Nurses: A Key to Health Care Reform

One of the few things that just about all sides agree upon in this health care debate is that we need more primary care providers -- lots more. And an already serious shortage will only get worse if we succeed in expanding coverage to some or all of the 47 million Americans who now lack it. That is one of the lessons of health care reform in Massachusetts, whose success in moving toward universal coverage has created what the Massachusetts Medical Society deems a "critical" need for internal medicine and family practice physicians.

The good news, however, is that there is a large army of reinforcements out there--primary care providers who are proving their worth every day, particularly in underserved areas like rural America. They're called ... nurses. More specifically, nurse practitioners. In 2006, there were nearly 145,000 nurse practitioners--registered nurses with advanced training--practicing in America. In 2007, another 3,700 graduated from masters degree and postmasters programs. (That same year, only 1,096* of the 2,603 family practice residencies offered to graduates of medical schools were filled.) Study after study has shown that the quality of primary care that the patients of nurse practitioners receive is as good or better than what they get from physicians, and that those patients are satisfied.

The problem is that nurse practitioners are often prevented by state regulation--and opposition by doctors' groups--from doing what they are trained to do. Though all 50 states now allow nurse practitioners to prescribe medication, for instance, the restrictions that are placed of them vary widely. In some states, they can operate independently; in others, they must have practically everything they do approved by a physician. And of course, the reimbursement they get is rarely commensurate with the value of the service that they are providing.

This morning, former HHS Secretary Donna Shalala and Pennsylvania Governor Ed Rendell--who has done much to empower the nurses in his state--will join with the American Academy of Nursing's Raise the Voice campaign in calling upon federal policymakers to make sure that nurses are given the role that they have earned in any drive to reform the health care system. Washington would do well to listen.

UPDATE: *Commenter plukasiak finds a link that corrects/clarifies one of the figures that I cited. But the point remains the same:

Karen, the 1096 number that you refer to is about the number of graduates of allopathic medical schools who were US citizens and who chose primary care for their residencies. The actual number of filled primary care residencies is 2,299.

Yet physicians continue to avoid primary care. This is most obviously apparent in the numbers from the "Match," the National Resident Matching Program process by which senior medical students select residency positions. A total of 2,299 of the 2,603 positions available for residency training in family medicine in 2007 were filled by 87 U.S. physicians who were prior-year graduates of U.S. allopathic medical schools, nine graduates of the Fifth Pathway, 335 U.S. citizens who were graduates of international medical schools, 538 non-U.S. citizens who were graduates of international medical schools, 227 osteopathic physicians and 1,096 U.S. citizens who were allopathic senior medical students.

UPDATE2: After the jump, a five-point proposal just unveiled by the National Nursing Centers Consortium:

The National Nursing Centers Consortium, a non-profit organization comprised of Nurse-Managed Health Centers throughout the country, has a five-point plan with new ideas to increase access to health care, improve care for patients with chronic diseases, and improve the efficiency of the health care system:

* Ensure Access to Care for the Underserved by Protecting the Government's Investment in Nurse-Managed Health Centers. Many Nurse-Managed Health Centers are affiliated with academic schools of nursing, and received federal start-up funding through the HRSA Division of Nursing. Although these centers serve a high percentage of uninsured patients, they often cannot qualify for the enhanced resources that the government offers Federally Qualified Health Centers (FQHCs). By increasing funding and reimbursement for this innovative model of care, the government can encourage the sustainability of existing primary care access points and help health centers offset the high costs of providing care to uninsured, low-income and vulnerable families.

* Improve Geriatric and Chronic Care by Adopting an Inclusive Definition of the “Medical Home.” Nurse practitioners are currently excluded from participating in a number of “medical home” initiatives – including the Medicare Medical Homes demonstration project administered by CMS – despite the fact that Nurse-Managed Health Centers serve as full-fledged primary care homes for hundreds of thousands of individuals. To ensure that America's increasing population of seniors has access to high-quality, comprehensive primary care models, it is essential that the concept of the “medical home” be expanded to include nurse-led practices.

* Create More Efficient Infrastructure for Health Care Administration. Even though the process of provider credentialing is essentially the same for every insurer, providers must submit multiple credentialing applications to all insurers in his or her market. A unified credentialing clearinghouse for all health care providers could reduce or eliminate unnecessary delays and redundancies in the credentialing process. This could reduce administrative costs in health centers by 25 percent.

* Increase Opportunities for Health IT Implementation. Nurse practitioners and Nurse-Managed Health Centers must have the same opportunities as other providers to take part in initiatives designed to improve primary care outcomes. To achieve this, the government must fund Health IT initiatives outside of its existing funding frameworks, which tend to focus on physician-led practices and existing FQHCs. Given the nation's growing shortage of primary care physicians, it is critical that the government ensures that Nurse-Managed Health Centers have access to incentives that would allow them to implement new Health IT initiatives and improve quality of care for their patients.

* Invite New Players to Join the Health Reform Discussion. Nurse practitioners are the fastest growing group of primary care professionals in the country. Although nurse-managed care models are a relatively new movement in health care, they reach large numbers of patients throughout the country. These providers have new ideas that promise to increase the accessibility and affordability of health care in the United States. Without their voices at the health reform table, we may lose the opportunity to implement a more interdisciplinary, team-based model of health care.