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Time to Ease Restrictions On Nurses?

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When President Obama's Affordable Care Act (ACA) takes full effect next year, a deluge of new patients will flood into our medical system.

Assuring that medical treatment would finally be available to tens of millions of Americans who had previously been excluded was, of course, a stated aim of health care reform.

The new law will extend help to the growing number of working poor people, whose low-paying jobs currently do not offer health care. Many in this population can't afford doctor visits, sometimes suffering high blood pressure, diabetes, asthma and other ailments as a result. The ACA will usher these patients and many others into medical clinics.

But to the extent the ACA serves the humane purpose of preventing vulnerable people from falling through the cracks, it means these patients must be accommodated by our health care infrastructure. And that's where we're likely to run into serious trouble, due to the already sharply-limited capacity of the American medical system.

A key factor is the drastic shortage of primary care doctors, whose encounters with patients often are scheduled far too tightly as it is. Some health insurers actually require that an average visit with your doctor last no more than seven minutes. It's easy to see how the coming surge of new patients will push this overstretched system to a dangerous breaking point. Imagine longer delays to see your doctor, waiting rooms overcrowded with irritable fellow-patients and physicians who are more prone to making medical errors because the system has swamped them.

This is not the fault of the new law which, for whatever its flaws, does grant access to more people who need health care when they're feeling sick. It's the result of health care economics, which abundantly reward doctors who become medical specialists (lured in part by the powerful and profitable medical technology industry). Meanwhile, the primary care doc you're waiting to see for your sore throat or aching back typically earns less.

What we're left with is a shrinking pool of primary care physicians at precisely the moment when demand for their services will intensify. This looming crisis has spawned a newly urgent discussion in medicine about the dearth of primary care providers.

And that leads to the logical question of why these providers must be doctors. What about nurses, who already spend much more time with patients than MDs and who constitute a far larger sector of the health care profession?

Not all nurses, of course, are qualified to take on duties traditionally handled by doctors. But more than a quarter million nurses are "advanced practice" professionals, who have attained master's or doctoral degrees. These include the field of highly-trained Nurse Practitioners (NPs), whom many health care experts view as a big part of the solution to our primary care shortage.

A widely quoted study published in 2000 in The Journal of the American Medical Association compared health outcomes of more than 1,300 patients treated either by MDs or NPs at multiple primary care clinics. Based on follow-up reports six months later, "no significant differences were found in patients' health status" as between those treated by doctors and those treated by nurse practitioners.

Still, there is broad agreement that nursing education overall needs to be strengthened, especially as health care reform inevitably will place greater demand on nurses. The Institute of Medicine (IOM), America's foremost source of medical research, weighed in on this challenge in a major 2010 report, which called for creation of residency training programs for nurses and recommended that the number of nurses who pursue doctorates be doubled.

A statement by the IOM affirmed the finding that advance practice nursing professionals "deliver safe, high-quality primary care" and urged the removal of "barriers that hinder nurses from practicing to the full extent of their education and training".

These barriers vary across the 50 states. NPs are permitted to practice independently in 16 states, while in others they must be supervised by physicians. Nurse practitioners sometimes complain that doctor oversight needlessly slows the provision of care. It is particularly problematic in some medically under-served rural areas, where physicians may be required to travel long distances to conduct supervision. This also complicates payment by health plans for services that NPs perform.

A perspective article in 2011 published in the New England Journal of Medicine said "there are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care".

The AARP has called for easing of regulations that limit the independence of NPs. Even the National Governors Association, some of whose members have acted to block state-level adoption of expanded Medicaid under Obamacare, released a paper in December 2012 suggesting "states might consider changing" restrictions on nurse practitioners and "assuring adequate reimbursement" to them.

But as many state legislatures are considering easing regulations on NPs, a turf struggle has developed between some physicians groups, who see their traditional dominion being eroded, and representatives of advance practice nurses. Lawsuits have been filed in California, Colorado and Iowa over whether NPs should be granted greater responsibility and leeway in the care of patients.

Once again, our access to health care may be decided by the courts.