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Medical Leaders and Consumers Lining Up To Support Nurses.

Posted Jun 08 2013 10:01pm

Posted on | June 7, 2013 |

On January 1, 2014, as a result of implementation of the Affordable Care Act,  the US will experience a major expansion of individuals covered by health insurance. The law includes three key pillars – insurers must provide coverage to all comers regardless of medical history; all citizens must pay in (either through purchase of insurance or penalty payments); and premiums for those with low income will be subsidized.(1)

From a human resource standpoint, the bottom line is that the already existing primary care deficits will be acutely exacerbated. It is this concern that drove the policy journal Health Affairs to update their White Paper on “Nurse Practitioners and Primary Care” several weeks ago, and to publish a study in partnership with the American Association of Medical Colleges (AAMC) on Americans’ support of nurse practitioners as primary care providers.(2,3)

First, some background. Currently 18 states allow nurse practitioners to treat patients without physician oversight. The federal government estimates that 55 million Americans in 5700 different locations currently suffer from limited access to primary care services. Fixing the problem will require 15,000 new practitioners if distributed properly. Attempts to address this need with primary care physicians have not been effective thus far. Training a physician, including schooling and residency requires 11 or 12 years compared to 6 years for a nurse practitioner or physician assistant.(2)

One solution is to allow nurse practitioners and physicians assistants to practice independent of physician oversight. As such, they would be able to establish their own care centers and offices, and would inject a level of competition into the health care system that could increase access, improve service and lower cost. The American Medical Association has steadfastly opposed such actions. As Health Affairs states, the organization “…asserts that encouraging patients to see nurse practitioners rather than primary care physicians may put patients at risk, although the evidence does not support these claims.”(2)

In fact, the Institute of Medicine, after a thorough review of 26 studies published since 2000, found no difference in care outcomes between the two groups, and recommended that state legislatures reform scope-of-practice laws.(4)

But would Americans be willing to see nurse practitioners and physicians assistants? The AAMC/Health Affairs survey says yes. Specifically, the study revealed that while approximately one half of those surveyed preferred to see a physician for care, when presented the choice of waiting 3 days to see a doctor compared to one day for a nurse practitioner, the majority chose the earlier nurse practitioner visit.(3)

As important, medical leaders are beginning to signal openness to new solutions. In the words of Darrell G. Kirch, MD, President and CEO of the AAMC, “As this nation faces a critical doctor shortage90,000 by the year 2020we must find ways to be certain patients have access to the care they need…This study shows that Americans are open to that possibility.  There is no single solution to this problem.  We need to focus on building our capacity to train physicians, while also embracing the roles in which other professionals can serve.”(5)

Health Affairs is even more explicit. Here is what they have to say about the value of allowing nurse practitioners to expand their scope of practice: “ … patients seeing nurse practitioners were also found to have higher levels of satisfaction with their care. Studies found that nurse practitioners do better than physicians on measures related to patient follow up; time spent in consultations; and provision of screening, assessment, and counseling services. The patient-centered nature of nurse practitioner training, which often includes care coordination and sensitivity to the impact on health of social and cultural factors, such as environment and family situation, makes nurse practitioners particularly well prepared for and interested in providing primary care.”(2)

Finally, on the issue of cost, in the 18 states where nurse practitioners are allowed to functiuon independently, they are reimbured at 85% of the physician rates under Medicare law. As for Medicaid, more than half the states pay nurse practioners less than physicians for the same services.(2)

As we approach the January 1, 2014 turning point, with a defined need, and a well documented and well supported cost-effective solution at hand, it makes good sense for the 32 states restricting nurse practitioner and physician assistant scope of practice to rethink their positions. As of one year ago, the National Conference of State Legislatures reported that there were 245 bills under consideration related to scope of practice, with 50 involving nurses.(2)

The movement toward “Medical Home” and “Accountable Care Organizations” fueled by the Affordable Care Act is driving us all toward team-based, personalized and preventive care models. To do so without fully mobilizing the human resources available to us makes little sense any longer.

For Health Commentary. I’m Mike Magee.


1. Accountable Care Act.

2. Nurse Practitioners and Primary Care: Federal and state laws and other policies limit how these health professionals can help meet the growing need for primary care. May 15, 2013. Health Affairs.

3. Dill MJ et al. Survey shows consumers open to a greater role of physicians assistants and nurse practitioners. Health Affairs. June, 2013. vol. 32 no. 6, 1135-1142.

4. IOM Study. The Future of Nursing: Leading Change, Advancing Health. October,

5. AAMC Press Release. June 3, 1013. Report Shows Patients Would Consider a Greater Role for Physician Assistants and Nurse Practitioners for Timely Access to Care.

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