I was teaching a group of nursing students at a major New York City hospital a few months ago when one young student came to me, pale and perspiring. She had been feeling sick for at least five days, but had not yet sought medical care. After moving from Los Angeles last year, she was unable to find a physician who would accept new patients. As an experienced family nurse practitioner and educator, I am all too often witness to the United States’ alarming shortage of primary care providers.
A 2010 report issued by New York’s Primary Care Coalition found that New York spent over a billion dollars on unnecessary ER use and pinpointed the loss of primary care providers as a driving factor. In addition to the added expense of an ER visit, people become sicker as they wait for care and the number of hospitalizations increase.
The latest data from the Association of American Medical Colleges projects a shortfall of more than 45,000 primary care physicians in 10 years. The Affordable Care Act will add an estimated 32 million new people on Medicaid, but we may not have the clinicians to deliver the care. The number of baby boomers over the age 65 is projected to increase 36 percent over the next decade. Who will take care of our newly insured, disadvantaged, and elderly patients?
Nurse practitioners have been vital providers of primary care since 1965. As registered nurses with a Master’s degree or Doctorate, we have a unique blend of holistic care and specialized training that allows us to treat a wide variety of patients. In addition to state board certification, many nurse practitioners are certified by national accrediting agencies in six specialties, including primary care. We formulate medical diagnoses, treat illnesses, and prescribe medications. When necessary, we provide referrals to specialists. With over 165,000 nurse practitioners in the U.S., and over 15,000 strong in New York State alone, we are well positioned to help address the shortage.
The scope of nurse practitioners’ practice is controlled by state laws and the difference among states is staggering. Only 17 states currently license them to treat patients with complete autonomy. In Louisiana they may work without physician supervision, whereas in New York they must sign collaborative agreements with physicians in order to treat patients. In Florida, they must sign collaborative agreements and their prescriptive privileges are limited; they are not allowed to prescribe narcotics and other controlled substances. I urge all states to follow the lead of 17 forward thinking states and dissolve the need for collaborative practice agreements.
Collaborative agreements only serve to create barriers to patient care. Services and treatments to patients may be delayed, as diagnostic tests and procedures, home care and hospitalizations must be authorized by the MD. Worse, if the physician moves or terminates the agreement, practitioners and patients both lose. This can be especially devastating in clinics run by nurse practitioners in rural areas, where the primary care provider shortage is particularly acute. With autonomy, nurse practitioners would have greater incentive to start new community practices.
The American Medical Association argues in national ads and position papers, that without collaborative agreements, NPs will not provide the same level of care as MDs. Ironically, the AMA also concedes that there is no evidence to support this claim. Its 2010 position statement on nurse practitioners acknowledged a pivotal 2000 research study published in its own journal, the Journal of the American Medical Association. The study measured nurse practitioner practices with the same degree of independence as comparison MD practices. The results showed no difference in the level of care and expertise between the two groups.
In striking contrast to the AMA, The Institute of Medicine’s 2011report, The Future of Nursing, included the recommendation that nurse practitioners should practice to the full extent of their education and training, and that nurses should be full partners, with physicians and other health professionals in redesigning health care in the United States.
Let us act now to hold off a worsening crisis in primary care. We need to increase pressure on lawmakers to revise current nurse practitioner statutes and dissolve mandatory collaborative agreements and practice restrictions. It is also important for the government to continue to include key nursing leaders and nurse scientists in the restructure and design of our changing health care landscape. In this way, the ACA may have a better chance of advancing its promise to provide optimal, comprehensive health care while ensuring that all Americans have access to it.
Down in the ER, a resident gave my student a handful of prescriptions to treat a complicated urinary tract infection. I gave her the name of a great NP practice a few blocks away.
Karyn Lee Boyar is a board certified family nurse practitioner. She is a clinical instructor at the New York University College of Nursing and is completing a Doctorate in Nursing Practice at Pace University in New York.