Thursday, May 16, 2013

The Status Quo and the Primary Care-Nurse Practitioner Row

The U.S. health system is at a critical  juncture in health care workforce planning.  Policy analysis have proposed expanding the supply and scope of nurse  practitioners address increased demand for primary care providers.  These proposals are controversial.

Karen Donelan,  et al, “Perspectives of Physicians and Nurse Practitioners on Primary Care Practices, “ New England Journal of Medicine, May 16, 2013

In case you missed it, a battle royal is going on between primary care and nurse practitioner associations.  The battle goes under the name of “scope of practice” and boils down to this:
 Given the mounting primary care shortage, which grows greater by the day, who shall care for the sick – primary care doctors or nurse practitioners? 
Who shall lead the teams taking care of these folks?   
What shall nurse practitioners be certified to do – write prescriptions,  admit and discharge from hospitals, act as “doctors” in all these and other realms? 
What does the term “doctor” mean anymore?

You will find the answers discussed at length in the May 16 edition of the New England Journal of Medicine.
·         Gordon and Moore Foundation, the Johnson and Johnson Campaign for Nursing’s Future, and  the Robert Wood Foundation, conclude,

”Current policy recommendation that are aimed at expanding the supply and scope of practice of primary care nurse practitioners are controversial, Physicians and nurse practitioners do not agree about their respective roles in the delivery of primary care.”  

For example, when asked whether they agree with the statement that physicians provide the higher-quality examination and consultation than do nurse practitioners during the same type of visit,  67.1% of physicians agree and 75.3% of nurse practitioners disagree. (“Perspectives of Physicians and Nurse Practitioners on Primary Care Practice.”pages 188-1906)

·          David Blumenthal MD and Melinda Abrams, MS,  of the Commonwealth Foundation,  put forth these principles and conclude,
Unless physicians and nurse practitioners collaborate to improve primary care, neither will be happy with the outcome.  We urgently need a facilitate, open dialogue about the roles of physicians and nurse practitioners that includes representatives of the public. (“Putting Aside Preconceptions –Time for Dialogue among Primary Care Physicians,” pages 1933-1934)

·         John K. Iglehart, “Expanding the Role of Advanced Nurse Practitioners – Risks and Reward(pages  (pages 1935-1942), “ says in this final paragraph,

“Given the partisanship that thwarts policymaking in the nation’s capital and many states, progress in restructuring delivery system may come more rapidly at the  practice levels, where physicians and  nurses, and other caregivers are free to innovate and to assign to a person on the basis of the full extent of their training  and makes organizational  sense.  Greater leadership among physicians and nurses  who are prepared to challenge  their guilds  may become imperative in addressing these complex issues.”

Fundamental  Disagreements

The fundamental problems between the collapse of talks between primary physician organizations and nurse practitioners organizations are these:

·         One, By 2015, a shortage of 61, 500 primary care physicians will exist, and in 2014 30 million more patients are slated to enter the system via Obamacare.  To fill the gap between supply and demand for primary care services,  180,000 nurse practitioners may be called upon to meet the demand.

·         Two doctors want to remain “captains of the ship,” leaders of practices that treat patients (82. 8% of physicians vs 17.8% of nurse practitioners).

·         Three.  nurse practitioners should be paid equally for providing the same services (3.8% of physicians vs. 64.5% of nurse practitioners) , In 2011, the median income for general internists was $200,114,  family practitioners $200,114.  fnurse practitioners $93,977 and physician  primary physicIan assistants $92,6359.
·         Four, physician involvement is need to diagnose, treat, and prescribe (24 states), physician involvement need to prescribe, but not to diagnose and treat (9 states), no physician involvement required (16 states)

Tweet :  Primary care doctors  and nurse practitioners disagree who should care  and be paid for 30 million new patients in 2014/




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