The Nurse Practitioner Will See You Now

Laura A. Stokowski, RN, MS


June 29, 2010

In This Article

The Nurse Practitioner Will See You Now

Will patients soon hear these words more often? As the shortage of primary care physicians in the United States becomes increasingly dire, some people believe that that qualified healthcare professionals should be uniformly permitted to function at their greatest potential as healthcare providers.[1]

Much has been said lately about "unleashing the potential" of nurse practitioners (NPs).[2,3] Nursing leaders decry the invisibility of NPs in the primary care landscape. Often working quietly in rural or underserved settings, NPs are not permitted to lead patient-centered medical homes, their names are not found on preferred provider lists, and they cannot secure funding for much-needed primary care programs. In many states, NPs are restricted in their abilities to practice under their own licenses or write prescriptions.

Why has such a huge rift developed between the educational preparation of NPs and their ability to practice after they graduate? And can anything be done about it?

In a recent address at a seminar sponsored by Health Affairs, Joanne M. Pohl, PhD, ANP-BC, Professor at the University of Michigan School of Nursing, and NP at the University of Michigan School of Nursing's Nurse Managed Health Centers, spoke about the need for unfettered practice by our nation's 150,000 NPs.[2]

The basic facts are:

  • The healthcare reform bill is expected to increase access to primary care services for 32 million more Americans;

  • We currently (and for the foreseeable future) have a shortage of primary care providers;

  • Two thirds of practicing NPs work in primary care and 20% work in rural areas, the most difficult settings to staff; and

  • Each year, 8000 new NPs graduate, and 7000 of these new graduates are prepared as primary care NPs.[2]

In contrast, new graduate physicians are avoiding primary care in droves. In a recent survey, only 7% of fourth-year medical students planned careers in adult primary care.[4] Medical students are reluctant to specialize in primary care because of the prospect of higher workloads and lower incomes.[4] The primary care workforce is clearly in jeopardy.

So, why aren't stakeholders welcoming NPs into the primary care workforce with open arms? Dr. Pohl explained the main barriers that currently block NPs from practicing to their full potential.

State scope of practice regulations. An uneven patchwork of varying state regulations now characterizes NP licensure and scope of practice in the United States. State laws define NP roles and oversight requirements; they govern practice and prescriptive authority.[5]

Laws in some states restrict NPs from practicing as their education has prepared them to do. However, the scope and autonomy of advanced practice nursing, and specifically NPs, varies from state to state, resulting in widely differentiated abilities to provide primary care, prescribe medications and order tests, be reimbursed, and be primary care providers of record. The recent advanced practice registered nurse (APRN) consensus guidelines, which delineate the essential elements of APRN practice and regulation (licensure, accreditation, certification, and education), hold promise for greater uniformity in nationwide NP scope of practice regulation.[6] However, adoption of these guidelines is still at the discretion of individual states, and no one can predict whether, when, and how the states will use these guidelines.

If states are to achieve conformity in NP regulation, perhaps it ought to begin with the question of who oversees and regulates NPs within the states. In 28 states and the District of Columbia, NPs are regulated solely by the boards of nursing. In the remaining 22 states, boards of medicine or pharmacy are authority over NPs along with the board of nursing.[3]

Nurse practitioners want the regulatory barriers to practice the way they were trained to practice lifted. They are ready, along with all primary care providers, to be held accountable for quality and efficiency of care measured by patient outcomes.[1]

Payer policies. The discrepancies between what NPs and physicians are reimbursed for equivalent services are well known. A shred of hope for pay parity with physicians is seen in the healthcare reform legislation, which specifies that for Medicare Part B patients, nurse midwives (who are essentially providers of primary care) will receive reimbursement equal to that of physicians. However, other nurse-managed health centers will not survive without a similar capacity to participate fully in the system of reimbursement from third-party payers.[1]

These inconsistent scopes of practice and varying payer laws and policies make it difficult to educate primary care providers to function as effective teams. The discordance between education and practice is an impediment to true collaboration.


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