Healthcare Reform’s Missing Link — Nurse Practitioners

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.

44 replies »

  1. 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.”

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

  3. 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.”

  4. 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.

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

  6. I agree wholly with AK. Doctor Jay, your points are petty and stupid. And I doubt that you are actually a physician.

  7. I agree (as a future NP.) MD’s do have to jump through more hoops. It is not fair that NP’s should get it easier. But the answer should be that many of the hoops should be taken away for all. Not added for NP’s.

  8. AK–
    One thing I would like to point out would be your spelling mistakes. Relavent as you have spelled it, is spelled relevant. Overutilize is two words, over utilize. Decomissioned as you have spelled it is really spelled decommissioned. Well trained is not to be hyphenated. Ressonates only has one ‘s’, resonates. Finally we have committment, which should be spelled commitment. If you are so well educated LEARN TO SPELL.

    The second thing I would like to point out is you are the type of physician that give doctors a poor name and in turn will make patients run to the “handholding” Nurse practitioner.

    You are a poor excuse for a physician!

  9. 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

  10. 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.

  11. 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.

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

  13. 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.

  14. 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

  15. 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.

  16. 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.

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

  18. “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.

  19. 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. .

  20. 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.

  21. 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.

  22. 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.

  23. 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?!

  24. 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.

  25. As what seemed to have happened with an OB case Johns Hopkins lost this summer to the tune of $55 million, how the plaintiff got away with shielding the role of a midwife who was involved prior to JHH taking the woman after complications ensued, well, maybe Case 1 example of why we need tort reform. And why NPs should be held to a higher standard if they are wanting it in the first place!!!

    Nice comment Dr Mike.

  26. As a physician who employs two NPs and a PA, I still must admit to some uncomfortable truths:

    1) A FP emerges from training with over 15,000 hours of clinical experience. A RN who moves straight on to FNP training emerges from training with maybe 3500 hours, probably less. There is no way you can make an argument that 3500 hours equals 15000 hours and still sound intelligent.

    2) NP training programs were designed around nurses with years of experience in the field. A newly minted RN does not come out of such a program with anywhere near the skills needed to practice independently. I have interviewed a few such NP grads – ask a few basic clinical questions and you start to shake your head in disbelief.

    3) The tort system still shields NPs from the consequences of their mistakes. A patient can see a NP for multiple visits, continue to decline and end up dying in the ER and only the ER doc gets nailed. There are multiple cases in which this has happened. This can’t last forever.

    Still, NPs have their place, it is just that the system needs to wake up to the fact that the quality of the new NP graduate is highly dependent on the level of experience they had prior to starting the NP program and programs need to adjust their training to recognize this fact.

  27. AK seems to have an air of sarcasm to that comment, but, I find it a bit lame and disingenuous for the NP supporters to argue for this profession to substitute for MDs and yet, what will be NPs malpractice rates for providing this same level of care? No one ever replies to this question, because, that would interject some painful reality to the situation, eh?

  28. Hide behind an untraceable screen name, yeah, that’s the way to establish cred. Pretty arrogant to boot. Your kind are, mercifully, dying off.

  29. AK, wow, I don’t know where you practice but your comments indicate someone with less than ideal intelligence for practicing medicine. 2nd class citizens? How dare you! Not an elitist? Would you prefer “buffoon”?

    Most physicians choose not to participate in family practice because it doesn’t pay well enough. Physicians created the specialty of Nurse Practitioner because someone had to care enough to work in rural areas and fill that need. And it’s not getting better. Nurse Practitioners have to fight now to have the autonomy to do what you asked us to do, when you refused to do it. Patients say they prefer the NP over the physician because they actually listen; this is because nurse practitioners perform better at diagnosing patients, not worse. They know their limitations and when to refer. That’s a positive thing.

    You said “Nurses intuitively understand the BS NPs try to pull….”. Really? I’m an RN. I understand COMPLETELY the difference between someone who has an Associate degree and someone who is Master’s or Doctorate level prepared. You are woefully misinformed, AK. But I do understand that you feel threatened by the absolute competency of NPs, because they can do what you do for a lot less money. You probably despise Health care reform; I’m willing to bet on it.

    NPs have extensive clinical experience requirements–I’m certain most people understand that “online” classes are for didactic learning.
    I will tell you that I spend an average of 40 hours a week on “easier” online classes that “require little brains or commitment” in addition to my work commitments. I don’t expect you to know this, however, because you obviously haven’t done the research to back up your comments. Unfortunately, the internet is a medium in which anyone can say anything they choose, even when it has no merit.

    Rather than be buffoonish and throw out insults, I choose to try to be a solution to our healthcare problem. NPs are great educators and know how to use resources to actually help people live healthier lives. That’s where healthcare is headed and you better get on board, AK, or your fears might be realized. Good day!

  30. As a physician, I will take every step to make sure NP’s practicing independently will fail. There are also forces that will ensure NP’s will always be second-class citizens for the next few decades at least.

    A) Less talent and less training do not equal better outcomes. Handholding patients is not the same thing as good care.

    B) No one, and I mean no one, who went to Harvard or Stanford ever aspires to be a nurse practitioner. Plenty went to top schools who want to become MD’s. This speaks volumes. If you say this is elitist, wait until you need a heart valve replaced and see how you feel.

    C) While more common diseases happen more commonly, an NP is not intiated to the times when something just looks like it’s common. Leukemia and a flu seem the same. Is this scenario rare? No, everyone gets majorly sick several times in their lifetime and they will need more than a Z-pack.

    D) Nurse practitioners are terrible at coordinating care. They have little idea what is relavent to specialists when they try to get advice and refer patients.

    E) NP’s will overutilize resources due to a lack of knowledge. Hey, this is in their own studies when they try to prove how great they are.

    F) How do you exactly learn to take care of patients by taking online classes? Not well, probably. In the early 1900’s plenty of “medical schools” were decomissioned due to inadequate training standards. This has not yet happened to NP programs run by little mom-n’-pop universities. When it does, maybe the degree will mean something.

    G) Litigation and just normal human progress favor more and more training, not less training.

    H) I and a lot of other physicians have no qualm about throwing NP’s under busses and taking away their patients and giving them to someone else. I make the point that NP’s, while not as well-trained as MD’s, are trying to charge as much from the insurance company for their services. This ressonates well with patients.

    I) Nurses intuitively understant the BS NP’s try to pull and aren’t too fond of someone who has minimally more training try to give them orders. Nurses will also sabotage NP’s.

    The above are truths. If you don’t like them, go to medical school instead. But I guess you rather go to some joke online class because, hey, it’s a lot easier and doesn’t require much brains or committment.

  31. A Davis, very well stated if your statements are accurate. Just a few respectful comments.
    First, the political warfare you speak of was not initiated by NP’s, just the opposite. Physicians initiated the political warfare against NP’s and for the most part are winning the war.
    Second, NP’s look out for the well being of the patient more so than any other provider. What makes an NP successful in every study comparing MD and NP is the fact that the NP is very good at knowing the limitations of their practice hence very lacked on referring the patient to an expert MD that is willing to collaborate with the MD, no egos here A Davis.
    Finally, the large studies that show NP and MD provide equivalent care are all based on collaboration with the MD. I have been doing this a long time and can tell you my success is only as good as it is because of my collaborating doctor, as is his success only as good as his trust in me that I know my limitations. This thing only works if we do it together, when done right you can’t beat the care that we give to our patients. Thanks for the comment. I can only hope that the expansion of our practice helps take away the bureaucracy that my collaborating doctor must endure to keep our team working as well as it is. It would allow more time doing what he loves, spending time with patients.

  32. I agree with GROUPEXCELLENT that utilizing nurse practitioners would be an excellent way to help address the increase in demand. Even if their training needs to be modified or added to, they are in a prime role to step up and help in the shortage of Primary Care Providers.

  33. Everyone raises an interesting point. What’s exciting to know is that our roles as nurses will expand allowing for greater career opportunity in light of the health care reforms. The situation is further compounded with the growth of our elderly population as a result of the baby boomer generation. I agree that utilization of nurse practitioners would be an excellent way to help address the increase in demand as the new laws roll out. I can’t see any better suggestion especially since we place patient advocacy as our highest priority.

  34. A big problem is the Nuse Practice Acts vary in scope from state to state and require dual regulation in some states. Licensure to become a nurse practitioner rquires a national exam. To be effective, the Nurse Practice Acts need to be common in scope in all states to take advantage of this resource. The southern states have the most limited scope of practice, yet could benefit the most from more primary care providers. There has been a few states bordering each other that commonized regulation and to date 16 states that allow independent practice of nurse practitioners. The AMA created the physician assistant and nurse practitioner positions in the 1970’s and it seems that unless they can control health care they will do anything to stop progress. Study after study have knocked down the AMA’s concerns. In many studies patient satisfaction is higher than for physicians. The Institute for Medicine released a statement that there is no safety concerns about nurse practitioners for basic primary care and support their use to fill primary care positions. Many physicians independently support using NPs also. It seems a small minority is making alll the noise (the AMA).

  35. Cost. There are many ways to look at this. A study comparing NP versus MD management of post-revascularization hypercholesterolemia found that patients managed by NPs are more likely to comply with the prescription regimen and achieve their health goals at a lower cost (Paez and Allen, 2006). In a cross-sectional comparison of retail clinics (staffed almost exclusively by NPs and PAs), researchers found that the cost of care provided in retail clinics is far lower than care provided in primary care physician practices and emergency departments, while quality remained constant (Mehrotra et al., 2008). Even with teaming, a collaborative NP/physician team was associated with decreased length of stay and costs and higher hospital profit, with similar readmission and mortality rates (Cowan et al, 2006; Ettner et al, 2006).

    Joe, you are right! So even if we can provide the same care but with a different theory of delivery, we should be held to the same standards (and we are with the requirements of education, certification, licensure, and accreditation). And if we can do this, then open the gates to allow NPs to give primary care to the fullest scope of practice as an independent provider. What we need is to move from a “sick” model of healthcare delivery to a “health” care system. We can do this with more primary care providers such as physicians and NPs.

  36. Studentnurse you have raised a valid point about remuneration. Primary healthcare givers need to be paid better. Physicians should not feel threatened by this because nurses face the same scenarios as doctors when they absolutely have to refer their patients to doctors when they have reached their limits. After all there is a higher demand for nurses than there is for physicians. Government policy makers need to look at ways of improving the quality of LPN training. Only then will the be respected enough to command higher salaries.

  37. The salaries of physicians are much higher than NPs. They are reimbursed at the same rate but take less home at the end of the day. And NPs referring to physicians is similar to the way that primary care doctors refer to specialists. Along the lines of what A Davis says, the scope of the NP is sufficient to provide care for common problems. If you start with the NP you are starting with the lowest paid provider.

  38. what Ms. Dennehy does NOT want is for NPs to have to follow all the rule and the same regulations as MDs have to — whether it be medical liability, etc.

    She wants NPs- who don’t get me wrong can be great- to be able to eat their cake and then have it too…

    If NPs needed to automatically inherit the regulatory structure on MDs, I am all for it…

    Even better, MDs should be regulated at the same level as NPs… does Ms. Dennehy support that?

  39. What’s different is nurse’s training. There’s an old phrase in medicine – “Common diseases occur commonly” – and that’s where NPs’ training concentrates. For doing the easy things that occur commonly, they are adequate. When the less common problems arise, they are not, and the political warfare that nurses have initiated against physicians makes it difficult form many NPs to swallow their pride and refer to a physician when they reach the limits of their training. NP care is better than no care, but NP’s need to recognize their limitations rather than call for an expansion of their practice beyond the scope of their training.

  40. The Institute of Medicine report you cite calls for Congress to “Extend the increase in Medicaid reimbursement rates for primary care physicians included in the ACA to advanced practice registered nurses providing similar primary care services.” This concept is backed by all major NP trade organizations, and it makes sense: equal pay for equal work.

    However, that leads to a very important question. How do advanced practice nurses save the system any money if they are reimbursed the same rate as physicians? In fact, shouldn’t advanced practice nurses cost more – the cost of their reimbursement, plus physician reimbursement to cover cases outside the NPs scope?

    I think this is an important issue; nurses are subject to the same economic incentives as physicians, or at least they want to be. We already see a trend towards greater specialization among advanced practice nurses, as well as a concentration in overserved areas, just as we see with physicians. What exactly is different about nurses?