Overcoming Clinical Bias

Trading Invisibility for a Working Wage

Matt Freeman, DNP, RN, MPH


Nurs Econ. 2021;39(5):214 

I want to thank Nursing Economic$ for publishing the article "APRNs: Overcoming Clinical Bias" (Bryan, 2021).

It is still a painful, ongoing struggle to overcome the misogynist infrastructure that governs so much of what we do. It has been more than 15 years since Suzanne Gordon published Nursing Against the Odds, and I sometimes feel that nothing has changed. And I speak with the benefits of white male privilege

We made so much progress toward autonomous practice but failed to make this independence economically viable. For example, one of the largest third-party payers in Arizona reimburses nurse practitioners (NPs) at just 60%-65% of the physician pay schedule. I might have total autonomy, but I can't afford the gasoline to make it to my office. (This includes fixed-cost items. A physician receives $100 for ordering a pneumococcal vaccine; I get $65. Even though a medical assistant will likely administer it in either case.)

Perhaps due to necessity, low self-esteem, or feeling that we're up against behemoths, NPs have become complicit in maintaining this structure. The overwhelming majority of NPs are billing under an incident to method. It gets the NP a fair wage, but it reinforces invisibility. I also think it really isn't so grey; it is fraud. NPs are frequently billing under the National Provider Identifiers of physicians they have never met, physicians in other cities, physicians who have never even seen the clinic where the NP works. But physicians are happy to oblige, thereby ensuring their prominence, and NPs trade invisibility for a working wage.

Interestingly, I think patients find such practices shady. But it isn't their job to fix it. Legislators would rather do anything than go against the commercial payers. Physicians seem to be a mixed bag. One friend from school has no problem trashing NPs on a universal level. She just says that I'm an exception: "The smartest nurse ever." (I doubt that.) Others are mystified as to why we aren't physicians. But their jaws drop when I tell them about the pay discrepancy. "You should have gone to med school," is the usual advice, and it's not helpful.

Several NPs told me – without irony – that the key to success as a primary care NP is to "marry rich." What year is it? Bryan (2021) also spoke to the natural aggressive responses so many of us have to the daily micro-aggressions toward our clinical practice. (Micro-aggression has become a charged word in the political circle, but I use it for lack of a better word.) A slow-witted administrator at a community college wouldn't accept my signature on a pre-participation athletic form last month. "It's in the bylaws; it's in the junior college athletic… we had a meeting… lawyers." These were all misstatements, disproven on Google in a matter of moments. She was really just making it up, and profoundly defensive. I drove to a friend's house, a physician, and he signed the form. He'd never met the student. I asked an NP colleague if she's received the same treatment. "Oh, I've signed those for years," she said, "I just leave off the NP part after my name." Again, fraud and invisibility pay.

That administrator would rather have a resident, ophthalmologist, pathologist, or radiologist sign the form, even though I ran a university sports medicine program for years, took the board exam in sports medicine, and I've been the student's primary care practitioner for years. And I've been in practice for 17 years. But, oops, wrong initials. Wrong kind of doctor.

I don't know the answer. But perhaps, as Bryan (2021) highlights, NPs need to be more visible in many ways. Maybe that means having a stronger, more assertive voice about fair pay and clinical autonomy. Bryan's voice to our collective frustrations means a great deal to me. We face a public health crisis if we cannot make NPs a respected and sustainable cornerstone of the primary care system.