Healthcare Reform’s Missing Link — Nurse Practitioners

Healthcare Reform’s Missing Link — Nurse Practitioners

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Within the next two years, if federal healthcare reforms proceed as expected, roughly 30 million of the estimated 50 million uninsured people in the United States — 6.9 million in California — will be trying to find new healthcare providers.

It won’t be easy. Primary care providers are already in short supply, both in California and nationwide. That’s because doctors are increasingly leaving primary care for other types of practices, including higher paid specialties. As the demand increases, the squeeze on providers will worsen, leading to potentially lower standards of care in general and longer wait times for appointments for many of the rest of us.

Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.

Clinics like the one I direct in the heart of San Francisco’s Tenderloin district — GLIDE Health Services — offer a hopeful glimpse into California’s healthcare future. We are a federally funded, affordable clinic, run almost entirely by nurse practitioners. At our clinic, we nurses and talented specialists provide high-quality, comprehensive primary care to more than 3,200 patients each year.

Despite the special hardships of our clientele, who daily cope with the negative effects on health caused by poverty, unemployment and substance abuse, our results routinely compare favorably with those of mainstream physicians. Our patients with diabetes, for example, report regularly for checkups, take their meds as directed and maintain relatively low average blood-sugar levels.


This high standard of care provided by nurse practitioners has been confirmed in several studies, including a 2009 Rand Corp. report, which found that “nurse practitioners provide care of equivalent quality to physicians at a lower cost, while achieving high levels of patient satisfaction and providing more disease prevention counseling, health education and health promotion activities than physicians.”

At last count, there were more than 250 nurse-run clinics nationwide similar to GLIDE Health Services. We and about 20 others are funded by a special federal program for affordable care. In all of these projects, nurse practitioners offer both primary and preventive care, including mental health services and screening for HIV and diabetes.

Researchers have confirmed that such clinics not only improve local health but also save taxpayers money. Nurse practitioners’ salaries are generally lower than those of physicians. At the same time, the comprehensive care we provide can significantly reduce the costly emergency room visits used by all too many low-income Americans as their default healthcare.

Unfortunately, some major obstacles stand in the way of expanding our money-saving model. One big hurdle is the reluctance of leading private health plans to contract with nurse practitioners as primary care providers. Even as Medicare, Medi-Cal and pioneering local programs for the uninsured, such as “Healthy San Francisco,” now contract with nurse practitioners to provide such care, a 2009 study by the National Nursing Centers Consortium found that nearly half of the country’s major managed care organizations don’t.

Some of the holdout companies require nurses to bill for their services under a physician’s supervision. California’s insurance code only requires insurance companies to contract with nurse practitioners for primary care when it involves Medicare or Medi-Cal. If the code were expanded to include all coverage, access in the state would be greatly improved. There is room for reform on these fronts and others, and we should get started now to enact change.

In October 2010, the Institute of Medicine, an arm of the National Academy of Sciences, issued a landmark report called “The Future of Nursing,” in which it urged that nurses be “full partners, with physicians and other health care professionals, in redesigning health care in the United States.” At clinics such as GLIDE Health Services, we’re showing that we’re more than ready to answer this challenge, and take our places on the front lines of healthcare reform in America.

Patricia Dennehy RN NP, is the director of GLIDE Health Services in San Francisco and a professor at the UC San Francisco School of Nursing. This post first appeared in the LA Times.

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44 Comments on "Healthcare Reform’s Missing Link — Nurse Practitioners"


Guest
Oct 7, 2013

I agree that NP s maybe the solution in the healthcare dilemma. But on the question weather they are qualified or not to expand their practice, they should take as a challenge to step up their knowledge and experience. Hence continuing education programs are needed. I have written a post summarizing the practice of nurse practitioners specifically for NICUs. ( http://www.theneonatalnurse.com/what-is-a-neonatal-nurse-practitioner )

Guest

A missed opportunity is to use Nurse Practitioner’s as care coordinators for people with complex chronic conditions. This group routinely accounts for a very large portion of the overall cost of health care, and little is done to coordinate between multiple specialists. As a patient I routinely feel overwhelmed and I find that I just ignore many of the directives I’ve been given. I don’t ignore them because I’m trying to be difficult – I ignore them because there are so many I don’t know what to do with all of them. I don’t know how to make them all fit together. Hence I go sit in a chair and fall asleep.

Guest
John
Oct 9, 2012

So what do all the doctors think about PAs? Why are you guys all pissed off? I didn’t read one negative thing about MDs

Guest
Susan Ferrari
Sep 20, 2012

Currently I manage my father’s care. He’s 87 and has (so all the physicians who may want exact diagnoses): glaucoma, HTN, chronic kidney failure secondary to the HTN (with two episodes of acute on chronic this year), non-conductive hearing loss, DJD, spinal stenosis, PVD, history of melanoma, and dental implants. And although he has a primary physician who does take the time to listen, we have found that I am left to coordinate and communicate between them. Now, as an experienced and educated (my bachelors are from the University of Pennsylvania and Wayne State University) nurse, I understand and can navigate the system fairly well. However recent visits to annual checkups have led me to believe that they are interested in looking only at their specialty, but not necessarily in communicating with each other. For example, the renal specialist upon reviewing my father’s medications commented about his prinivil dose being ineffective but did NOT change it. Instead he told me that the prescribing physician needed to do that. Now, so you can understand some background, Dad was hospitalized four times and in extended re-hab twice since January, and receives his med’s through a service at his apartment complex. Since this renal doctor knows that my father only sees him regularly for blood pressure management , why didn’t he adjust the medication? He is supposed to be the one managing that condition. There are other experiences over this last year, where physicians only looked at one piece of Dad’s care and we would have to make visits to other specialists who didn’t adjust anything in his care. Then of course, have to make another visit with the primary physician to follow up on the specialit’s visit. How many doctors is one patient supposed to see? His BP has been stable for years, his glaucoma pressures haven’t changed in ten years, he has no pain or debility from the stenosis. I don’t believe that we are unique. Why isn’t the PCP coordinating this? And if physicians are much better than NP’s than diagnosing, treating, and coordinating the care of moderately to very complex patients, why do we have to see sooooo many? For those of you who contend that NP’s over refer, my direct experience with my father leads me to believe it really can’t be any more than what we see with physicians.

Guest
Sep 17, 2012

Ms. Maher, I got no further than the opening paragraph when I spotted an inaccuracy that stands to give nursing what it doesn’t need: A BAD NAME: “roughly 30 million of the estimated 50 million uninsured people in the United States — 6.9 million in California — will be trying to find new healthcare providers”

Thing is, there are NOT 50 million uninsured in the US. If you eliminate the illegal aliens, the gen ‘x’ers who have made it their choice to roll the dice and not obtain health insurance, or the children who are eligible for SCHIP (but who’s parent’s don’t enroll them), you whittle down to a more workable figure (THOUGH NOT GOOD BY ANY STANDARD) of 16-20 Million.

That figure is still unacceptable in this society, but you have a more accurate figure to work ‘with.’

I agree with the rest of your supposition that the role of NPs will increase as the numbers of physicians decrease, but the NPs will need to keep up with the health-care field (As a patient with numerous chronic illness and a nurse, I look for a certain level of care in my MD/DO/NP/PA. Though many NPs have a good sense of what is really going on, they must sharpen diagnostic skills beyond the ‘sniffles’ to a much broader range of chronic and rare disorders, but disorders none-the less.

I’m feeling positive that this step needs to be taken before NPs (and I’m a nurse who almost became an NP!) is taken seriously in many cases or is considered as, “hey you, almost a doctor!”

However your article is true and so on the money. NPs have this window of opportunity, to be the saviors of the nursing profession.

Guest
southern doc
Sep 16, 2012

Crickets from Ms. Mahar.

Guest
platon20
Sep 13, 2012

BTW, NPs end up costing the system MORE money than MDs do, despite the fact they get paid less for each visit/procedure.

The reason is specialist referrals — NPs refer MANY MORE patients to specialists that would otherwise be dealt with only by a PCP. Teenager with low back pain x 3 months? Refer to orthopedics. Acne not responsive to topical benzoyl peroxide and cleocin? Refer to dermatology.

When you add up all those extra specialist referrals that patients dont need, then you end up costing the system a lot more.

Guest
platon20
Sep 13, 2012

I always laugh when I see nurses like Patricia Dennehy use an alphabet soup behind their names because they are obviously jealous of the title/status that MDs have in this country. They go around the hospital strutting around in their embroidered white coats that look like this:

Patricia Dennehy, BS, NP, BLS, NRP, ALS, PALS, LOL, WTF

Guest
platon20
Sep 13, 2012

I take it that Maggie Mahar is AGAINST the proposals by every major nursing organization that they should get paid the exact same per CPT code as physicians?

If so, why dont you say that Maggie? And if you think NPs should get “equal pay for equal work” then please explain to me how they are going to save money.

Guest
DeterminedMD
Sep 13, 2012

Some people just do not hold physicians in much regard. Sometimes, their words are in fact their deeds. At least they are consistent.

Guest
southern doc
Sep 14, 2012

Some things never change: death, taxes, and Ms. Maher’s contempt for MDs.

Guest
southern doc
Sep 13, 2012

“Whena NP spends more time with patients–actually listening to them, and talking to them about managing chronic disease–he she she does save money.”

But not doctors?

“Recently a pediatric nurse practioner diagnosed a 3-month old’s heart problem that the pediatrician had completely missed. I know the mother– the child will have heart surgery when he is a little older.”

Well, that anecdote proves it. End of discussion.

Guest
Sep 13, 2012

Whena NP spends more time with patients–actually listening to them, and talking to them about managing chronic disease–he she she does save money.

Recently a pediatric nurse practioner diagnosed a 3-month old’s heart problem
that the pediatrician had completely missed. I know the mother– the child will have heart surgery when he is a little older.

Spending more time with patients can result in savings. .

Guest
OliverHolmes
Dec 20, 2012

Funny, because I’ve never known an NP to accurately diagnose anything at all.

Guest
NurseSusy
Mar 10, 2013

OliverHolmes, You just refused to acknowledge the accuracy of an NP diagnosis to you of being thoughtless.

Guest
platon20
Sep 13, 2012

Maggie mahar is lyign as usual, but I’ll play her game. Exactly WHAT heart condition did the NP diagnose? And please dont say “heart murmur” I want the EXACT diagnosis.

Guest
Sep 12, 2012

Patricia–

Thank you for writing this post.

I have written about NPs expanding the prrimary care workforce in the past, and heard from dloctors who said that they worked with NPs and found them
better than they are in some areas–particularly when it comes to talking to patients about helping to manage their own chronic diseases. (See both the post and comments at http://www.healthbeatblog.com/2010/04/hey-nursie-the-battle-over-letting-nurse-practitioners-provide-primary-care/

There, you’ll find links to research showing that Nurse practioners spend more time Listening to these patients & spend more time on the patient’s history.

As you know the Affordable Care Act calls for funding that will expand the capacity of community health centers by 50%. Some will be run by NPs, and
NPs will be working in all of them. The ACA also provides funding for more
scholarships and loans for nursing students who want to become NPs.

Some doctors may not like it, but this is the future:
Everyone will working to the top of their license.

When NPS spend time with patients suffering from “commonplace” but nonetheless serious, painful ,and life-changing chronic diseases, this will free up primary care docs to deal with hard-to-diagnose cases. Increasingly, I suspect that NPS also will be practicing telemedicine, responding to emails from patients, etc.

This also will give PCPs more time to spend with
patients who need 45 minuites face-to-face, not 15 minutes.

As for the cost of using NPS. Right now, median income for a primary care physicians is about $180,000. Half earn more.

And yet, many feel underpaid; they tend to compare themselvs to
specialists who may earn $400,000, $800,000–or more.

Median income for nurse practioners is now around $90,000. As they take on more responsibilities, they should earn more–but they don’t believe that they should be earning $400,000

I can easily see median income for NPs going from $90,000 to $120,000 in the next few years. (At that point, they would be earning more than 90% of other Americans.In other words, this is a salary that indicates that society greatly respects what you do.)

But I’m certaint that they will continue to be less expensive than PCPs, in part
because they don’t spend as many years training as MDs do, in part because they don’t graduate with such gigantic loans, and–perhaps most importantly–
in part because they are not resentful that they are not earning $400,000.

Tlhey will expect to see their salaries rise, but a NP doing primary care will not be shooting for $200,000 (in today’s dollars).

The people who choose to become NPs– and make it through a doctoral program– are a self-selecting group. They’re very smart and hard-working. Many could enter a profession where they could earn more (in business as well as in medicine). But they don’t. Money is not their main priority.

Guest
southern doc
Sep 14, 2012

How does “resentment” increase the the cost of health care?

Guest
southern doc
Sep 13, 2012

180K vs 120K, when cost of doc/NP is only about 30% of the cost of providing care, and when NP spends more time with each patient (sees fewer patients but overhead remains constant) equals no savings.

Guest
Bob James
Sep 12, 2012

They don’t want to be called MD’s…some have doctorate degrees and want to be called Doctor so and so. Maybe with the degree they deserve it but it will be sooooo confusing to everyone concerned in a clinical situation.

Guest
Bob James
Sep 12, 2012

As a M.D., J.D. one thing that bothers me are NPs with doctorate level training wanting to be called “Doctor” in clinical situations. This will only further confuse the patients as to which type of provider they are actually seeing for their care.

Guest
NurseSusy
Mar 10, 2013

Bob James, Chiropractors are called Doctor with less training than a Registered Nurse. Why doesn’t that bother your? I have known of people go to “Doctor” chiropractors for ankle sprains, rotator cuff tears, osteoarthritis because their “Doctors.”

Guest
Bob James
Mar 11, 2013

I don’t see anything in my comment about calling chiropractors “Doctor.” You only assume that it doesn’t bother me. As a matter of fact, it does. It also bothers me that a patient would be so uninformed as to go to a chiropractor for an orthopedic problem. The only thing that concerns me about doctorate level NP’s being called “Doctor” is the element of patient confusion. BTW…the correct word is “they’re.”

Guest
DeterminedMD
Sep 12, 2012

I know you aren’t, but the shock of reading it makes me ask anyway, you are kidding about them wanting to be called MDs?!