Health Reform May Expand Role of Advanced Nurses

When Dr. Claude Harwood retired in 1990 after 34 years as an old-fashioned family doctor in rural Glasco, Kan., population 600, his patients faced an uncertain future: There was no physician in town to replace him.

Instead, he turned his practice over to two nurse practitioners--nurses with advanced medical training who in many states can even write prescriptions.

“There were a few people who said: ‘I’m not going to a nurse, I want a doctor,’ and a few wondered how they would get their medicines, but as a whole, the town has been very supportive and receptive,” said Debbie Folkerts, one of the nurses who has since assumed the practice by herself.

Folkerts, whose patients are mostly farmers and retirees, frequently treats conditions such as hypertension, diabetes, respiratory illnesses, congestive heart failure, acute trauma and injuries from accidents. She stays in close contact with a supervising physician 22 miles away, near the region’s main hospital, who comes to town one afternoon a week for consultations if needed. In an emergency, Folkerts sends her patients via ambulance to the hospital.

For many nurse practitioners and physician assistants--who are trained to deliver primary care--the Glasco solution answers one of the most vexing health delivery problems plaguing the nation as it attempts to reform the system: the dearth of primary care physicians, particularly in rural communities and inner cities.

Nurses and physician assistants are lobbying the Clinton Administration to be included more often as front-line care givers, arguing that they can perform many of the same services as physicians--and at a lower cost.

Of the nation’s 2.1 million registered nurses, 400,000 already are providing some level of primary or preventive health care services, according to the American Nurses Assn.

Similarly, more than 25,000 physician assistants in the United States practice in almost all health care settings and in every medical and surgical specialty, according to the American Academy of Physician Assistants.

The White House health care reformers seem to like the idea of an enlarged role for these groups. First Lady Hillary Rodham Clinton, architect of the Clinton Administration’s health reform effort, has spoken on numerous occasions of the boost nurses are likely to receive under the new plan--much to the discomfort of the medical Establishment.

“They (nurses) make the claim that they can do 80% of what a primary care physician can do--and cheaper--and I would agree with them, retrospectively,” said Dr. James Todd, executive vice president of the American Medical Assn. “But, prospectively, can they tell the 20% from the 80%? And do patients want to risk going to someone who is not trained to look at the fine nuances of disease processes and physiology?”

Also, he adds, “if the nurses suddenly become primary care providers, who’s going to take care of patients in hospitals?”

But those who support an expanded role for nurses in the coming years say that doctors are simply feeling threatened by the possibility that they will have to share some of their longstanding authority in the medical community, as well as their income.

“It’s turf, turf, turf,” says Art Caplan, a University of Minnesota medical ethicist who worked with the White House health reform task force. “The resistance is dressed up in language about inadequate training, inappropriate preparation and lack of skills, but the bottom line is that it’s a fight over turf. Authority and prestige are the issues.”

Further, he adds, “rattling in the background are the bones of about 100 years of sexism, in which nurses were basically mistreated, underappreciated, taken for granted and viewed by too many doctors as being third-rate citizens doing fourth-rate jobs.”

Nurses and physician assistants insist that they are qualified to perform many primary care procedures and know when a health situation requires a referral.

“We can manage the patients initially,” says Folkerts, the Kansas nurse practitioner. “That frees up the physician to take care of more seriously ill patients. They don’t have to take care of the colds or the stable diabetics. They can concentrate on patients who need expertise at their level.”

Nurses say there should be no reason why they can’t perform such common tasks as well- and ill-baby care, a Pap smear, depression counseling, prescribing antibiotics for ear infections, prenatal care, delivery for a normal pregnancy and diagnosing and treating hypertension.

Similarly, physician assistants are trained to perform many of the same functions as physicians, including minor surgery.

But a major difference in goals under health reform exists between the two groups.

Advanced practice nurses--nurses with training beyond nursing school, who include nurse practitioners, certified nurse midwives, certified registered nurse anesthetists and clinical nurse specialists--seek to practice primary care independent of supervising physicians.

Physician assistants, while seeking an enlarged primary care role under the coming reform, typically work with physicians and are satisfied to maintain that relationship.

State regulations vary across the nation as to the ways each group may function. Many states have restrictive reimbursement policies, or limit what nurses and physician assistants can do.

In California, both advanced practice nurses and physician assistants are allowed to work at sites distant from their supervising physicians, but must still have a physician who is responsible for them. Also, physician assistants and nurse practitioners in the state are permitted to write prescriptions, but only under the physicians’ name--not their own.

Physician assistants say they are content to work under the direction of a physician but would like to have the authority to write prescriptions on their own.

Nurses argue that all the restrictions should be lifted--that they can write prescriptions for standard ailments and that they should not have to have a doctor looking over their shoulder, literally or figuratively, while they perform routine services.

“Overall, nurses have been delivering primary health care since 1966 as independent practitioners in rural and indigent communities, where physicians do not want to practice,” says Gwendylon Johnson, a member of the American Nurses Assn. board of directors. “And in every study that has ever been conducted on this subject, the nurse practitioners have delivered care as competently as the physicians and for less money.”

Nevertheless, the idea of independent practice for nurses provokes a strong reaction from many physicians.

“The medical profession feels very strongly that while nurse practitioners and PAs can be valuable adjuncts to physicians, they cannot operate independently,” says Dr. Daniel Ein, a past president of the Medical Society of the District of Columbia. “They must have physician cooperation and supervision. They’re just not trained to be independent practitioners. I’m all for using them--but they need to report back to physicians.”

If the medical Establishment now feels threatened, “to a large extent organized medicine has brought this on itself,” says Johnson of the nurses’ association. “In the 1960s, physicians did not want to practice in rural areas and slums. They encouraged the federal government to train a new class of primary care nurses. The result is that the nurses are delivering this care as competently as physicians.”

Moreover, she adds, “if nurses are qualified to treat the indigent, who are frequently in worse health because of their poverty and lifestyle, then why can’t nurses treat the non-poor? Why should middle Americans be denied quality affordable health care that focuses on prevention and wellness, which is the essence of the nursing philosophy?”

Physician assistants, who are trained in one of 55 specially designed PA programs located at medical schools, teaching hospitals and the military, perform many of the same services as doctors, including some surgery--but never independent of a physician.

“PAs and nurses will not replace physicians, but in talking about a more effective delivery system, one that is cost effective, we will need a different mix,” said Bill Finerfrock, director of federal affairs for the American Academy of Physician Assistants.

“What we will then have is physicians handling the level of care for which they are trained--and PAs and NPs handling the level of care for which they are trained,” he added.

Unlike that of the nurses, the physician assistant approach has been embraced by the AMA.

“The physician assistants fully understand their limitations,” Todd says. “They have recently written us a letter saying they are anxious to be part of health reform, but know they have to be under the supervision of a physician--and they welcome it.”

Exactly how nurses and physician assistants will be used in the coming reform is still unclear. But they will almost certainly be doing a lot more than they are now.

“We’re great believers in nursing and nurses and PAs as primary care providers--we believe in that,” says Michael Lux, special assistant to President Clinton for public liaison.

“It makes sense, particularly in a managed care model or in rural areas where nurses can be front-line providers,” he adds. “Having said that, however, we don’t want to have people in a situation where they don’t have access to a physician. We want to strike a balance.”

Their Medical Expertise

Faced with a shortage of family doctors and looking for ways to lower medical costs, the Clinton Administration is considering a larger role for physician assistants and advance practice nurses under health care reform. Here is a comparison of their education and training:

MEDICAL DOCTORS

College degree from a four-year college, followed by four years of medical school and then three to five years in a residency or fellowship, usually involving a specialty, even if that specialty is family or general practice.

ADVANCED PRACTICE NURSES

An umbrella term given to a registered nurse who has met advanced educational and clinical practice requirements beyond the two to four years of basic nursing education required of all RNs. Under this umbrella fall four principal types of advanced practice nurses:

* Nurse practitioners: Most of the approximately 150 NP education programs in the United States confer a master’s degree. At least 36 states require NPs to be nationally certified by the American Nurses Assn. or a specialty nursing organization.

* Certified nurse midwife: Requires an average 1 1/2 years of specialized education beyond nursing school, either in an accredited certificate program, or like NPs, at the master’s level.

* Clinical nurse specialist: These are registered nurses with advanced nursing degrees, either master’s or doctoral, who work in clinical settings, community or office-based settings, and hospitals and are experts in a specialized area, such as cardiac or cancer care, mental health or neonatal health.

* Certified registered nurse anesthetist: Registered nurses who complete two to three years additional education beyond the four-year bachelor of science in nursing, as well as meeting national certification and recertification requirements.

PHYSICIAN ASSISTANTS

Educated in one of 55 specially designed PA programs at medical colleges and universities, teaching hospitals and through the armed forces. PA programs generally require at least two years prior college education and previous experience in health care. PA education lasts two years and is approximately two-thirds that of medical students. In fact, PAs often attend many of the same classes as medical students. The first year of PA education is in the classroom. The second year is spent in clinical rotation with direct contact with patients.

Source: Los Angeles Times