Should Nurse Practitioners Be Allowed to Practice Independently?

For several years, health care experts have been concerned about an impending shortage of physicians. This concern accelerated in 2014 due to expanded health coverage available as a result of implementation of the Affordable Care Act. Policymakers have suggested that nurse practitioners (NPs) could fill this gap. They have argued that since their reimbursement is lower, nurse practitioners could also help reduce health care costs.

Advocates for NPs note that they could fill the growing primary care shortage more quickly than physicians, since it takes NPs, on average, six years to complete their education and training, including undergraduate and graduate degrees, compared to an average of 11 to 12 years for physicians, including schooling and residency training.

Medicare pays NPs, practicing independently, 85 percent of the physician rate for the same services. Medicaid fee-for-service programs pay certified pediatric and family practice NPs directly, but these rates vary by state. Some states pay them the same rates they pay physicians for some or all services, but more than half of the states pay NPs a reduced fee. Health insurance plans have significant discretion to determine what services they cover and which providers they recognize. Some plans do not cover NP services, and many managed care plans require their enrollees to designate a primary care provider but do not always recognize an NP in that role.

Background and Training

In order to become a nurse practitioner, students with a high school diploma usually study for a Registered Nurse (RN) certification, or for a degree in nursing. These degrees include the Associate Degree in Nursing (ADN) and the Bachelor of Science in Nursing (BSN) which can be completed in approximately two and four years, respectively. After the completion of a degree program, students must first obtain the RN certification and then enroll in a Master of Science in Nursing (MSN) program. The Master’s degree in nursing is normally completed in about two years, but for enrollees who already have some work experience in a health-care-related field, the degree can be completed in as little as 18 months.^1,2

A new nurse practitioner, without any other nursing experience, acquires between 500 and 1,500 hours of clinical experience in a minimum of 1.5 years of postgraduate training, an equivalent of less than a third-year medical student. In contrast, a new family physician acquires more than 15,000 hours of clinical experience in a minimum of seven years post-graduate training. This amounts to a difference of at least 13,500 hours in clinical experience.³

Currently, there are 21 states where NPs have the statutory authority to practice without physician collaboration, supervision or oversight. The other 29 states require physician supervision for prescribing but have various requirements for physician involvement for diagnosing and treating.⁴ According to the AMA, only a handful of states require independently practicing NPs to submit information regarding their location of employment. Of those states, none keep track of the number of independently practicing NPs.⁵

Current Missouri law prohibits NPs from independently prescribing, diagnosing or treating patients without physician supervision or collaboration. Furthermore, Missouri NPs are governed by the Missouri Board of Nursing and do not fall under the jurisdiction of the Board of Healing Arts.

Reports Debate Expanded NP Scope of Practice

In 2010, the Institute of Medicine (IOM) issued a report in conjunction with the Robert Wood Johnson Foundation, entitled, “The Future of Nursing: Leading Change, Advancing Health.” The goal of this joint effort was to explore options to increase access to health care as a result of the passage of the Affordable Care Act. Their conclusion was that “Advanced Practice Registered Nurses (NPs) should be called upon to fulfill and expand their potential as primary care providers across practice settings based on their education and competency.”⁶ Of the 18 committee members, only two were physicians, one of whom was the chief medical officer for CVS Caremark.

The Council of Medical Specialty Societies (CMSS), which represents 34 societies with an aggregate membership of more than 650,000 U.S. physicians, believes that “non-physician clinicians are critical stakeholders in the health of our nation and that nurses are irreplaceable members of a high-performing, patient-centered health-care team.” In their rebuttal of the IOM report, CMSS states that “nurses, within the context of the physician-led medical home, are ideally suited to help deliver these newly covered preventive services.”⁷

Existing studies of the geographic distribution of NPs in the United States show that they are more concentrated in urban areas than are physicians: 85 percent of NPs work in metropolitan counties and only 5.5 percent of NPs practice in remote rural counties.^2,8 Furthermore, according to CMSS, the IOM report “lacks detail concerning the necessary clinical and educational standards which would undergird such an expansion, and does not give sufficient attention to the cost ramifications associated with its recommendations.” The CMSS points out, in criticizing the IOM report, that a recently graduated NP with only 500 hours of clinical experience would be permitted to legally admit patients to a hospital or hospice, lead the patient-care team, and receive the same level of reimbursement as a physician.⁷ Other studies have shown that NPs tend to order more laboratory and diagnostic tests than physicians, defying the concept of reducing health-care cost.^9,10

The American Medical Association (AMA) acknowledges that non-physician practitioners, including NPs, can provide essential patient care, but that such care is “most appropriately provided as part of a physician-led team.” In addition, the AMA states that, “nurses are critical to the health care team, but there is no substitute for the education and training of physicians. With a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage. Research shows that in states where nurses can practice independently, physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped solve shortage issues in rural areas. Efforts to get health care professionals in areas where shortages loom must continue in order to increase access to care for all patients.”¹¹

In conclusion, we all desire excellent patient care but must remember that physicians are indisputably the most educated and trained to lead the health care system. We must not confuse accessibility with quality in health care by allowing NPs to practice without physician supervision.

Biography

Samer Cabbabe, MD, FACS, MSMA member since 2010, is with Cabbabe Plastic Surgery in St. Louis and President of the St. Louis Metropolitan Medical Society.

Contact: cabbabes@yahoo.com

Reprinted with permission from St. Louis Metropolitan Magazine