Why Not a Nurse?

After Hurricane Katrina hit New Orleans, several hundred thousand refugees descended on Dallas, Houston and other Texas cities. Many of them needed medical care. Unfortunately, Texas wasn’t prepared.

If a natural disaster hit Oregon, the victims would have fared much better. The state’s 8,500 nurse practitioners (NPs) are free to come to the aid of people in need of care, with no legal obstruction. In Oregon, nurses with the proper credentials and licensure may open their practices anywhere they choose and operate in the same capacity as a primary care physician without oversight from any other medical professionals. They can draw blood, prescribe medications, and even admit patients to the hospital.

In Texas, which has some of the most stringent regulations in the country, however, a nurse practitioner can’t do much of anything without being supervised by a doctor who must:

  • Not oversee more than four nurses at one time.
  • Not oversee nurses located outside of a 75 mile radius.
  • Conduct a random review of 10 percent of the nurses’ patient charts every 10 days.
  • Be on the premises 20 percent of the time.

Note that under the rubric of “nurse,” there are a host of subcategories. In general, nurse practitioners have the skills to prescribe, treat and do most things a primary care physician can do. They generally must have completed a Registered Nurse and a Nurse Practitioner Program and have a Masters or PhD degree. In addition, there are physician assistants, registered nurses, licensed vocational nurses, emergency medical technicians, paramedics and army medics. In most states, each of these categories has its own set of restrictions and regulations, delineating what the practitioners can and can’t do.

If all this sounds like the reinvention of the Medieval Guild system, that’s exactly what it is. In Capitalism and Freedom, Milton Friedman argued that these labor market restrictions are no more justified today than they were several centuries ago. The proper role of government, said Friedman, is to certify the skills of various practitioners; then let consumers decide what services to buy from them.

Take JoEllen Wynne. When she lived in Oregon, she had her own practice. As a nurse practitioner, she could draw blood, prescribe medication (including narcotics) and even admit patients to the hospital. She operated like a primary care physician and without any supervision from a doctor. But, JoEllen moved to Texas to be closer to family in 2006. She says, “I would have loved to open a practice here, but due to the restrictions, it is difficult to even volunteer.” She now works as an advocate at the American Academy of Nurse Practitioners.

Texas’ misguided attempt to protect its citizens from people like JoEllen Wynne makes it virtually impossible for nurses to practice outside of a primary care office. Take the requirement that a doctor be present and spend at least 20 percent of her time supervising her nurses. If they are employees of her office, she automatically meets the requirement simply by being on site. Otherwise, she must travel and spend 20 percent of her time out of the office.

Walk-in clinics manned by nurses in pharmacies and shopping malls seem to have overcome these legal barriers. But in poorer areas — especially in poor, rural areas — the obstacles may be insurmountable. In 2009, approximately 30 percent of Texas counties had poverty rates of 20 percent or more. Most of these are rural counties. Yet the farther a nurse is located from a doctor’s office, the less likely the doctor will be to make the drive to supervise the practice. In medically underserved areas, a doctor must visit a nurse practitioner at least once every 10th business day. This means that people living in poverty-stricken counties in Texas must drive long distances in order to get simple prescriptions and uncomplicated diagnoses.

The requirement that a nurse practitioner’s practice must be located within 75 miles of a supervising physician creates another complication: if a doctor supervises independent nurses, she must travel to their locations to supervise them. A physician with four nurses located in rural areas could end up driving hundreds of miles a week, taking valuable time out of her practice to spend reviewing the patient charts.

Another example of the harmful effects of medical practice statutes is provided by the State of California:

After more than 6,600 people overwhelmed volunteers at a free mobile health clinic in Los Angeles last year, California legislators passed a law making it easier for out-of-state medical personnel to assist with future events.

But just over a week before the massive clinic returns, the state has failed to adopt regulations needed for the additional volunteers to participate. As a result, only medical personnel licensed in California will be able to treat patients and some people could be turned away.

Think about that. Doctors from Nevada, Arizona and Oregon can’t even cross state lines and deliver free care to people who need it!

The inability of paramedical personnel to deliver care they are capable of delivering will exacerbate the expected primary care shortages in the coming years. There are 778,000 practicing doctors in the United States. Just under half of them are primary care physicians. Even before health reform, the Association of American Medical Colleges estimated a growing shortage of nearly 131,000 physicians by 2025. The United States will need an additional 65,000 primary care physicians just to keep up with demand.

In a world of rapidly rising health care costs and inadequate access to care, state legislatures should be widening the market for highly-trained primary care providers, not restricting it.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum. This post was written with Virginia Traweek.

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21 replies »

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  2. I think John makes a good point, there needs to be less restrictions put on nurses – considering the current availability of healthcare in the US.

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  4. Patients do need to be aware that physicians have far more tiinrang and experience than PA’s and NP’s, and that is why they must practice under the supervision of an attending physician. As with doctors, there are good PA’s and NP’s and there are bad ones. PA’s in Illinois I believe have 2 years of tiinrang after a 4 year college Bachelor’s degree. Primary care physicians have 4 years of med school and at least 3 years of residency (7 years total) after college, and are much better at inpatient patient care than PA’s and NP’s.In my former practice, I let the PA handle relatively simple and/or acute illnesses when my schedule was booked. I am more hands-on than most physicians, so I really preferred to do the physicals, chronic disease management, preventive health care, and handle the tougher issues myself. This came in very handy if patients had to be hospitalized because I already knew their case rather than just depending on the PA. Of course, one problem with this was burn-out and lack of financial compensation given the ridiculous reimbursement system is this country. Primary care physicians are not rewarded for doing a good job, but certainly pay the price in malpractice when they do a bad job. Another upsetting situation was that our largest HMO (30% of total business) financially penalized me for spending too much money, despite having the very highest rates of keeping patients up to date with their preventive health care (e.g. mammograms, colonoscopies, immunizations, stress tests when indicated, etc.) which costs time and money. No good deed goes unpunished. One thing is certain there is a shortage of PCP’s (and RN’s)in this country, especially in rural areas. PA’s and NP’s can partially fill the void, but health care in this country will continue to decline unless major reform of the health care system is undertaken.

  5. One new solution to the problem discussed is the new degree program just now initiated at San Jose State University, namely the academic degree of DNP which was only recently authorized by the Calif. State Legislature and signed into law by the Governor. This Doctor of Nursing Practice degree will give recipients the power to do all the things the nurse could do in Oregon. The degree is in conjunction with CSU/Fresno while three more sites have been authorized in Southern California, San Diego State, CSU/Long Beach and CSU/Fullerton.

  6. I don’t think I’ve ever actually had an office visit with a NP. However, I know some that I highly respect. I like the idea of giving people a choice to see NPs / PAs / MDs / DOs in whatever setting they choose to practice. I also like the idea of a mid-level practitioner making the decision to be open evenings and weekends without the consent or supervision of a licensed physician who may not want the hassle of staffing evenings and weekends.

    I believe patients in the marketplace are in a better position to work out the details of who practices independently than lobbyists for medical societies.

  7. Maybe you should ask John Goodman who he says for his primary care (and other care also). No names needed John, just whether or not they are NPs.


  8. Nurse Practitioners (NPs) have been shown to be both effective and safe in numerous studies, and APRNs (Advanced Practice Registered Nurses) which includes NPs are leading the charge in measuring quality in their practice. The state of Vermont, where I practice, now requires NPs to institute quality indicators and benchmarks as well as methods of quality monitoring into their practice guidelines.

  9. Margalit –

    While my cardiologist is also my PCP, he’s in NYC and easy to get to when I’m at work. In the evenings and on weekends, though, when I’ve had a non-acute problem, I go to a local urgent care clinic staffed mainly be NP’s and I’ve been generally well satisfied with the care I received. I’ve also on several occasions used my insurer’s nurse hotline including once when I was 2,000 miles from home on vacation. In each case, I received guidance that saved me a trip to the ER.

    Experts have told me that a good NP can handle about 85% of likely PCP encounters. PCP’s, for their part, count on a reasonable percentage of “easy” cases to help offset the inadequate compensation they are paid for the more challenging cases. I’ve always thought that PCP’s are generally underpaid but as in most other fields, it’s most cost-effective to have issues handled and resolved by the least expensive person who can competently and safely do the job. I don’t need to hire and pay for a union electrician to replace the light bulb in my lamp when it burns out. I can do that myself thank you.

  10. “Curious, how many commenters here see just a Nurse Practitioner for all your care needs outside acute care needs like trauma or an MI?”

    I am curious too…. not just commenters here, but all the experts that recommend cost-effective solutions for rural health and poor neighborhoods, including but not limited to, using NPs instead of physicians.

  11. 1) Nurses are just as strict on credentials, maybe more so, than docs.

    2) As an employer, I need some way to determine whom I can safely hire. Do away with credentials, and we will need to reinvent them. If I hire someone w/o credentials and they have a bad outcome, I am hosed.

    3) My advanced practice nurses all want regular hours. They do not give me nearly the flexibility I have with docs.


  12. Hmm, state legislatures should be determining who should have certain clinical care acess and responsibilities, almost none in those legislatures who have any health care backround as providers, and not include input from such inconsequential bodies, like state medical and nursing boards who supervise directly those clinicians in the state?

    Wow, let’s replicate what the federal government did per PPACA in every single state in the country. Yeah, then PPACA will be invalid. So will people’s lives if laws are passed sheerly based on convenience and cost.

    Curious, how many commenters here see just a Nurse Practitioner for all your care needs outside acute care needs like trauma or an MI?

  13. “In a world of rapidly rising health care costs and inadequate access to care, state legislatures should be widening the market for highly-trained primary care providers, not restricting it.”
    Couldn’t agree more.

  14. Pleasant surprise to see a non partisan topic from the author.

    It’s not mentioned who in TX is enforcing the tough rules referred above. I would guess its state Medical boards. That has been an institution which has hardly been challenged, even though they have significant say and impact on healthcare practice.

  15. I generally thought PAs were more prevalent than NPs in a primary care capacity but I would need to look at the stats.

  16. Barry – Yeah. I know people my parent’s age who are retiring to southern Delaware (which for the most part is still really rural with lots of farms except along shore) for many of those same reasons you mentioned – cheap housing, no state sales tax & low property taxes, low cost of living, and a moderate drive to major urban centers including Philly/Wilmington & Norfolk/Newport News areas.

  17. Interesting how it is often people who are NOT doing the clinical work who are so well versed to advise how it should be done.

    The question is: is something ALWAYS better than nothing? You decide.

    Watch that fan in the corner of the room, you never know when something brown and foul is going to smack it!!!

  18. The issue of credentials is less important than whether what any health professional does is either effective or safe?

    I have never heard Dr. Goodman address this issue? He seems to readily accept that most of what we do in US Medicine actually works and is safe? It isn’t!

  19. I agree with John 100% on this issue. NP’s should be allowed to practice at the top of their license period. Restrictions that currently exist are likely little more than yet another example of the physician lobby trying to stifle competition at every turn. The shortage of primary care doctors is especially acute in rural areas because relatively few will find the lifestyle acceptable let alone attractive.

    MG – While I wouldn’t want to live in a rural area either, there are some advantages. The main ones are low living costs and wide open spaces for people who like that. Housing costs and property taxes are far, far lower than in most desirable urban and suburban MSA’s. A friend of my wife’s from college lives in such an area in Ohio and claims to live quite comfortably on $1,100 per month. She has a fully paid for home on 22 acres of which 20 acres are rented out to a local farmer to grow soybeans. Only gasoline costs more because of the need to drive considerable distances for routine shopping.

  20. Doubt this would do much to address the access issues in rural America which have much more profound and deep running trends but I generally agree with Goodman here.

    The question is who really wants to live in very rural (and mostly poor/very poor) parts of America for prolonged periods. My guess is very few.