Wider use of nurse practitioners seen as remedy to predicted shortage of doctors

Stateline Midwest ~ April 2013

In response to an ongoing shortage of primary-care providers — coupled with the fact that millions of Americans will be added to Medicaid and private insurance rolls under the federal Affordable Care Act next year — state policymakers are considering how to better train and deploy their health care workforces.

One strategy being considered by at least 12 states is to leverage an asset that already exists, by allowing certain “advanced practice” nurses to open their own practices.

Advanced-practice nurses are registered nurses who have graduate degrees; they include certified nurse midwives, certified registered nurse anesthetists and certified nurse specialists. But recent concerns about access to primary care have put increased focus on a fourth category: nurse practitioners, which are the largest group of advanced-practice nurses.

NPs are trained to provide primary-care services and prescribe medications. But some states do not allow NPs to practice independently, requiring them to work under the supervision of a medical doctor.

Proponents of giving these professionals more autonomy say it is a much-needed step to relieve stress on primary-care systems. The Association of American Medical Colleges reports that the United States will see a shortage of 45,000 primary-care providers by the year 2020. And a 2011 University of Minnesota study found that by 2019, the number of primary-care visits in the United States will jump by as many as 25 million.

Many critics of expanding these nurses’ “scope of practice” have concerns about safety, pointing out that physicians have more-extensive training. Others believe that nurses should be members of teams that include physicians ­— not serve as replacements for medical doctors.

But Taynin Kopanos of the American Association of Nurse Practitioners says this view of nursing is antiquated.

All states currently allow nurse practitioners to evaluate patients, make diagnoses, order and interpret diagnostic tests, and prescribe medications. But whether NPs can practice independently varies by state.
In 16 states (including Iowa and North Dakota), NPs can see patients on their own and provide care similar to that provided by a primary care doctor. But in most states, NPs must have a relationship with a physician, which can range from a verbal agreement to a legal document.

Kopanos maintains that the agreements are unnecessary because NPs already have the expertise and training to examine patients and prescribe medications. She adds that current regulations can be particularly onerous in rural areas, where it can be difficult to find a physician who will agree to oversee an NP.

“The care that you can get is vastly different based on the state laws where you access it,” says Kopanos, a nurse practitioner who practices family medicine.

So far this year, 12 states nationwide have considered bills that would allow NPs to practice on their own.
Minnesota’s bill, HF 435, was introduced after a gubernatorial task force found that allowing nurse practitioners to practice without supervision was one way to deliver health care more effectively. The measure, however, did not receive a committee hearing.

Similar bills have been introduced in Illinois (SB 73), Michigan (SB 2) and Kansas (HB 2251).