Rx FOR DOCTOR SHORTAGE
Expanding nurses’ range of duties is one way to address our nation’s shortage of doctors.
By Kara Nett Hinkley
America faces a critical shortage of doctors—as many as 91,000 by 2020, according to some estimates. Aging baby boomers, coupled with an influx of 30 million Americans into the health care system under the Affordable Care Act, are expected to create an unprecedented demand for medical services.
Legislators are exploring a number of ways to meet the need, including filling the doctor shortage with nurses who have advanced degrees in family medicine. Since January 2011, state legislatures have considered nearly 2,000 bills that address nurses’ and other health professionals’ range of duties, or scope of practice. Most of the roughly 200 bills debated so far this year would lift restrictions on advanced practice nurses and physician assistants and allow them to do what primary care doctors do—examine patients, order tests, diagnose and treat illnesses, and prescribe and administer drugs.
The level of autonomy of advanced practice nurses (who are often called nurse practitioners) varies by state. In 17 states and the District of Columbia, they are allowed to work independently of doctors. Another 10 states require them to be supervised by doctors, although the amount of supervision varies.
In 22 states, nurse practitioners must have collaborative, written agreements with physicians outlining each other’s specific roles, rights and responsibilities, usually as defined by the state. But many argue these agreements serve little purpose and only impede the nurses in establishing their own practices. Legislators in a few states have considered measures eliminating this requirement and allowing nurse practitioners to confer with a physician when they must perform procedures beyond their training. But none has passed.
New York Assemblyman Richard Gottfried (D) believes the collaborative agreement is outdated. He sponsored the Nurse Practitioners Modernization Act this year “to strengthen and expand the nurse practitioner profession.”
Elsewhere, Kentucky is looking at keeping the collaborative agreement but allowing nurse practitioners to prescribe most drugs. West Virginia also is considering allowing nurse practitioners to write prescriptions, and Texas is debating whether to allow both nurse practitioners and physician assistants to prescribe medicine.
Some primary care physicians argue patient care will suffer if nurse practitioners don’t collaborate routinely with doctors. The American Academy of Family Physicians, representing more than 105,000 doctors, favors a physician-led, team-based approach to care. In a report last fall, the group argued that substituting nurse practitioners for doctors should not be the answer to a shortage of primary care physicians. “Nurse practitioners are not doctors—nurse practitioners do not have the substance of doctor training or the length of clinical experience required to be doctors,” the report stated.
The American Academy of Nurse Practitioners, with 155,000 members, responded that more than 100 studies have shown patients fare as well, if not better, under the care of nurse practitioners as physicians. “Making full use of the nurse practitioner workforce is a critical piece of a multi-pronged solution to address the urgent need for health care access in our nation,” the group argued.
Lawmakers will be studying all sides and considering what’s best for their states, as they seek consensus with emergency room urgency.
Licensed practical/vocational nurse (LPN/VN): Has completed a state-approved practical or vocational nursing program, usually one year; has passed a national exam; and is licensed by a state board of nursing to provide patient care. Normally supervised by a registered nurse, advanced practice registered nurse or physician.
Registered nurse (RN): Has received a bachelor’s or associate degree in nursing (four- and two-year programs, respectively) from a state-approved school, has passed a national exam, and is licensed by a state board of nursing to provide patient care.
Physician Assistant (PA): Works under the direction of physicians and surgeons. Formally trained to examine patients, diagnose injuries and illnesses, provide treatment and prescribe medications. Most have a master’s degree.
Advanced Practice Registered Nurse (APRN): Registered nurse with a master’s or doctorate degree and clinical experience, usually specializing in one of four categories: midwifery, clinical care, primary care (nurse practitioner) or anesthesia. They can diagnose and treat illnesses and prescribe medications, depending on state regulations. In some states, they are supervised by, or work in collaboration with, a physician. In other states, they can practice independently but within perscribed parameters. Still other states allow them to work completely independently.
Kara Hinkley worked in the health policy area while at NCSL.