With the above-the-fold Dec. 26 editorial entitled “Health care reform should draw doctors toward primary care”, the Austin American-Statesman joined the national chorus of plaintive calls for more physicians to practice primary care, as this nation faces an acute shortage of primary care providers in both the public and private sectors. Despite millions of federal incentive dollars, 1992 saw an all-time low of medical students pursuing general medicine, only 14.6 percent, and many of these will have subspecialized five years into practice. Yes, we do need more physicians in primary care. But if the goal of universal coverage is realized with health care reform, many more qualified providers of primary care will be needed to care for the 37 million Americans who are now uninsured.
Conspicuously absent from the Statesman editorial was a call for more advanced practice nurses (APNs) to fill the void. In the 1960s physicians began opting out of general practice for the more lucrative specialty practices, and since that time APNs have answered the call to serve economically disadvantaged and medically underserved populations in rural and inner city areas. Obviously someone must do this work. APNs number about 100,000, and their preparation, which extends about two years beyond that of a registered nurse, emphasizes prevention. Nurse practitioners (NPs) have a 25-year track record of providing high-quality, cost-effective primary care services, such as physical exams, screenings, immunizations, well- and ill-baby care, and treatment of acute and chronic illnesses.
The antiquated regulations constraining nurses’ practice date back to the 1930s when nurses, who were mainly women, were seen as assistants to physicians, who were mostly men. In many states, NPs must be supervised by physicians, even if physician services are not needed; NPs may not be allowed to prescribe even simple medications; NPs may not have financial autonomy, so that physicians bill Medicare and insurance companies and then compensate NPs at their discretion.
Clinton’s proposed Health Security Act, as well as other health care reform bills, both Democratic and Republican, call for the removal of barriers which currently exist at state and federal levels to better enable advanced practice nurses to provide many primary health care services. APNs have significant autonomy in many states such as New York, Arizona, Oregon, and Alaska.
The American Medical Association (AMA), which does not represent all physicians, takes a very dim view of this prospect. The AMA attacks the credibility of nurse practitioners by insisting that nurses are not qualified to practice medicine without the direct supervision of doctors. In light of their glaring inability to produce enough providers to meet the needs of all citizens in all geographic areas, one must question why this group of physicians would oppose nurses filling the void. Could it be control? More specifically, control over healthcare dollars?
Nurse practitioners have been subjected to hundreds of effectiveness studies for more than 20 years, and virtually all of these studies have demonstrated that the quality of care rendered by APNs is at least equivalent to that provided by physicians for comparable services. The 1986 study undertaken by the Office of Technology Assessment is the most comprehensive study to date of APNs. This study found that with relation to patient satisfaction, APN care was superior to that of physicians, especially with regard to shared control, quantity and quality of information given, reduction of professional mystique, and costs of care. The study also noted that successful malpractice cases against NPs are extremely rare.
In this millennial age, may the new year bring policy-makers the courage and wisdom to act in the consumer interest and cease the perpetuation of the formal provider hierarchy created by the medical profession. May health care reform result in the full utilization of nurse practitioners to better this nation’s health by preserving quality and improving access while reducing costs.
Austin, Texas