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A New Role for APNs?

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“Nonphysician” is a term advanced practice nurses love to hate. Truth is, they know they’re not physicians, but their ranks are growing. The APN title encompasses four nursing areas that require advanced degrees: nurse practitioners, clinical nurse specialists, certified nurse midwives and certified registered nurse anesthetists. According to the most recent National Sample Survey of Registered Nurses, APNs make up 8.3 percent of the total R.N. population, numbering 240,461 in 2004 (up from 196,000 in 2000).

Many healthcare consumers equate the APN with community-based primary-care clinics and physician offices, says Colleen Conway-Welch, Ph.D., R.N., dean of the School of Nursing at Vanderbilt University in Nashville, Tenn. But APNs also provide specialty care in hospital neonatal intensive care units or cardio-pulmonary wards. With APNs providing many of the same services as physicians—and medical students gravitating toward specialty care—APNs seem poised to shoulder greater primary-care responsibilities.

But APNs face some significant obstacles. Licensing regulations that vary by state, some say, hinder many nurses from making the jump to advanced degrees. Factor in perceived competition with physicians and misconceptions about the profession, and it’s clear that these “nonphysicians” still have hurdles to overcome before assuming an expanded role in the healthcare landscape.

Don’t fence me in

Regulation of APNs varies widely from state to state. According to Ruth D. Corcoran, Ed.D., R.N., CEO of the New York-based National League for Nursing, each state board of nursing is autonomous and sets its own practice guidelines. Standards run the gamut from Tennessee, which comes across as somewhat “oppressive” toward APNs, to Wyoming, which relies on “basically a handshake between the APN and collaborating physician,” says Conway-Welch. Rural states in greater need of primary-care access tend to be friendlier toward APNs, she says.

Although CRNAs have always administered medication, Conway-Welch says only recently have all states relaxed the rules to allow certified nurse midwives and nurse practitioners to prescribe. Nursing associations also target restrictions regarding “supervision”—another term most nurses could do without. States like Tennessee require physicians to do regular chart reviews on all APNs. It’s up to the APNs, Conway-Welch says, to hire physicians to do the reviews.

While some states afford APNs a certain degree of independence, others do not. Nurses are allowed to admit patients in few emergency departments, because a doctor’s authorization is typically required. Bruce Bagley, M.D., medical director for quality improvement for the American Academy of Family Physicians, says even the physician in the typical office may become an authorization bottleneck. “There needs to be a loosening of that, and it comes with good training and teamwork,” he says.

To nursing advocates, it’s a matter of working with physicians, not for them. The board of nursing in some states is also part of the medical board, Corcoran says, which raises red flags for nursing advocacy groups leery of physicians trying to determine the scope of APN practice—a job they feel is best left up to the profession itself. The American Nurses Association, for example, is currently mounting a response to an American Medical Association resolution that would commission a study of such factors as qualifications, education and certifications required of “limited licensure” healthcare providers. The ANA believes the resolution would limit APNs’ scope of practice.

Pride and prejudices

The intersecting roles sometimes played by APNs and physicians means the two groups are bound to clash over practice parameters. Although the question of turf invariably comes up, Conway-Welch and Bagley agree that competition is generally a low priority for primary-care physicians because there is no shortage of patients. Instead, Bagley says physician apprehension may stem from concerns—warranted or not—about APNs’ depth of knowledge of physiology, psychology and other aspects of physician training used to treat patients. As a result, physicians may have the sense that the system cost of providing care might be higher under APNs. A 2002 report to Congress by the Medicare Payment Advisory Commission, however, was unable to find reliable data to discern clear differences in the two groups’ outcomes and expenses.

Turf battles aside, one sticking point in the future of APN professions is the issue of reimbursement. Medicare rates currently reimburse APNs at 85 percent of the physician rate. Health plan reimbursement stipulations vary widely; often, nursing schools and organizations with nurse-run clinics, like Vanderbilt’s Vine Hill Community Clinic, don’t qualify for reimbursement from payors. Vine Hill only receives payments from Medicare and Tennessee’s TennCare program.

But not all nurse-run facilities face repayment disparities. Columbia University School of Nursing’s pioneering NP-run primary-care practice, founded in 1994, is touted as the first in the country to win reimbursement from health plans at a rate equal to physician groups. Still, determining APN reimbursement rates remains complicated. The 2002 MedPAC report compared providers’ outcomes, costs, services and other factors, but ultimately found insufficient data to determine whether APNs’ current reimbursement should be changed.

Breaking the primary-care barrier

As APN advocates continue to make inroads, a growing need for primary-care providers is helping their cause. With low reimbursement and lifestyle concerns making primary care a less attractive career option, medical students are entering primary-care specialties at a slower rate than in the past, says Bagley.

While APNs may be able to help fill the gaps in access, Bagley is not in favor of independent practice for APNs—or for primary-care physicians. Instead, the AAFP promotes the idea of “team care,” which Bagley says encourages cooperation and relationship-building by everyone in the medical office who interacts with patients. Bagley, who practiced in Albany, N.Y., for 28 years in a group that included NPs, fears independent practice limits a provider’s ability to hand off a case they do not feel capable of handling.

Nurses don’t necessarily feel the same way about the potential downside of independence. Considering the physician and nursing shortages, Conway-Welch suggests the healthcare system would be well-served in recognizing APNs’ ability to handle relatively common cases and allow physicians to redirect their energy toward more specialized or demanding areas. “This is very provocative, but it happens to be true,” says Conway-Welch. “We don’t really need family practice physicians as back-up to family nurse practitioners who can treat the majority of patients without need for referral.”

Physicians could cut costs and make better use of their time and expertise if they stopped sweating the small stuff and used APNs in greater numbers and in broader ways, Conway-Welch says. “The whole point is our healthcare system needs the right person, at the right salary, doing the right thing, for the right patient, at the right time, for the right cost.”

Kara Olsen is a staff writer with HealthLeaders magazine and managing editor of HealthLeaders Online News. She may be reached at kolsen@healthleadersmedia.com.