Thursday, October 11, 2018

Primary Care: Expanding the Role of Nurse Practitioners

For most of us, most of the everyday health care we get is from a primary care doctor. But there's a limited number of primary care doctors, not enough to match the number of patients, especially in rural areas. An option slowly being used more broadly across the US health care system is let nurse practitioners (NPs) do primary care. Peter Buerhaus makes the case for accelerating this movement in "Nurse Practitioners: A Solution to America's Primary Care Crisis," written for the American Enterprise Institute (September 2018).

To set the stage, here's what primary care involves: 
"Primary care clinicians typically treat a variety of conditions, including high blood pressure, diabetes, asthma, depression and anxiety, angina, back pain, arthritis, thyroid dysfunction, and chronic obstructive pulmonary disease. They provide basic maternal and child health care services, including family planning and vaccinations. Primary care lowers health care costs, decreases emergency department visits and hospitalizations, and lowers mortality."
Here's evidence on the shortage of primary care physicians:
"The Association of American Medical Colleges (AAMC) estimates that by 2030 we will have up to 49,300 fewer primary care physicians than we will need ... Despite decades of effort, the graduate medical education system has not produced enough primary care physicians to meet the American population’s needs. When geographic distribution of primary care medical doctors (PCMDs) is taken into account, the problem begins to feel like a crisis. In 2018 the federal government reported 7,181 Health Professional Shortage Areas in the US and approximately 84 million people with inadequate access to primary care, with 66 percent of primary care access problems in rural areas."
Nurse practitioners (NPs) are already a recognized health care specialty, with additional training and autonomy beyond a registered nurse. Here's and overview:
"In the words of the American Association of Nurse Practitioners (AANP): `All NPs must complete a master’s or doctoral degree program, and have advanced clinical training beyond their initial professional registered nurse preparation.' Didactic and clinical courses prepare NPs with specialized knowledge and clinical competency to practice in primary care, acute care, and long-term health care settings. NPs assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans. They also prescribe medications, including controlled substances, in all 50 states and DC, and 50 percent of all NPs have hospital-admitting privileges. The AANP reports that the nation’s 248,000 NPs (87 percent of whom are prepared in primary care) provide one billion patient visits yearly.
"NPs are prepared in the major primary care specialties—family health (60.6 percent), care of adults and geriatrics (21.3 percent), pediatrics (4.6 percent), and women’s health (3.4 percent)—and provide most of the same services that physicians provide, making them a natural solution to the physician shortage. NPs can also specialize outside primary care, and one in four physician specialty practices in the US employs NPs, including psychiatry, obstetrics and gynecology, cardiology, orthopedic surgery, neurology, dermatology, and gastroenterology practices. Further, NPs are paid less than physicians for providing the same services. Medicare reimburses NPs at 85 percent the rate of physicians, and private payers pay NPs less than physicians. On average, NPs earn $105,000 annually.
"NPs’ role in primary care dates to the mid-1960s, when a team of physicians and nurses at the University of Colorado developed the concept for a new advanced-practice nurse who would help respond to a shortage of primary care at the time. Since then, numerous studies have assessed the quality of care that NPs provide ... and several policy-influencing organizations (such as the National Academy of Medicine, National Governors Association, and the Hamilton Project at the Brookings Institution) have recommended expanding the use of NPs, particularly in primary care. Even the Federal Trade Commission recognizes the role of NPs in alleviating shortages and expanding access to health care services. Most recently, the US Department of Veterans Affairs amended its regulations to permit its nearly 5,800 advanced-practice registered nurses to practice to the full extent of their education, training, and certification regardless of state-level restrictions, with some exceptions pertaining to prescribing and administering controlled substances."
So what's the problem? A number of states have rules limiting the services that NPs are allowed to provide. And a number of doctors support those rules, in part out of a fear that allowing NPs to do more would reduce their income or even threaten their jobs: 
"A 2012 national survey of PCMDs found that 41 percent reported working in collaborative practice with primary care nurse practitioners (PCNPs) and 77 percent agreed that NPs should practice to the full extent of their education and training. Additionally, 72.5 percent said having more NPs would improve timeliness of care, and 52 percent reported it would improve access to health services. However, about one-third of PCMDs said they believe the expanded use of PCNPs would impair the quality and effectiveness of primary care. The survey also found that 57 percent of PCMDs worried that increasing the supply of PCNPs would decrease their income, and 75 percent said they feared NPs would replace them." 
It's a nice thing that the health care industry provides jobs for so many workers, including doctors. But the fundamental purpose of the industry is not to provide high-paying jobs: it is to provide quality care to patients in a cost-effective manner. As Buerhaus writes:
"Drop the restrictions on PCNP scope-of-practice! These are regressive policies aimed at ensuring that doctors are not usurped by NPs, which is not a particularly worthwhile public policy concern, especially if it comes at the expense of public health. The evidence presented here suggests that scope-of-practice restrictions do not help keep patients safe. They actually decrease quality of care overall and leave many vulnerable Americans without access to primary care. It is high time these restrictions are seen for what they are: a capitulation to the interests of physicians’ associations."
Buerhaus also quotes a 2015 comment from the great health care economist Uwe Reinhardt, who died late last year. Reinhardt said:
"The doctors are fighting a losing battle. The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side." 
In this arena, it would be nice if economics and common sense could win out a little faster.