Nurses Demand Autonomy; Doctors Demand Oversight
June 10, 2013
A gap is widening between the need for healthcare and the availability of doctors in the U.S. Nurse practitioners offer to help meet the demand, especially for primary care, but the medical establishment has its concerns. With the 2014 implementation of the Affordable Healthcare Act, up to 30 million people who were previously uninsured could become eligible for health insurance, and many are expected to seek primary healthcare. The U.S. could face a shortage of more than 130,000 physicians by 2025, The Association of American Medical Colleges warns.
One solution proposed would be to broaden the role of the nation's more than 157,000 nurse practitioners, who are registered nurses with advanced practice master's or doctoral degrees. NPs can already diagnose and treat patients and prescribe medication without a physician's involvement in certain states plus the District of Columbia. Although most states still require nurse practitioners to have physician oversight in some capacity, some states have legislation pending that could significantly increase the responsibilities of nurse practitioners.
Nurse practitioners and the demand for primary care
Primary care is an area where NPs could have an impact. These statistics illustrate the demand for primary care in the U.S.:
- In 2008, out of about 956 million visits to doctors' offices, 51.3 percent were to primary care physicians (Agency for Healthcare Research and Quality).
- Only 20 to 25 percent of internal medicine residents remain in primary care, down from over 50 percent in 1998 (Journal of the American Medical Association, 2012).
- In 2010, the approximate median annual compensation for primary care physicians was $200,000, vs. $300,000 to $400,000 for specialty care physicians (Medical Group Management Association).
- The median annual income for nurse practitioners in 2010 was $92,000 (American Academy of Nurse Practitioners).
- About 88 percent of nurse practitioners are prepared in primary care (American Association of Nurse Practitioners).
Physicians speak out on role of nurse practitioners
A survey in the New England Journal of Medicine shows the controversy surrounding the scope of practice for primary care NPs. A Bloomberg article describes how medical associations are lobbying against legislation to allow nurse practitioners to practice independently. The concerns these organizations raise include quality of care, refusal of some insurance companies to reimburse nurse practitioners and potential overprescribing of antibiotics. Physicians have also cautioned that patients who see nurse practitioners are less likely to seek preventive care in the future.
A Rand Corporation study of different types of medical facilities found lower-cost services at retail clinics, which are typically staffed by NPs, compared to similar care at physicians' offices, urgent care centers and emergency departments. The report suggests that the different facilities offered a comparable level of care, with a similar number of antibiotic prescriptions. In addition, the percentage of patients who sought preventive care after their first visit was similar in the various settings.
The U.S. government has also weighed in on the issue, according to The Century Foundation, with proposals for health reform legislation that could reward primary care providers, including nurse practitioners, and encourage training for advanced practice nurses.
Exploring possible solutions for primary care
- More people are expected to seek primary healthcare in the near future
- A shortage of physicians is likely, particularly in primary care
- Primary care physicians earn less than specialists, which discourages new entrants into primary care practice
- Nurse practitioners receive lower salaries and can offer less expensive primary care
The controversy about the role of advanced practice registered nurses may continue, as each side offers support for their point of view. Physicians often feel that they provide higher-quality examinations and consultations due to their extensive training. However, qualifications for advanced nursing practice are scheduled to become more rigorous, with requirements changing from a master's degree to a doctorate as of 2015.
Whether or not NPs gain a wider scope of practice, employment opportunities are expected for nursing professionals as the need for healthcare grows. The Bureau of Labor Statistics projects faster-than-average job growth for RNs between 2010 and 2020, with high demand for nurse practitioners and other types of advanced practice RNs (bls.gov, 2012).
American Academy of Nurse Practitioners, "2009-2010 AANP National NP Sample Survey: Income & Benefits," http://www.aanp.org/images/documents/research/2009-10_income_Compensation.pdf
American Association of Nurse Practitioners, "NP Fact Sheet," http://www.aanp.org/all-about-nps/np-fact-sheet
American Healthcare Research and Quality, "The Number of Practicing Primary Care Physicians in the United States," http://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html
Association of American Medical Colleges, "Fixing the Doctor Shortage," https://www.aamc.org/advocacy/campaigns_and_coalitions/fixdocshortage/
Bloomberg, "Nurses Spar With Doctors as 30 Million Seek Care," Shannon Pettypiece, March 3, 2013, http://www.bloomberg.com/news/2013-03-04/nurses-spar-with-doctors-as-30-million-insured-seek-care.html
American Association of Colleges of Nursing, "FAQ," http://www.aacn.nche.edu/dnp/faqs
Medical Group Management Association, "Highlights of MGMA's 2011 Physician Compensation Survey," http://www.mgma.com/blog/Highlights-of-MGMAs-2011-Physician-Compensation-survey/
New England Journal of Medicine, "Perspectives of Physicians and Nurse Practitioners on Primary Care Practice," K. Donelan et al., http://www.nejm.org/doi/full/10.1056/NEJMsa1212938
Rand Corporation, "Health Care on Aisle 7: the Growing Phenomenon of Retail Clinics," http://www.rand.org/pubs/research_briefs/RB9491-1/index1.html
Rand Corporation, "Retail Clinics Play Growing Role in Health Care Marketplace," http://www.rand.org/health/feature/retail-clinics.html
Registered Nurses, Bureau of Labor Statistics, Occupational Outlook Handbook, 2012, http://www.bls.gov/ooh/Healthcare/Registered-nurses.htm#tab-6
Taking Note, A Century Foundation Group Blog, "The Battle Over Letting Nurse Practitioners Provide Primary Care," http://takingnote.tcf.org/2010/04/the-battle-over-letting-nurse-practitioners-provide-primary-care-.html
The JAMA Network, "General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents," 2012, http://jama.jamanetwork.com/Mobile/article.aspx?articleid=1475191
The White House, "The Affordable Care Act: Secure Health Coverage for the Middle Class," June 28, 2012, http://www.whitehouse.gov/the-press-office/2012/06/28/fact-sheet-affordable-care-act-secure-health-coverage-middle-class
Wharton School: University of Pennsylvania, "Nurse Practitioners are In - and Why You May Be Seeing More of Them," February 13, 2013, http://knowledge.wharton.upenn.edu/article.cfm?articleid=3183