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Report Calls for Bigger Role and Equal Reimbursement for Nurses

md0006131By Andrew Villegas and Mary Agnes Carey
Kaiser Health News

A new report released last week may give nurses with advanced degrees a potent weapon in their perennial battle to get the authority to practice without a doctor’s oversight.

The Institute of Medicine report says nurses should take on a larger and more independent role in providing health care in America, something many doctors have repeatedly opposed, citing potential safety concerns.

It calls for states and the federal government to remove barriers that restrict what care advanced practice nurses — those with a master’s degree — provide and includes many examples of nurses taking on bigger responsibilities. “A qualified health care professional is a terrible thing to waste,” Cheryll Jones, a pediatric nurse practitioner in Ottumwa, Iowa, told the authors.

The report calls for elimination of “regulatory and institutional obstacles” including limits on nurses “scope of practice” — which are state rules about what care people who are not physicians can provide.

The findings come from the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, a collaboration among nurses, doctors, health care business leaders and academics that studied the issue for two years. While the report addresses an ongoing battle being played across state legislatures, it’s not clear if the new report will have any impact on those battles. The panel is planning a meeting next month to discuss ways to implement its recommendations.

The new federal health care law provides more funding for nursing education and nurse-led clinics, but this study could also propel the nurses’ argument for more authority to deliver care independently from physicians.

“We cannot get significant improvements in the quality of health care or coverage unless nurses are front and center in the health care system — in leadership, in education and training, and in the design of the new health care system,” said Donna Shalala, a former Health and Human Services secretary and chair of the IOM’s committee on the future of nursing. “We can’t be fighting with each other if we really are going to have a high quality system that we can afford.”

For years advanced practice nurses — as well as a host of other caregivers such as chiropractors and physical therapists —have butted heads with doctors over “scope of practice” considerations. Doctors maintain that even with an advanced degree, these nurses do not have the same education that physicians get in medical school and residency programs and that patient safety could be compromised. They are also wary that their practices could see significant patient losses if the nurses were allowed to practice more independently.

In a statement responding to the report, Dr. Rebecca J. Patchin, a former nurse who is now an anesthesiologist and member of the American Medical Association’s Board of Trustees, said, “A physician-led team approach to care – with each member of the team playing the role they are educated and trained to play – helps ensure patients get high quality care and value for their health care spending. … Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience, most nurse practitioners have just two-to-three years of postgraduate education and less clinical experience than is obtained in the first year of a three year medical residency. These additional years of physician education and training are vital to optimal patient care.”

In its recommendations, the committee said Medicare and Medicaid should reimburse advanced practice nurses the same as a physician for providing the same care. “When you do the same job you ought to be paid the same,” Shalala said.

Also, the report calls for nurses to be allowed to admit patients to the hospital or to a hospice and for the Federal Trade Commission and the Department of Justice to review existing scope of practice provisions for “anticompetitive” practices.

The Obama administration has signaled its commitment to increasing the number of primary care providers, including nurses. Late last month the Department of Health and Human Services announced $320 million in grants to strengthen the health care workforce. The grants include $31 million to 26 nursing schools to increase full-time enrollment in primary care nurse practitioner and nurse midwife programs and $14.8 million for nurse-managed health clinics. In addition, Peter Buerhaus, a registered nurse, heads the newly formed National Health Care Workforce Commission, which was set up under the new law to advise lawmakers on how to change the health care workforce to better fit America’s needs.

Experts predict that more physicians, nurses and other medical professionals will be needed to care for the 32 million additional Americans who will get coverage beginning in 2014 under the sweeping health care law. Nurses’ groups say that they can help ease a physician shortage. Last week, the Association of American Medical Colleges said in a report that in 2015, there will be a shortage of nearly 63,000 doctors across all specialties in America.

The battle is being waged across the country. Colorado, for instance, recently became the 16th state to allow nurse anesthetists to work without a doctor’s oversight. In Michigan, nurses are pushing for legislators there to allow advanced practice nurses to prescribe drugs. Other fights over scope of practice for registered nurses loom in Kentucky, North Carolina, Iowa and Minnesota.

But, Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, said the clashes between nurses and doctors scare the public. “It’s exactly what people worry about when they worry about what health reform will bring,” he said. “Patients and voters say ‘If you’re talking about taking the docs out of my health care, I want no part of it.'”

This article originally appeared on Kaiser Health News and is reprinted with permission.


  1. Laura (almost)DNP

    Interesting conversation.

    Our health care system, if you can call it a “system” of fragmentation and episodic health care, is in dire need of an overhaul. ALL of the players in the United States health care system are vital. We need the technicians to help with the splinting of fractures, we need the nurse to talk to the patient and teach them how to take their medications, we need the paramedic to know about airway-breathing-circulation, we need the physician to diagnose and figure out the best treatment for someone who is seriously sick or injured. What we don’t need is the continued bickering about who is the best person to do these things.

    The non-physician provider (NPP) concept evolved in the 1960’s from the maldistribution of physician providers (i.e., urban versus rural, indigent versus wealthy, etc.). Nurse practitioners (NPs), certified nurse midwives (CNMs), certified registered nurse anesthetists (CRNAs), and physician’s assistants (PAs) are all required to attend rigorous training programs and pass certification requirements (including exams) in order to provide care at the level BETWEEN the nurse and the physician. A “good” mid-level provider does recognize when a patient’s condition requires a medical physician’s evaluation; however, continued legal restrictions on practice and reimbursement have become a prominent barrier. In addition, there is so much variation between how states allow a mid-level to practice, that it is utterly confusing to us and to our patients. There is quite a bit of research available to establish that a mid-level provider DOES provide high-quality and cost-effective care because they show greater personal interest in patients and cost significantly less.

    In 2006, the American Academy of the Colleges of Nursing (AACN) decided that in 2015, the entry level for an advanced practice nurse (i.e., NP, CNM, etc.) will be a clinical doctorate via a Doctor of Nursing Practice (DNP). This clinical practice doctorate puts nursing at the table with other practice doctorates: Medical doctors (MD), doctor of osteopathy (DO), optometrist (OD), dentist (DMD), clinical psychologists, PharmDs, chiropractors, and more. The DNP requires even more training, including extensive training in evidence-based practice, collaboration, leadership, and more. While the DNP does not equate to the training of an MD (or for a clinical psychologist, or any others), it is the highest level of training for a nurse to use her/his nursing background, medical training (including pathophysiology and pharmacology), and experience to provide the best possible health care to the population we serve.

    I envision the DNP to become the primary care providers and advanced triage for persons entering the health care system at different points (i.e., the general or specialty office, the urgent care, the emergency department, the OR, etc.). Just as a clinical psychologist or an optometrist can screen and treat, but refers to the psychiatrist or ophthalmologist when more extensive evaluation and treatment is necessary, our physician (MD and DO) colleagues will be utilized for the most challenging cases.

    It is imperative for a NPP to have collaborative relationships with physicians, just as it is for general physicians (internists, pediatricians, family practice physicians, etc) to have relationships with specialists. Medicine is not an exact science and as such, requires the expertise of many disciplines. Our health care “system” would be enhanced greatly by the ability of ALL parties involved to be able to work together and minimize the threats we each have about another’s role.

  2. I have to agree w/Dr Frischer’s 2nd note.. If I want to see a doc, I want M.D./D.O. after the name. If I want to see a specialist, I expect to see Neurology, Gastroenterology,etc. following this. I’m expecting experience and training in this area. This doesn’t mean nurses are incompetent, however! I personally don’t want to be held liable for anything I am not trained to do. If I’m trained to work in Orthopedics w/traction, I shouldn’t be expected to work on Oncology with chemo. The point where this gets dangerous is when the nurse is not willing to admit she is out of her scope/training of practice, should this arise.

  3. Robert Frischer, M.D.

    The personal attack is uncalled for. You wouldn’t get on a plane with the stewardess doing the flying even if she/he were trained as as a private pilot. This is a matter of experience. An individual nurse may be as intelligent as a physician but just not have the broad background and experience that a physician with a residency program has. We take a different track in our training as physicians than what nurses train for. I welcome all you would be physicians to become physicians. There is no argument that I would be a lousy nurse. Not in my training or mindset. I would have to go to nursing school to learn how to be a nurse and just because I was a physician doesn’t make me qualified to be a nurse.

  4. I’ve studied with Medical Students at multiple levels during their education, I’ve taught MD PhD students, and now am happily employed as an RN. Plain and simple: I know smart Docs, I know smart Nurses… and I know several individuals whom I’d fear to have any hand in my healthcare! It is futile to generalize that “all docs are better than all nurses” or visa versa (regardless of ego!) Look at the big picture people – we have lives to care for, illnesses that are becoming increasing complex, and a field with exponentially expanding vastness (Just think… Docs treating patients in the 50’s didn’t have to take genetic material into consideration for their diagnosis — but they do now!) I propose to stop the bickering between healthcare providers over nickels and dimes, and “I’m smarter you’re not” childish tactics; Let us PLEASE look at how to re-design a healthcare system that if left in place under existing circumstances is set up to FAIL the amercian public.

  5. Dr. Frischer,

    Sounds like you may be intimately aware of the least competent doctor you know. Your arrogance is disgusting. Let your patients beware.

  6. Robert Frischer, M.D.

    Yugo and Mercedes mechanics are the same too I guess. The least competent doctor I know is still better than the best nurse practicioner I know. Let the public beware.

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