THCB

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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HuldaEmily BradburyHome healthcare fresnoIrfanPeter M. Buzanski, Ph.D Recent comment authors
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Hulda
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Emily Bradbury
Guest

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.

Home healthcare fresno
Guest

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Peter M. Buzanski, Ph.D
Guest

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.

Devon Herrick
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Devon Herrick

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… Read more »

steve
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steve

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.

Steve

Barry Carol
Guest
Barry Carol

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… Read more »

Margalit Gur-Arie
Guest

“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.

steve
Guest
steve

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.

Steve

DeterminedMD
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DeterminedMD

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… Read more »

DarellC
Guest

“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.

Vikram C
Guest
Vikram C

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.

SP
Guest
SP

Link to study showing health outcomes and nurse practitioners (nurse practitioners are advanced practice nurses):

Advanced Practice Nurse Outcome 1990 – 2008: A Systematic Review

http://www.nursingeconomics.net/ce/2013/article3001021.pdf

MG
Guest
MG

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

MG
Guest
MG

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.