Nurse Practitioners Are In -- and Why You May Be Seeing More of Them

Published: February 13, 2013 in Knowledge@Wharton

Despite continuing protests from some physician groups, the role of nurse practitioners (NPs) in U.S. health care is expanding and will likely change both the costs and type of care experienced by millions of Americans.

Partly driving this change is The Affordable Care Act, known as Obamacare, which will extend health care coverage to approximately 30 million more individuals, most of whom have not been able to afford health insurance in the past.

Predictions for a shortage of family practice doctors are adding to the impetus for a broader role for nurse practitioners, who are already the main non-physician providers of primary care. NPs have more advanced training than registered nurses (RNs), typically acquired through completion of a Master of Nursing or other graduate degree.

The effort to expand the scope of nurse practitioners' authority to treat patients, however, has been opposed by a number of physician groups, including the American Medical Association (AMA), the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association, all of which support direct supervision of NPs by physicians. Some doctors -- concerned about the ability of NPs to diagnose complex illnesses -- have fought legislation on the state level that would allow these changes. Those in favor of giving NPs more authority say physicians are also worried about the loss of income they will face if too many patients opt to see an NP rather than an MD.

Physicians may be facing a losing battle. "That horse has already left the barn," says Linda Aiken, professor of nursing at the University of Pennsylvania School of Nursing and director of the Center for Health Outcomes and Policy Research. "With Obamacare coming in and millions of people getting insurance, there is no other way to provide them with reasonable access in the short term except to expand the role of NPs and physician assistants (PAs). It takes 20 years to train a doctor, so there isn't any alternative." According to an article titled, "Broadening the Scope of Nursing Practice," published in 2011 in The New England Journal of Medicine, "between three and 12 nurse practitioners can be educated for the price of educating one physician, and more quickly."

"Doctors have always been wary of others poaching on their turf," says Lawton R. Burns, Wharton professor of health care management. "And highly trained nurses are always looking for more recognition, responsibility and autonomy rather than being under a physician's thumb. It's these types of dynamics that pose a challenge to health care reform."

Comparable Care

In the U.S., each state is responsible for deciding and regulating what services health care practitioners are qualified to provide. According to a National Governors Association report in December, 16 states and the District of Columbia allow NPs to practice "completely independently of a doctor and to the full extent of their training -- i.e., diagnosing, treating and referring patients as well as prescribing medications." The remaining states require NPs to have some level of involvement with, or supervision by, a physician.

Wharton professor of health care management Robert J. Town, among others, questions the patchwork state regulatory system, including its restrictions on nurse practitioners' scope of practice. Giving NPs the right to treat patients and prescribe mediations without a doctor's supervision "doesn't seem to have any negative consequences, and it provides a lot of people with more access to primary care, whether it's in a retail clinic or whether it means patients can see their primary care provider without having to see the physician," he says.

Rules governing the scope of nurse practitioners' authority, he adds, "are determined by state legislatures, not by rational cost benefit analysis," and some of those legislatures have ruled against an expanded role for NPs "because of physician opposition. If doctors can keep nurses off their territory, it increases the number of patients these doctors can see and how much they get paid." But change may be on the way, he notes, "either because insurers are pushing to have more alternative providers available, or the alternative providers are getting greater clout with legislators. Or perhaps physicians know they are at capacity" and simply will not be able to take on all the new patients expected to be covered by Obamacare.

One health research group estimates that the country can expect a shortage of 90,000 doctors by 2020. Many of those shortages will be in the primary care field, in part because primary care physicians are typically paid significantly less than specialists.

Given predictions like these, Obamacare includes a number of incentives, including financial, that it hopes will encourage more physicians to specialize in family medicine. "We will have to see how that plays out in practice," says Ashley Swanson, Wharton professor of health care management, adding that "each side has a valid perspective. Physician groups may be concerned that changing the position of nurses, especially in primary care, will change doctors' reimbursement rates and their ability to continue practicing. Doctors are also concerned that NPs won't be able to provide the same kind of diagnostic quality of care."

That is the main argument put forth by the AMA and other physician groups. A spokesperson at the AMA did not provide the name of a physician to speak with, but did offer several policy statements with regard to physician assistants and nurse practitioners. These guidelines state, for example, that "the physician is responsible for managing the health care of patients in all settings" and "the physician is responsible for the supervision of the physician assistant in all settings."

Various press interviews with doctors indicate that they are not opposed to letting NPs handle such routine matters as earaches and immunizations, but object to giving them authority to treat more chronic diseases like diabetes, or conditions that involve more complicated diagnoses such as possible broken bones or concussions. One paper from a physician association suggested that allowing NPs to practice independently "would create two classes of care: one run by a physician-led team and one run by less-qualified health professionals.... Everyone deserves to be under the care of a doctor."

The move to expand nurse practitioners' authority has its supporters as well, ranging from the AARP to the American College of Physicians to the Institute of Medicine. In addition, "There are literally hundreds of studies showing that the care offered by NPs is comparable -- and in some cases, better, in terms of patient satisfaction -- than the care offered by doctors," says Aiken. "In other outcomes, like teaching patients how to take care of themselves, NPs do better as well." 

According to a 2012 Health Policy Brief in Health Affairs, "a systematic review of 26 studies published since 2000 found that health status, treatment practices and prescribing behavior were consistent between NPs and physicians." And the authors of the New England Journal of Medicine article cited earlier write that while some physician groups suggest that their longer and more in-depth training means NPs "cannot deliver primary care services that are as high quality or safe as those of physicians ... there is no measureable difference in the quality of basic care services" when compared to the quality of care provided by NPs.

Good for Business

Heather Helle is COO and divisional vice president of Walgreens' Take Care Health Systems Consumer Solutions Group. Walgreens, headquartered in Deerfield, Ill., is the largest drug retailing chain in the U.S., with sales last year of $72 billion. The company has more than 370 "Take Care" clinics in 19 states, and more are on the way. NPs are typically the single provider on site, and in the clinic model, they often practice independently, providing care that "equals, and in some cases exceeds, what you find in a physician's office. They are a clinical resource that, for many years, has been underutilized," says Helle, adding that the company has contracts with most national and regional insurers. Walgreens' position, she states, is that "NPs are uniquely positioned to deliver high quality, affordable and convenient care. That has been the hallmark of the retail clinic industry."

The dynamics of health care have changed since the first retail clinics opened 12 years ago, Helle says, noting concerns back then about the autonomy of NPs and the quality of care they offered. But now, "with the advent of the Affordable Care Act and all the health challenges we are facing -- including a physician shortage, an aging population, the prevalence of chronic disease and more than 30 million more patients [eligible for coverage under Obamacare] -- you are seeing a real shift. Everyone used to say that we don't have enough primary care physicians to serve these patient populations. The conversation has now [moved] to, 'How do we think about ... leveraging NPs so that we are complementing doctors, health systems and communities?'"

Along those lines, the company's Take Care Health Systems Group is collaborating with Ochsner Health System in New Orleans to improve patient access to health care -- including, for example, after-hours care in their clinics so that "instead of clogging already overburdened emergency rooms (ERs), patients can be triaged in a more appropriate setting to get less expensive care with equal quality," says Helle. The collaboration will also facilitate and promote medical information sharing with patients and with patients' health care providers.

Other companies, as well, have seen the value of in-house clinics. CVS operates more than 600 drug store Minute Clinics in 24 states, while Walmart and Target offer clinics in their retail stores. That business model is expected to save companies -- and state health care budgets -- significant sums of money. A Rand Corporation study published 15 months ago in the American Journal of Managed Care reported that health care at retail clinics is 30% to 40% less expensive than similar care at a physician's office, and 80% less expensive than care provided in an ER. Research published in 2010 in Health Affairs calculates it another way: Between 13.7% and 27.1% of ER visits could have taken place at retail clinics or urgent care centers; in addition, some patients who go to retail clinics have saved $279 to $460 per visit compared to the cost of going to an ER.

Economics also is playing an increasing role in individual states' decisions on nurse practitioners' scope of practice. Companies like Walgreens and CVS that favor more autonomy for NPs "are exerting themselves on some of these policy decisions," notes Aiken. "If a state has restrictive practice requirements for nurses, it costs these companies a lot more to locate their [clinics] there. So you have a coalition opposing the AMA that wasn't there in the past."

The amount of money at issue isn't trivial. In its evaluation of the Massachusetts health reform legislation, first enacted in 2006 and later amended, the Rand Corporation concluded that if the state -- which has more restrictive rules governing NPs than some other states -- broadened the scope of practice for these NPs, it could save $8 billion over 10 years, in part by offering an option for health care besides expensive ERs. Convenient care centers can't operate in states like Massachusetts "without losing money," says Aiken.

Pennsylvania offers a different outcome. In January 2007, then-governor Edward Rendell announced Prescription for Pennsylvania (Rx for PA), a comprehensive blueprint for reforming the state's health care system. One of its major initiatives was to expand the legal scope of practice for NPs and other advanced practice registered nurses (APRNs). Within three years, 51 retail clinics using APRNs were set up through the state, providing care to 60% of the state's uninsured. It is estimated that about half of the 300,000 visits to these clinics would otherwise have been to ERs.

Insurers and big health systems, as well, have a role to play in what looks to be an ongoing restructuring of health care. "They are very supportive of NPs by, for example, using them to do utilization reviews and to act as case managers whose goal is to keep people out of hospitals," says Aiken. "And the federal government uses them to expand federally qualified health centers. NPs are everywhere."

Modified Reimbursements

The experience level of health care practitioners is a relevant issue in this debate, says David Asch, a physician, Wharton health care management professor and former executive director of the Leonard Davis Institute of Health Economics. "The value of education attenuates very rapidly. I will take a very experienced NP over an inexperienced doctor any day because so much of what people learn that will be of particular use comes after they have completed their degree program.... There is some optimal point of experience that is somewhere between right out of training and ready to retire."

He also notes that when he was chief of general medicine 20 years ago at the Philadelphia VA Medical Center, where he still practices, he hired NPs and PAs whose scope of practice was "virtually identical to doctors'. So this is nothing new. We are at a time when there is widespread recognition of shortages in some areas of health care, especially primary care, which can be substantially served by NPs and PAs."

Others agree. A report from the National Governors Association released two months ago recommends that states ease restrictions on NPs and modify their reimbursement policies to increase the role of nurse practitioners in providing primary care. As it is, NPs are typically paid less than physicians for providing the same service. For example, according to research published in Health Affairs, Medicare currently pays NPs at a rate that is 85% of what physicians receive; in Medicaid fee-for-service programs, more than half the states pay NPs a smaller percentage of the rates charged by physicians.

A report in 2010 from The Institute of Medicine titled, "The Future of Nursing: Leading Change, Advancing Health," recommended action "at the state and federal levels to allow NPs to practice to the full extent of their education," and suggested that Congress amend the Medicare law "to make coverage of NP services consistent with coverage of physician services."

For Wharton's Swanson, it gets down to making sure health care practitioners are fairly paid for their expertise and experience. "Both physicians and nurses have invested a lot in their education," she says. "They have a lot to lose, and they want to make sure their careers are safe going forward. We all want to make sure people are getting something for investing in their education. But at the same time, we are in a period of great flux. A lot of changes are happening because the current system no longer works."

Doctors and nurses, she adds, "are concerned about the uncertainty surrounding the Affordable Care Act. But in the long run, anything that makes our system more sustainable will be good for both groups."