Dee Swanson, RN, MSN, NP-C, FAANP, president of the American Academy of Nurse Practitioners, recently saw a patient in her 60s who had been suffering from vaginal bleeding for a year. The woman had not pursued medical care for one reason: she was uninsured.
Swanson knew the condition could be serious, as vaginal bleeding in postmenopausal women is usually a sign of uterine cancer, she says. The woman likely would need a Pap smear, endometrial biopsy and pelvic ultrasound to determine the cause of her bleeding, but she did not have the financial resources to pay for the necessary tests.
Swanson, a nurse practitioner at Salt Creek Family Practice in Nashville, Ind., sees many people who face similar dilemmas. Swanson typically has to refer these patients to a clinic that offers care to the uninsured, but changes on the national level give Swanson hope that there may soon be more options for patients such as this woman.
The Patient Protection and Affordable Care Act, the healthcare reform package that was approved in March, will pave the way for more than 30 million Americans to gain health insurance in the next few years. Although media reports have fueled fears that this influx of newly insured patients could create a physician shortage, nurse leaders such as Swanson suggest advanced practice nurses are poised more than ever to meet that need.
We have to stop thinking healthcare is all about physicians, Swanson says. There will continue to be a shortage of healthcare providers if we look at physicians as the only providers who can care for new patients. Nurse practitioners can help these patients, and there is evidence that they provide high quality and safe care.Dee Swanson, RN
A Perfect Storm
The new reform laws are expected to add to a healthcare demand that is already expected to surge in the next 15 years with aging baby boomers driving up the need for services. Also, more than one in three physicians is currently older than 55 and likely to retire in the next two decades, according to the Association of American Medical Colleges. The U.S. is expected to face a shortage of more than 124,000 physicians in the next 15 years, particularly in the area of primary care, according to the AAMC.
These statistics might be alarming, but Swanson points out there are more than 135,000 NPs in the U.S., and the highest percentage of NPs more than 70% work in primary care, according to the American Academy of Nurse Practitioners.
The truth of the matter is there is a shortage of physicians going into primary care, and this opens up great opportunities for NPs, says Marsha Siegel, EdD, FNP-BC, president of the American College of Nurse Practitioners. NPs stand ready to provide the primary care services that are lacking.
Although NPs are in a position to care for the influx of patients, state laws vary in the degree of physician supervision required. Swanson and Siegel hope the reform laws will increase state lawmakers willingness to enable more NPs to practice independently of physicians, which ultimately will reduce the barriers to providing care.
Twenty-eight states, for example, still require NPs to collaborate with a physician in order to diagnose and treat patients as well as prescribe medications, according to the 2010 Pearson Report. Seven states require collaboration with a physician in order to prescribe medications, but not for diagnosis and treatment. The Pearson Report is an annual state-by-state overview of nurse practitioner legislation and healthcare issues written by Linda Pearson, DNSc, FPMHNP-BC, FAANP.
These regulations can create obstacles in caring for a patient, Swanson says. For example, NPs may not have the authority to order hospice for a patient theyve seen for years, perform a workmans compensation physical or order physical therapy.
The barriers to NP practice are barriers to patients and that is the bottom line, she says. To reduce the barriers for patients, laws have to be changed. The rising demand for healthcare may make it easier for the laws to be changed.
Hope for the Future
Although some physicians are resistant to the idea of nurse practitioners filling in the gap as demand for services increases, researchers point to the fact that the quality of care provided by NPs is at least as high as that of physicians.
Fortunately, several decades of experience with nurse practitioners and dozens of published studies show quality is not a problem with reforms that would allow them to provide more services, according to a 2010 article in the Journal of the American Academy of Nurse Practitioners. Of more than 100 reports published in the last 20 years on the quality of care provided by both nurse practitioners and physicians, not a single study has found that nurse practitioners provide inferior services within the overlapping scopes of licensed practice, writes Jeffrey Bauer, PhD, a healthcare economist and author of the article.
There are signs that there may be fewer barriers to NPs providing such care in the future. For example, nurse practitioners gained support on a federal level through the healthcare reforms in several key areas. First, according to an April 13 Associated Press article, $50 million has been allocated to nurse-managed health clinics that offer primary care to low-income patients. Additionally, $50 million annually between 2012 and 2015 will go to hospitals to train nurses with advanced degrees to care for Medicare patients.
Other changes in the regulations allowed nurse practitioners to be recognized along with physicians as eligible care providers in certain parts of the country. The new laws state there will be 10% bonuses from Medicare from 2011 to 2016 to primary care providers, including nurse practitioners, who work in areas where doctors are scarce.
There also is a boost in the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a physicians reimbursement.
As laws increasingly recognize the value of nurse practitioners, Siegel is optimistic that patients will reap the benefits.
I cant tell you how many times patients have told me they enjoy seeing NPs because they listen to them, talk to them, and are partners in deciding the plan of care, says Siegel, who works at the Cheyenne VA Medical Center in Wyoming. NPs really combine the world of nursing with that of medicine because we tend to be more patient focused while treating their disease.
Swanson agrees. We offer comprehensive care, she says. We focus on health promotion, disease prevention and chronic disease management. If you cant access healthcare to get preventive care, something is going to go wrong at some point and it is really good to catch things like diabetes and hypertension early.
Swanson volunteers at a clinic where she consistently witnesses the reality that early access to care will benefit millions of Americans. She recently saw a patient in her 40s who was out of breath every time she walked a few steps. She has high blood pressure but could not afford her blood pressure medication. At this clinic, Swansoncould order the necessary tests to determine if the woman was suffering from heart failure.
It is an exciting time to be a nurse practitioner, she says. We are finally in a position where what we offer to the patient is being highlighted, and that is a good thing. If healthcare leaders are patient-focused and really concerned about providing care, the barriers to nurse practitioners should come down.
Heather Stringer is a freelance writer.