-run clinics help patients avoid the emergency department, which studies show results in "large savings in paramedic, police, emergency room and hospital use." Of course, physician-run clinics do that too, but they are less likely to be found in underserved areas.
Rosenberg closes with a discussion of the barriers to the expansion of nurse-led clinics. She notes that there are now about 150,000 NPs in the U.S.--pretty amazing considering their low visibility in popular media--but that only about a thousand "practice" in nurse-managed clinics. (She actually uses the word "practice," commendably suggesting that the NPs are professionals, as physicians are.) Rosenberg explains that nurse-run clinics must "overcome regulatory and financial obstacles," pointing to the strong opposition from physician groups that Rowe discussed in his Atlantic piece, particularly baseless claims from the American Academy of Family Physicians that NPs are "less qualified." Rosenberg says that restrictions in the states that do not allow complete NP independence can be bizarre. In Indiana itself, NPs can do everything except "prescribe physical therapy or do physicals for high school sports." And the executive director of the Carroll County clinics, Jim Layman, suggests that although NPs care for most of the Medicaid patients in Indiana, they are not permitted to act as the "primary caregiver of record," so his clinics and others employ a physician off-site a few hours a week to examine a "sample" of records and consult as needed, and they bill in that physician's name.
Rosenberg also says that it's hard for nurse-run clinics to become Federally Qualified Community Health clinics, which enables them to get federal grants, apparently because most of the NP clinics are affiliated with universities who don't want to cede control. The Carroll County clinic did receive that status, and the resulting grants "probably saved them from collapse." Rosenberg notes that the Affordable Care Act authorized $50 million for five years for nurse-managed clinics, and that $15 million of that has gone to 10 clinics.
The Fixes piece concludes with the insight that although NP-run clinics are a "throwback" to the "small-town family practice" in the sense that they take a holistic approach to patients, asking about things like schoolyard bullies and the effects of family unemployment, "it's important to encourage and support these clinics. They may be old-fashioned, but that doesn't mean they should be financed with bake sales."
We thank those responsible for both these pieces and hope that policy-makers heed the authors' calls for the expansion of APRN practice, which can save lives and money.
See the article by John W. Rowe "Why Nurses Need More Authority" published May 7, 2012 in The Atlantic.
See the commentary by Tina Rosenberg "The Family Doctor, Minus the M.D.", published October 24, 2012 on the website of the New York Times.