Nursing the primary care shortage back to health: how expanding nurse practitioner autonomy can safely and economically meet the growing demand for basic health care.

• Author: Zand, Michael B.

1. INTRODUCTION II. OVERVIEW A. History and Background B. Educational Requirements C. Policy Arguments III. NURSE PRACTITIONER AUTONOMY A. Opposition from the Medical Establishment B. Physician Involvement C. Prescriptive Authority D. Identification IV. MEDICAL REIMBURSEMENT V. MALPRACTICE VI. CONCLUSION I. INTRODUCTION

   The role of nurse practitioner (NP) has emerged as a profession capable of closing the gap between the declining number of primary care providers caused by the dearth of family practice physicians and the growing number of Americans in need of health care. Studies have shown that NPs are equally as competent as physicians when it comes to diagnosing and treating basic ailments. NPs cost less, spend more time with patients, and garner high satisfaction reviews from those patients.

   Due to the popularity and efficiency of NPs, the medical establishment has viewed the profession as a threat to their livelihood. In the forty plus years since the first NP graduated, NPs have had to continually fight and lobby for the right to practice their profession, preferably independent of physicians. The result has been a state-by-state patchwork of laws and regulations governing NPs' scope of practice.

   This article first discusses the history and educational requirements of the NP profession. It then discusses the policy reasons why NPs should, and do, play an important role in the country's health care delivery system. The core of the article deals with the legal issues surrounding the NP's scope of practice including the need for collaborative agreements with physicians, authority to prescribe drugs, and identification. Finally the article discusses how NPs fit into the health insurance scheme and their liability for malpractice.

2. OVERVIEW

   1. History and Background

      A nurse practitioner (NP) (1) is a registered nurse who has undertaken additional education in order to perform tasks more traditionally associated with the medical profession. (2) The American College of Nurse Practitioners provides the following definition: nurse practitioners are "registered professional nurses who are prepared, through advanced graduate education and clinical training, to provide a wide range of health care services, including the diagnosis and management of common, as well as complex, medical conditions...." (3) NPs distinguish themselves from physicians by emphasizing that, as nurses, they are patient focused--examining the patient's history and family--while physicians are disease focused. (4) While some NPs specialize in areas such as neonatal, geriatric, psychiatric, or acute care, the majority of NPs provide primary care. (5)

      The role of NP began in the mid-1960s in response to a nationwide shortage of physicians. (6) The first NP program began as a master's degree at the University of Colorado School of Nursing in 1965. (7) Other NP educational programs began springing up throughout the country. (8) At the outset, most NPs practiced in traditional settings by associating with physician groups or hospitals. (9) However, in 1977, the Arizona State University School of Nursing began a federally funded nurse-managed health care center, (10) paving the way for NP independent practice.

      By the 1990s, the number of NPs had skyrocketed (11) and between 1996 and 2001 the number doubled. (12) Between 1999 and 2009, the number doubled again. (13) As of 2009 there were 157,782 NPs in the United States. (14) As of 2007, there were 250 nurse-managed health care centers, mostly in medically underserved rural and urban communities. (15) However, the majority of NPs practice in settings supervised by physicians. (16)

   2. Educational Requirements

      In most states, the NP profession is regulated by the state Board of Nursing (BON). (17) However, in a minority of states, NPs are regulated by the BON and the Board of Medicine (BOM) or some other regulatory authority. (18) In either case, the regulatory authority sets the minimal requirements needed for becoming a licensed NP.

      All NPs must at least achieve the degree of a registered nurse (RN). (19) Forty-two states also require a master's degree with the remaining states requiring completion of a specific course of study beyond the RN. (20) NP programs generally consist of courses in "advanced practice nursing philosophy, advanced health assessment, diagnosis, advanced pathophysiology, advanced pharmacology, primary care, and clinical decision making." (21) In 43 states and the District of Columbia NPs are also required to pass a national certification examination. (22) NPs can gain additional certification in a number of specialties such as neonatal, geriatric, psychiatric, acute care, (23) or midwifery. (24)

      Doctors argue that NPs' education is insufficient to allow them to practice independently. According to James King, president of the American Academy of Family Physicians, "[w]ith four years of medical school and three years of residency training, physicians' understanding of complex medical issues and clinical expertise is unequaled." (25) NPs counter that they have a proven track record of providing quality care (26) and that new technologies allow them to cost-effectively diagnose common illnesses without extensive medical education. (27) As for physicians' argument that NPs' lack of a comprehensive medical education will lead them to misdiagnose atypical cases, (28) NPs reply that as professionals, they can recognize when a problem goes beyond the scope of their training and requires referral to an appropriate physician. (29)

      NPs can raise their level of education by pursuing a "doctorate of nursing practice" (DNP). Over 200 nursing schools have established or plan to establish such programs that generally require two additional years of training including a year of residency. (30) According to Mary Mundinger, Dean of the Columbia University School of Nursing, the goal of DNP programs is to produce nurses who will have "hospital admitting privileges, coordinate care among specialists.... and [the ability to] manage[] complex illnesses such as diabetes and heart disease." (31) Similarly to NPs, there is no national standard for the certification of DNPs. However, a voluntary DNP certification exam, which will be based on the exam physicians take to receive their medical license, is being developed. (32) While some NIP groups want to make the DNP degree the standard for all NPs, (33) there has been opposition from the medical establishment (34) as well as from NPs themselves. (35)

   3. Policy Arguments

      There are a number of policy arguments that support the use and expansion of the NP role to provide health care. These include the inadequate number of physicians available to provide care, cost effectiveness, and patient satisfaction and quality of care.

      The surge in the NP profession has coincided with and perhaps resulted from a steep decline in the number of medical students entering primary care. In 2007, less than half of the available family practice residency programs were filled (36) as only seven percent of medical school graduates chose family practice. (37) According to the American Academy of Family Physicians, the decline is attributable to "factors related to lifestyle and educational debt." (38) This has resulted in some areas of the country not meeting the general standard of one primary care physician per 1000-2000 people. (39) As will be shown below, NPs offer an affordable and efficient way to fill this gap without compromising on the quality of patient care.

      NPs provide economically efficient health care by reducing the cost of buying basic care and freeing up physicians to focus on complex illnesses. On a basic level, since the time required to become a licensed NP is significantly less than the time needed to attain a medical license, training costs for NPs are much lower. (40) NPs also provide care at a lower cost than doctors as insurance generally reimburses NPs 85% of what it would pay a physician for similar services. (41) At forty to seventy dollars a visit, prices at retail health care centers, (42) in which NPs provide service, are significantly lower than physician fees. (43)

      In a 2000 Harvard Business Review article, a professor of business administration and two physicians argue that since most patients see doctors for relatively straightforward illnesses, it is inefficient for physicians to treat such illnesses. (44) That is because making a simple diagnosis "tap[s] but a small fraction of what our medical schools have prepared physicians to do." (45) Because new scientific technology allows NPs to easily diagnose illnesses that a generation ago could only be made by doctors after extensive observation, (46) it is a waste of resources to require such a diagnosis to be made by a physician. (47) The authors note that "[h]istory tells us that major new growth markets coalesce when products, processes, and information technologies let less highly paid groups of people do things ..." (48) The authors compare regulations requiring doctors to supervise NPs making simple diagnoses to requiring every personal home computer buyer to also purchase a mainframe computer. (49) While there will always be some businesses that require large, expensive mainframes for complex data crunching, personal computers are more than adequate for simple tasks such as e-mail and word processing. (50) Similarly, if NPs could independently diagnose and treat simple illnesses, doctors would have more time to treat more complex illnesses. (51)

      Even if NPs are needed to fill the primary care gap and prove to be more cost effective, these arguments are moot if NPs provide inferior care. However, a number of studies have shown that NPs provide the same or better quality of care than physicians. The first such study was conducted in 1986 by the Office of Technology Assessment of the United States Congress (OTA), which found that "the quality of care provided by NPs functioning...