Tuesday, June 23, 2009

Qualified nurses seek authority to provide primary care

The following op-ed was published this morning in The Honolulu Advertiser:

Trained nurses can ease doctor shortage

By Marilyn Lee

A bill that allows nurses with advanced training to deliver primary health care independent of physicians is before the governor to be signed into law. Primary health care refers to the first contact a patient has with the health care system. It's the basic, initial care that you receive when visiting a clinic or a doctor's office, the care you get before being referred, if necessary, to a specialist.

This issue has been coming before the Legislature for several years, and we have been moving steadily toward giving nurses more autonomy and responsibility, advancing boldly into territory previously controlled by physicians. Actually, registered nurses have been delivering this kind of care for decades.

In recent years, however, nurses with advanced training, such as nurse practitioners and nurse midwives, have been moving toward greater independence.

This has occurred as the country has experienced a growing shortage of primary-care physicians. In many states, including New York, nurse practitioners are allowed to write prescriptions and be reimbursed by third-party insurers. A growing number of health maintenance organizations are using nurses as primary-care providers, and some nurse practitioners are going into practice on their own.

As long as nurses were working for doctors, there wasn't much of a problem. The nurses lighten the workload, and they help bolster profits. For routine visits, some patients end up seeing only the nurse, even though they are paying for a visit to the doctor.

Unfortunately, the American Medical Association has criticized virtually every argument supporting greater autonomy for nurses. The AMA rejects the idea that nursing care is less expensive than physician care. It contends there is no convincing evidence that nurses are more cost-effective health care providers. This is particularly interesting when you consider that the average income for doctors last year was $170,000, but for nurse practitioners was $43,600.

The cornerstone of the doctors' argument is that nurses acting independently threaten the health of their patients. There does not seem to be any evidence for that argument. The dean of the Columbia University School of Nursing noted nurse practitioners have been delivering primary care since 1965, and hundreds of studies have examined the quality of their work, including their diagnostic ability and management effectiveness.

Not a single study shows any lapses, and most of the studies were done by physicians. When asked if any studies had shown problems with the quality of care delivered by advanced-practice nurses, Dr. Lonnie Bristow, former AMA chairman said, "No, certainly not. In fact, we believe the quality of care is quite good."

Dieticians, physical therapists, occupational therapists, social workers and others work alongside physicians, and we don't worry they are going to cause liability for the physicians. We just passed a bill allowing Physician's Assistants the right to practice independently, so why not nurses? There will be a two-year report by the insurance commissioner on how well this new law is going. Any problems that arise can be addressed at that time.

This year, the Legislature has made fantastic progress in improving access to care for patients in rural areas and underserved communities. Recent discussions on health care reform packages emphasize primary care and add considerable weight toward greater responsibility for advanced-practice nurses. With health care costs creating economic havoc, it is not likely that doctors or anyone else will be able to slow the movement. If nurses with special training are delivering high quality care at a reasonable cost, then we need a reason other than doctor's anxiety to stop them.

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