It has an all-star cast. Winkler County nurses Anne Mitchell and Vickilyn Galle; town doctor Rolando G. Arafiles Jr.; hospital administrator Stan Wiley; former Winkler County Sheriff Robert L. Roberts; Winkler County Attorney Scott M. Tidwell; Attorney General Greg Abbott; state Sen. Jane Nelson, R-Flower Mound; and state Rep. Donna Howard, D-Austin.

Anne Mitchell, foreground, and Vickilyn Galle

A good setting: A dusty, isolated West Texas town, Kermit in Winkler County. Thick good-ol’-boy culture. Squat courthouse. Twenty-five bed community hospital.

Plot: It’s 2007, and the small town is desperate for a doctor. Arafiles rides into town. He’s an affable guy hired despite the red flag of a stipulation on his Texas medical license. The town sheriff quickly befriends the doctor, and they become golfing buddies.

According to published reports, the doctor’s colleagues become increasingly uncomfortable with his standards of practice. The doctor sells a dubious nutrition supplement called Zrii to his patients as a sideline, following up with emails. They question his examining and billing for genitalia exams of people coming to the ER with maladies such as sore throats and headaches.

By 2009, the doctor’s fellow practitioners have had enough. They report him to the Texas Medical Board. Two who anonymously report him were the no-nonsense hospital quality assurance nurses, Mitchell and Galle, who between them had 46 years of experience at the hospital and immense respect.

When notified of the report, the doctor becomes outraged and enlists his buddy the sheriff to find out who made the report. The sheriff obtains confidential information from the medical board through fraudulent means, and the reports are traced down to the two nurses. The hospital administrator, Wiley, instantly fires the nurses.

The story gets really weird here. What transpired next is something that has not happened in any state. In a stunning display of prosecutorial might, the nurses are indicted on felony charges of misuse of official information. If convicted, they face a maximum of 10 years in prison and/or a $10,000 fine. The case makes national headlines.

The two nurses and their families wait nearly a year for their trial. They have lost their jobs and incomes. Galle retires early. Mitchell, who is 15 years shy of retirement age, finds another county job, but not as a nurse. She takes a $35,000 annual pay cut, just as her son enters college.

The criminal charges against Galle are dropped, but Mitchell endures a four-day trail before the jury acquits her after less than an hour of deliberations. Once again, the case makes national headlines.

After Mitchell’s acquittal, Abbott opens an investigation into the case. In January, the doctor, sheriff, county attorney and hospital administrator are indicted on charge of retaliation against the nurses.

Roberts, the former sheriff, and Tidwell, the county attorney, each face six counts — two counts each of misuse of official information and retaliation (third-degree felonies) and official oppression (class A misdemeanor).

Wiley, the hospital administrator who hired Arafiles and fired the nurses, is indicted on two charges of retaliation. In March, he pleads guilty to abuse of official capacity for his role in the firing of the two nurses and promises to cooperate with the prosecution.

Last week, after a seven-day criminal trial and less than two hours deliberation, a Midland County jury convicted Roberts on all charges. He was sentenced — and unable to appeal — to four years of felony probation, $6,000 in fines and 100 days behind the bars of the same jail he ran for 20 years. He will be removed from office and must surrender his peace officer’s license. He will also retire from the county — with full benefits. Wiley testified during Roberts’ trial.

Two defendants await trial: Tidwell and the doctor. Arafiles continues his $200,000 job at the hospital even after the indictments. His contract is not renewed, and he now practices in Grand Saline. If convicted of a felony, he will lose his medical license.

Despite the legal vindication, the nurses have lost their careers, half of their incomes and their quality of life. Why? For doing the right thing to protect patients.

The case prompted legislative action to protect nurses from criminal prosecution for patient advocacy. Howard and Nelson co-sponsored successful legislation to keep this nightmare from happening again. The governor should sign this bill.

Oh, if only this were all a movie script and not real life.

As a 30-year neonatal intensive care unit nurse, I know that America funds and delivers the finest high-technology care in the world.

But when I admit so many babies of working parents with no insurance and work way too hard to find primary care providers for the babies we send home, I know our country has a terrible problem. It’s a senseless paradox to have easy access to the most complex care yet at the same time have such difficulty accessing preventative care and treatment for acute (fevers, sore throats and the like) and chronic illnesses.

As President Barack Obama said Wednesday night in an address to a joint session of Congress, “Our health care problem is our deficit problem.” Reform should ensure that all Americans have coverage as well as easy access to primary care.

How much healthier would we be and how much more efficiently would we spend health care dollars if everyone could get the care they need when they need it? A recent study reported in the American Journal of Medicine found that in an average-size metropolitan area, each 1 percent increase in the number of primary care physicians led to a decrease of 503 hospital visits, 2,968 emergency room visits and 512 surgeries.

An acute shortage of primary care providers is one of this country’s deep-seated problems. In the 1960s, physicians began opting out of general practice for the more lucrative specialties because of lopsided physician reimbursement.

Counterintuitively, primary care — arguably the most complex specialty — is one of the most poorly reimbursed. As a result, only 2 percent of current medical students — who may well begin practice with $140,000 in loans — plan to take up primary care. That’s down from 14.6 percent in 1992.

Obama’s reform plan more fairly reimburses primary care providers. This country must stop looking solely to physicians to meet primary care needs.

A more sensible, rational way to deliver primary care is through large collaborative practices staffed with physicians, nurse practitioners and physician assistants who are salaried. Nurse practitioners and physician assistants begin careers with far less debt than physicians and are eminently qualified and prepared to offer primary care. They do not hesitate to refer to physician specialists as necessary.

Albeit not primary care, the collaboration of salaried neonatologists, neonatal nurse practitioners and pediatricians and electronic health records functions beautifully where I work in neonatal intensive care. That’s the way Pediatrix, a large, national physician management group, operates.

The Cleveland Clinic that the president visited in July has salaried physicians with no bonuses and annual contracts. These collaborative practices provide high-quality and cost-effective care and should be replicated nationally for primary care in a reformed system.

To meet primary care needs, all qualified providers must be able to practice unencumbered and unfettered. 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. Such contraints include limits on scope of practice, direct reimbursement and prescriptive authority.

Many states have made significant progress in removing barriers, but we are not where we need to be to meet the country’s needs. Individual states must continue to legislatively remove barriers to advanced nurse practice.

Other evolved democracies have realized national imperatives to ensure their citizens have coverage and access to primary care. These countries have empty emergency rooms, save for trauma, heart attacks, strokes and people needing those rare procedures not available elsewhere.

Obama said Wednesday that it is our calling, our character to meet big challenges, that “we did not come here just to clean up crises. We came to build a future.”

This article describes current and projected numbers of nurses in the workforce, the demand for registered nurses, the effect nursing shortages have on patient care, and anticipated employment opportunities for RNs in 2004.

NURSING THE NUMBERS

Every four years since the mid 1970s, the Bureau of Health Professions of the U.S. Department of Health and Human Services has provided the most extensive and comprehensive statistics available on registered nurses currently licensed to practice in the United States. The following data are from the most recent survey, conducted in 2000, available online at http://www.bhpr.hrsa.gov/nursing/sampsurvpre.htm.[ii]

How many are we? According to the survey, the estimated number of licensed RNs in the United States is 2,696,540. Although this figure represents a 5.4% increase from 1996, it is the lowest increase reported since the beginning of the quadrennial surveys. (Between 1992 and 1996, the total number of RNs increased by about 14.2%.) Of the total number of licensed RNs, 58.5% work full time, compared with 52.0% in 1980; 23.2% work part time, down from 24.6% in 1980; and 18.3% are not employed as RNs, down from 23.4% in 1980. The total number of RNs employed in nursing is 2,201,813.

How old are we? As a workforce, we are aging. The average age of an RN is 45.2; the average age in 1996 was 44.5 years. In 1980, 52.9% of RNs were under 40. According to the 2000 data, 31.7% are under 40. A recent exhaustive study by Buerhaus and colleagues in the Journal of the American Medical Association predicted that the total number of equivalent RNs per capita working full time would peak around the year 2007 and decline steadily thereafter as the largest cohorts of RNs retire.[iii] By 2020, according to the study, the RN workforce will be roughly the same size as it is now, which will be 20% below projected demand. The study found that the main reason for the older workforce is a decline in the number of young women choosing nursing as a career since 1980.

How have we been prepared? During the past 20 years, entry-level nursing education has shifted away from diploma to associate-degree or bachelor’s degree programs. In 1980, 63% of licensed RNs had received their basic nursing education through diploma programs, compared with 29.6% now. In 1980, 19% of nurses graduated from associate-degree programs, compared with 40.3% now; 17.3% had baccalaureate degrees in 1980, compared with 29.3% now. The net effect of these changes is that nurses are spending less time on their entry-level education. Even though the number of bachelor’s and master’s programs is increasing, a far greater increase is seen in the number of nurses in associate-degree programs than in the number of nurses in hospital programs. Associate-degree programs are two years long; hospital programs are three.

The number of two-year community colleges with RN programs exploded in the 1960s and has steadily increased since then. At the same time, three-year hospital diploma programs have been closing. Not only was the demand greater for the two-year programs, but hospitals were forced through harsh economic forces — brought about by the managed care system — to close unprofitable programs.

One result of these shifting trends in basic nursing education is that, according to Donley and Flaherty, practicing nurses are undereducated when compared with other members of the health care team. This is a real problem, as they view it, because “undereducated members of the health care team rarely sit at policy tables or are invited to participate as members of governing boards. Consequently, there is little opportunity for the majority of practicing nurses to engage in clinical or health care policy.”[iv]

On the bright side, more nurses than ever are pursuing postgraduate education. In 1980, 5% of the 1,662,382 RNs had a master’s or doctoral degree. According to the last survey, 10.2% of nearly 2.7 million RNs have such degrees. These statistics also reflect the dramatic increase in the number of master’s degree programs in nursing available to people who have bachelor’s degrees in areas other than nursing. The influx of baccalaureate-prepared people from other fields into nursing increases our diversity and broadens our perspective.

Where do we work? Of today’s employed RNs, 59.1% work in hospitals, 18.3% in public and community health (including occupational and school health settings), 9.5% in ambulatory care, 6.9% in nursing homes and extended care facilities, 2.1% in nursing education, and 3.6% in other settings (such as prisons, jails, and insurance companies). The settings that saw the largest increase in number of RNs were the public and community health sectors, including state health departments, community health centers, and visiting nursing services.

How much do we make? The Bureau of Health Professions survey measures average RN earnings through two indices: the actual average earnings of RNs employed full time and the “real” average earnings of those RNs, based on the consumer price index for 1982 to 1984. The actual average annual salary of a full-time RN is at an all-time high of $46,782—it was $17,398 in 1980.[v] However, real compensation amounts to only $23,369 when changes in the purchasing power of the dollar are taken into account through the consumer price index. Real salaries have been about the same since 1992.

How many of us work in advanced practice? The number of nurses prepared to be nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists rose to 196,279 by 2000, or 7.3% of RNs—up from 6.3% in 1996. Of nurses working in advanced practice, most are nurse practitioners; the next largest group is clinical nurse specialists. These two together, including people who are trained to do both jobs, make up approximately 80% of all APNs. Nurse midwives account for 4.7% of APNs (up from 1996), and nurse anesthetists comprise 15.2% (up from 1996).

NURSING THE DEMAND

Today there are more than 126,000 unfilled nursing positions—around 7% below the workforce requirement.¹ The nursing shortage is expected to continue at this rate so that the number of nurses is 12% below what’s needed by the year 2010, 20% below by 2015, and a staggering 29% below the workforce need in 2020.³

Advances in medical technology and pharmaceuticals as well as healthy lifestyle choices have resulted in “the graying of America” as life expectancy increases and quality of life improves. The current number of unfilled nursing positions pales when compared with the number of nurses needed when 78 million baby boomers begin placing unprecedented demands on the system when they hit 65 in a few years.

WHY THE SHORTAGE?

Why, if there’s job security and decent pay, is there such a profound shortage of nurses? The reasons are numerous and complex. A 20-year buildup of conditions created the “perfect storm”—our current protracted, calamitous nursing shortage. The economic pressures that started with the introduction of the managed care system in the 1980s and continued with hospital mergers in the 1990s necessitated a rethinking of how care was delivered.

This transformed healthcare system transferred much of inpatient care to the outpatient setting and to the home. This shift is reflected in the dramatic decrease in hospital average lengths of stay in the last two decades. In 1980, the average length of stay was 7.3 days.[vi] In 2000, the average length had fallen to 4.9 days.[vii] What this means for the nearly 60% of RNs who work in hospitals is that today’s patients are sicker than in the past, requiring more intense nursing care.

Another factor that has influenced today’s shortage was a 1995 report by a blue-ribbon commission funded by the Pew Charitable Trusts. The report warned that hospital mergers would close the doors of almost 50% of our nation’s hospitals by 2000, which would mean a loss of 60% of hospital beds and a surplus of 200,000 to 300,000 nurses.[viii] The Pew prediction was wrong, and far fewer hospitals closed than anticipated, but the report left its mark on history by discouraging young people from entering the nursing field.

The reshaping of health care by market forces has meant fewer hospital resources for nursing. Dealing with intense assignments and extra shifts (including mandatory overtime), nurses are overworked and have become stressed, burned out, and left with little job satisfaction; all these contribute to the nursing shortage. Furthermore, as nurses get older and retire, more people are leaving than entering the profession, even with increased enrollments in schools of nursing. Women account for 95% of nurses, and young women are not choosing to become nurses as frequently as they once did. This is leading to a further reduction in the number of nurses. But at the same time that nursing enrollment is down, the number of women entering medicine is up. Medical schools now boast a 50:50 female to male enrollment ratio (see www.aamc.org/data/facts/famg52002a.htm for information.) We don’t have the capacity to educate as many nurses as we used to, as evidenced by a far higher number of applicants than enrollees.

Gail Collins wrote about the shortage in a 2001 New York Times article: “[Nurses are] unhappy, and they’re spreading the word. . . . Management has a right to be efficient and demand results, as long as everybody remembers that the nurses of the future have a right to sign up for dentistry or accounting.”[ix]

NURSING THE EFFECTS

According to a white paper by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nursing shortage is “a prescription for danger.”¹ The JCAHO report shows that the shortage contributed to a staggering 24% of the unanticipated problems in hospitals that result in patient death or injury, citing insufficient numbers of nurses as a reason for those cases. The JCAHO used its “sentinel event” reporting system (a computer database that includes 1,609 reports of patient deaths and injuries between 1996 and the report date), as well as detailed explanations from hospitals to generate these results.¹

The paucity of nurses affects more than patient injuries and deaths. It contributes to some of the thorniest problems in health care today. It’s a major factor in ED overcrowding and “diversions,” cancellation of elective surgeries, discontinuation of clinical services, and limitations in the health care system’s ability to respond to mass casualties. Ninety percent of nursing homes report that they do not have enough nurses to provide even the most basic level of care, and some home health agencies are being forced to refuse new admissions.¹

WHO CAN FIX THE SHORTAGE?

Reversing the nursing shortage will not be simple, but the shortage is fixable, and it’s up to us. It will take a community—nurse executives, hospital leadership, policymakers, schools of nursing, physicians, accreditors, private industry, and nurses ourselves. The cited 20002 JCAHO report also called for reforms to the nursing education system and for the federal government to tie Medicaid and Medicare payments to a hospital’s improvement in nursing care and nurses’ work environments.

The nursing profession. Perhaps the greatest hope for alleviating the nursing shortage is the Magnet Recognition Program, the brainchild of the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association. Magnet hospitals are desirable settings for RNs and better patient outcomes than do other hospitals; this gives them an edge in recruiting and retaining nurses in a tough market.

The Magnet program came about in response to the severe nursing shortage of the early 1980s. The American Academy of Nursing, the ANA, and a group of nurse executives were looking to combat that shortage and decided to conduct a national study to identify those hospitals that attracted and retained nurses. That study led to 41 hospitals receiving the designation “Magnet hospital.”[x] There  are now two groups of Magnet hospitals — one from the early 1980s, the other certified since the early 1990s.

In the early 1990s the ANA, through the ANCC, formalized the (Magnet) program to acknowledge excellence in nursing. It’s a form of external peer review available to all hospitals and healthcare organizations. The Magnet designation is awarded according to 14 standards of nursing: high-quality care, strong nursing leadership (including a nursing staff that makes decisions about clinical care and its own practice), dynamic performance improvement, large number of APNs, heavy involvement on the part of nurses with the community, and high degree of interdisciplinary collaboration. Organizations are evaluated in a process that consists of several stages, including documentation of attainment of the 14 standards and on-site review. Currently 85 organizations in the United States and Britain have been awarded this nursing seal of approval. Magnet status is elite: Fewer than 2% of hospitals have achieved this rigorously determined certification.[xi] Magnet recertification is required every four years. Studies by Linda H. Aiken, PhD, RN, FRCN, FAAN, and others have demonstrated the value of the Magnet program in terms of fostering both positive patient outcomes and satisfactory work environments for nurses.^{10, [xii]}

Policymakers. The nursing shortage has certainly gotten the attention of the U.S. media. Policymakers at the state and national levels have watched the news, read their newspapers, listened to their constituents, and begun to pass legislation to alleviate the shortage.

In mid 2002 Congress passed, and President Bush signed, the Nurse Reinvestment Act. This law modified funding for existing nursing programs—including ones for advanced practice nursing, basic nursing (nurse education, practice, and retention), nursing workforce diversity, and loan repayment and scholarship—and created geriatric care training and faculty loan programs. For fiscal year 2003, Congress appropriated a total of $113 million for all nursing programs—an overall increase of $20 million over levels from fiscal year 2002 but still less than the recommended $250 million.{Public Law No. 108-007. Omnibus appropriations bill for FY03, passed February 20, 2003.}

Most states have begun to address the shortage through legislation and funding to expand nursing. Some states have passed laws to improve the workplace. Texas, for example, addressed nurse staffing ratios administratively: The Texas Hospital Association and the Texas Nurses Association worked with the state’s department of health, which has rule-making authority, to change nurse staffing plans in March 2002. Texas hospitals are now also required to form advisory committees with mandated input from front-line nurses. The implementation of California’s safe-staffing law, signed in October 1999, proved difficult; all hospitals in California must comply by January 1, 2004. In 2003, states’ hands were tied when all but a handful of states experienced huge budget shortfalls.

Private industry. It’s in the best interest of private industry for our nation to have a full and sustainable nursing workforce. One example of private industry aggressively addressing the shortage is Johnson & Johnson’s 2002 advertising campaign, featuring the “dare to care” television spots which portrayed nurses very positively and appealingly. In February 2002, the company launched a two-year, $20 million campaign to attract more people to the nursing profession. The campaign includes scholarships for undergraduate nursing students and nurse educators; television ads celebrating nurses and their contributions; national fundraising events to honor excellence in nursing (and to support the student and faculty scholarships); and recruitment brochures, posters, and videos for distribution in 20,000 high schools, 1,500 nursing schools, and nursing organizations. In addition, the company launched a Web site, www.discovernursing.com, that offers information on careers in nursing, profiles of 105 nurses across the nation in different jobs, a database of nursing schools, and more than 300 nursing scholarship programs.

Nurses ourselves. It used to be said that nurses “eat their young,” holding recent graduates to very high standards, sometimes resulting in their departure from the profession. Today, established nurses embrace new nurses and traveling nurses. Nurses everywhere feel the strain of the shortage every day, and they’re happy to get what help they can; they show their appreciation.

When I see new graduates I thank them for going into nursing. When I see promising young people, I ask them if they’re happy with their jobs, and if not, I ask them to think about becoming nurses. Nurses ourselves are surely our profession’s best recruiters.

One of the most basic ways individual nurses can contribute is by joining the ANA, state and national professional nursing organizations, as well as specialty organizations. Organized nursing plays a critical role in informing the public and policymakers about the needs of the profession. The people in these organizations are the voice of nursing in the halls of state houses and in Congress (sometimes with the help of the media). Nurses must prompt elected officials when nursing bills come up for vote.

NURSING THE OPPORTUNITIES

Both the complexity of health care and the shortage have brought about unprecedented opportunities for nurses. The following are only a few areas of nursing that are innovative and promising.

Staff nursing. The need for hospital staff nurses has continued to rise, and the good news in nursing is that nurses can continue to work at the bedside while finding fulfillment. With the move toward Magnet nursing, the bar has been raised for staff-nurse contributions in hospitals. Staff nurses have opportunities that did not exist before.

I am a staff nurse at a Magnet hospital. Staff nurses are encouraged to participate meaningfully in making decisions that affect patient care and the work environment. I participate in a refined shared governance structure and culture consisting of a strong chief nursing officer, a nursing executive council, a nursing congress, and eight specialty councils (acute and postacute care, ambulatory care, behavioral health, critical care, emergency care, pediatrics, perinatal, and surgery). This hospital, like other Magnet hospitals, has a high degree of interdisciplinary collaboration, which I find very rewarding. We have a clinical ladder program that rewards nurses for participating in shared governance and for promoting health on a volunteer basis in the community.

Teaching. There is also a shortage of nurse faculty members.{Hinshaw AS. A continuing challenge: the shortage of educationally prepared nursing faculty. Online Journal of Issues in Nursing. January 31, 2001. http://www.nursingworld.org/ojin/topic14/tpc14_3.htm.} New money from government to increase the supply of nurses will have little effect if there aren’t enough teachers. Furthermore, the faculty shortage is a major factor limiting enrollment in schools of nursing.

The average age of a nursing teacher is 50.2, and with the retirement of this “graying professoriate,” the shortage is expected to escalate.{Hinshaw 2001 (above).} (This phenomenon is unique to nursing because nurses are encouraged to gain clinical experience before earning higher degrees and teaching.) A nurse with five years’ solid experience can teach. With opportunities to guide future nurses as well as chances to do important research, teaching can be very rewarding. Nurses wanting to teach may do well to consider pursuing that goal earlier in their careers than the last generation did.

Genetics nursing. The remarkable work of the U.S. Human Genome Project is a catalyst for growth in the number of opportunities available to nurses. Coordinated by the Department of Energy and the National Institutes of Health, the project, which began in 1990, has mapped the human genome—the collection of about 35,000 genes and the sequences of the 3 billion base pairs that make up human DNA.{Human Genome Project Information found at http://www.ornl.gov/TechResources/Human_Genome/home.html} The implications for health care are profound. Most health conditions are believed to result from a combination of genetics and environmental influences; the new knowledge will improve the prediction, diagnosis, and treatment of many illnesses.

Physicians, nurses, and other health care workers, regardless of specialty, will need to integrate new information on genetics into routine practice, especially when explaining responsiveness to treatment and options for care.{Jenkins JF. An historical perspective on genetic care. Online Journal of Issues in Nursing. Sept. 30, 2002. http://nursingworld.org/ojin/topic13/tpc13_2.htm.} In response, medicine has developed a specialty, offering services, resources, and education in genetics. For example, where I work in the NICU, when a neonatologist suspects a patient has a particular syndrome but is unsure of which one, another medical specialist—a geneticist—is called in to help identify the syndrome. The geneticist identifies the syndrome, gives a prognosis and the probability that the syndrome will occur in other children of the same parents. Staff nurses assist in reducing complex information into practical, understandable terms for families.

As part of genetics teams, nurses provide care in regional genetics networks, private office settings, and specialty genetics clinics, offering assessment, education, counseling, testing, and interpreting of test results. The International Society for Nurses in Genetics (ISONG) (www.globalreferrals.com) is recognized as the main organization in offering annual conferences, developing nursing standards of practice, and promoting communication and research on genetics.

Nurses with a master’s in nursing may qualify for the credential of APN in genetics. Those with a bachelor’s may qualify for the genetics-nurse credential. The Genetic Nursing Credentialing Commission (www.geneticnurse.org), a subsidiary of ISONG, recognizes clinical nursing practice with a genetics component by granting credentials based on a portfolio of evidence indicating professional experience.

Advanced practice nursing. This collective term refers to four specialties: nurse practitioner, clinical nurse specialist, certified nurse midwife, and certified registered nurse anesthetist. The number of APNs has increased with a rise in opportunities for employment: In 2000, there were nearly 200,000 APNs, or 7.3% of the total RN population, up from 6.3 in 1996.{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).}

APNs are trained by nurses, credentialed by nurses, regulated by nurses, and most have their own medical malpractice insurance. These highly qualified providers are legally allowed to practice in all 50 states. Certain requirements, such as that they be supervised by physicians, vary from state to state and are specified through the states’ nursing practice acts and medical practice acts, the rules of their nursing and medical boards, and hospital licensing laws. {Inglis T. Nurse anesthetists: one step forward, one step back: physician supervision requirements for CRNAs jeopardize access to care. AJN 2003;103 (1):91-4.}

I’ve worked in the same NICU for the past 24 years. In the 1990s, our medical coverage evolved from 100% neonatologists to around 50% neonatologists and 50% neonatal nurse practitioners (NNPs), all employed by a national physician management group. Most of the NNPs here are former NICU staff nurses who completed advanced NNP training and stayed at our hospital. Their work involves nursing and medicine: They write orders (cosigned by a neonatologist) and expertly perform most of the procedures neonatologists perform, such as intubation, insertion of arterial lines, and lumbar punctures. The NNPs have improved the scope of medical care because of their holistic approach to practice and by providing relief to overworked physicians burdened by a neonatologist shortage.

In the hospital where I work, APNs work in other positions. Certified registered nurse anesthetists work alongside anesthesiologists to deliver anesthesia care. Certified nurse midwives deliver infants in a highly sought-after method of childbirth. Nurse practitioners and clinical nurse specialists make up roughly 80% of APNs,{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).} and their subspecialties are as varied and numerous as nurses’ interests: community health, gerontology, family practice, medical–surgical, neonatology, pediatrics, perinatal care, psychiatry and mental health, and women’s health, to name just a few.

Infusion nursing. Happily for patients and nurses, medicine is no longer dependent on peripherally inserted short-term catheters for venous access. Implanted, tunneled, and peripherally inserted central catheters (PICCs) are used for long-term venous access, ideal for patients receiving chemotherapy with irritant or vesicant drugs, long-term antibiotic therapy, and total parenteral nutrition. The insertion procedure, which is a sterile technique, with placement confirmed by X-ray, requires a medical order.

Where I work in the NICU, nurse clinicians take an eight-hour class from nurses hired by the makers of the neonatal PICCs. After three successful supervised insertions, participants are deemed by our institution competent to insert them. For the rest of the adult and children patient population in our hospital network, a cadre of “venous-access” nurses are on call to insert them. National certification as an infusion nurse is available through the Infusion Nurses Society (see www.ins1.org for information).

End-of-life nursing. The aging population has increased the demand for gerontology nurses. At the same time, a national movement toward dignifying the death experience has been taking place, giving renewed life to hospice and palliative care.

In the 1990s, numerous studies revealed disturbing data about people dying in U.S. hospitals being subjected to unwanted extraordinary measures. Family members were not happy with how patients were treated at the end of their lives. Then, in 2000, Bill Moyers’s public-television series, On Our Own Terms: Moyers on Dying, opened a dialogue about death and dying. (The show was partially funded by the Robert Wood Johnson Foundation, which exerted more cultural influence on health care by providing grants for programs that improved end-of-life care. )

Nurses comprise and manage end-of-life, palliative, and hospice care teams in many settings—at patients’ houses and in hospitals, and elsewhere in the community. Staff nurses whose patients are dying (in NICUs, EDs, ICUs, and long-term care facilities, for example) are finding more enlightened collaboration possible with physicians and other healthcare workers.

Public health nursing. The largest increase in RN employment from 1996 to 2000 was in the public and community health settings (state health departments, for example).{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).} Because of the events of September 11, 2001, it is likely that more RNs will be employed in this setting. The Centers for Disease Control and Prevention is working with universities, the Department of Homeland Security, and state and local health departments to prepare for and respond to acts of terrorism. Last year, nurses were asked to voluntarily immunize themselves against smallpox — a vaccination not without potentially lethal side effects.

ALWAYS IN DEMAND

The areas discussed here represent only a tiny fraction of the boundless opportunities available to nurses. One thing is clear: Nurses can now choose alternatives, and because of the changes brought about by the Magnet program, they can work in settings where they are valued and can positively affect patient care and their own work environments.

The high demand has increased the number of choices for nurses. Travel nursing is in full bloom to fill seasonal needs at hospitals and elsewhere, and this kind of work is a wonderful opportunity for young nurses looking for the right community. As nurse consultants, meanwhile, nurses can work in offices, home care, health care licensing and regulating agencies, schools, legal practices, jails, and insurance and pharmaceutical companies—the list is long.

Qualified nurses are always in demand, as “the primary source of care and support for patients at the most vulnerable points in their lives,” as the JCAHO recently stated.{from JCAHO report August 7, 2002.} “Nearly every person’s health care experience involves a registered nurse. Birth and death, and all the various forms of care in between, are attended by the knowledge, support, and comfort of nurses.”

[ii][ii] Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000. Rockville, MD: U.S. Department of Health and Human Services; 2002. http://www.bhpr.hrsa.gov/nursing/sampsurvpre.htm.

[iii] Buerhaus PI, Staiger DO, and Auerbach DI. Implications of an aging registered nurse workforce. JAMA 2000;283(22):2948-54.

[iv] Donley R, Flaherty MJ. Revisiting the American Nurses Association’s first position on education for nurses. Online Journal of Issues in Nursing. May 31, 2002. 7:2, manuscript 1. http://www.nursingworld.org/ojin/topic18/tpc18_1.htm.

[v] http://www.bhpr.hrsa.gov/nursing/images/avgsalary.jpg.

[vi] National Center for Health Statistics, Vital and Health Statistics, series 13, as cited by the Statistical Abstract of the United States, 1997, published by the U.S. Department of Commerce.

[vii] National Center for Health Statistics, Fast Stats AtoZ, Hospital Utilization, Advance Data from Vital and Health Statistics, No. 329, June 19, 2002. http://www.cdc.gov/nchs/fastats/hospital.htm.

[viii] Pew Health Professions Commission. Critical challenges: revitalizing the health professions for the 21st century. December 1995. http://www.futurehealth.ucsf.edu/summaries/challenges.html.}

[ix] Collins G. Nursing a shortage. New York Times, August 13, 2001.

[x] Aiken LH, Havens DS, and Sloane DM. The magnet nursing services recognition program: a comparison of two groups of magnet hospitals. AJN 2000;100(3):26-35.

[xi] American Nurses Credentialing Center, Magnet Recognition. http://www.nursingworld.org/ancc/magnet/magnet2.htm.

[xii] Aiken, Havens, and Sloane. 2000 (above). and Aiken LH. Superior outcomes for magnet hospitals: the evidence base. In: McClure ML and Hinshaw AS (eds.), Magnet hospitals revisited: attraction and retention of professional nurses. Washington, DC: American Nurses Publishing, 2002: p. 61-81.

On January 18, 2001, as one of the numerous “midnight” regulations of the Clinton administration, the federal requirement for hospital physician supervision of nurse anesthetists was dropped. But on November 13, 2001, just before the January ruling was to go into effect, it was reversed by the Bush administration.

The November ruling requires physician supervision of CRNAs in hospitals receiving Medicare reimbursement. The ruling compromises by permitting state governors to request a waiver to opt out of the requirement, if deemed in the best interest of the state’s residents. The governor may do so only after consulting the state’s boards of nursing and medicine, and after determining if opting out is consistent with state law. To date, six states have opted out of the requirement — in order, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, and New Mexico.

Although nurse anesthetists are legally allowed to provide anesthesia in all 50 states, some states require that they do so with supervision. However, 31 states don’t require physician supervision of CRNAs. This is specified though the states’ nursing and medical practice acts, the rules of their nursing and medical boards, and their hospital licensing laws: all three must be in accordance in order to secure exemption from the new ruling.

How the Rulings Effect Practice

“In my judgment, the supervision rulings do not affect practice or the quality of anesthesia care,” said Sandi Peters, CRNA, former president of the Texas Association of Nurse Anesthetists. “I practice in three rural hospitals. In one practice site Im employed as a staff anesthetist; in the other two I independently contract. The physician who supervises me is usually a surgeon who likely has hd no advanced anesthesia training. Physician supervised or not, my practice is the same at all three hospitals.”

“Physician supervision of nurse anesthetists has absolutely nothing to do with practice or patient safety,” says Ira Gunn, MLN, CRNA, FAAN, who for nearly 50 years has practiced anesthesia and worked extensively with state legislatures, the Congress and administrative bodies regulating the nurse anesthesia profession. The 30,000-member American Association of Nurse Anesthetists (AANA) established a professional advocacy award in her name. “It has to do with politics, turf, control and income. It’s a holdover from the days of the ‘captain-of-the-ship’ legal doctrine, which became obsolete long ago in most jurisdictions.”

Gunn clarified a common misperception about who exactly “supervises” CRNAs. “People assume that physician supervision rulings are about anesthesiologists supervising nurse anesthetists. That isn’t true. Physician supervision rulings refer to any physician, including those without advanced anesthesia training. In practice it’s likely a surgeon,” said Gunn. “The American Society of Anesthesiologists (ASA) successfully campaigned to convince surgeons that they were liable for CRNAs. Nothing could be further from the truth. CRNAs carry their own medical malpractice insurance. Nurse anesthetists are trained by nurses, credentialed by nurses, and regulated by nurses. The profession is independent of medicine.”

Peters agrees. “ASA’s misleading information made surgeons feel that they would be liable for any mishap if they didn’t supervise CRNAs. The surgeons I work with haven’t had advanced anesthesia training, and many tell me they don’t feel qualified or comfortable supervising my anesthesia care.”

“In another twist on the subject, HCFA (the federal Health Care Financing Administration) never defined ‘supervision,’” Peters continues. “In practice, it could mean anything from a physician being somewhere in the building to one looking over the old ether screen and asking the CRNA if everything’s okay. So, there’s no consistency. Supervision is meaningless in real-life practice.”

“The Bush administration reversal was deeply disappointing to practicing CRNAs,” Peters says, “because it meant an opportunity was lost to lose unnecessary encumbrances to practice. It also places a procedural burden on state governors to opt out.”

Deborah Chambers, CRNA, MHSA, past president of AANA, says, “The AANA believes that CMS (Centers for Medicare & Medicaid Services) got it right the first time with the January 2001 rule on supervision. But since the November 13 ruling is in place, the AANA will work with that rule to ensure safe, high-quality anesthesia care for all Americans. We are confident that governors will make the right decisions for the citizens of their states by choosing to opt out of the requirement.”

Witkowski, too, is disappointed in the latest ruling. “It promotes a phony hierarchy of providers, granting physicians greater status and economic reward. It’s demoralizing to the ‘underlings,’ the dedicated people who do the work. It makes them feel beaten down and leave the profession, contributing to the shortage of anesthesia providers. What’s worse, rulings like these drive up prices and limit access,” she says.

A question of Geography

Access to health care is a challenge in U.S. rural areas, as most healthcare providers prefer to practice in urban areas. Thus, the Clinton administration’s January 2001 ruling was strongly supported by the both the American Hospital Association and the National Rural Health Association. Small wonder, as CRNAs are the sole providers of anesthesia in many inner-city hospitals and in more than 65% of rural hospitals, according to the AANA. [http://www.aana.com/crna/ataglance.asp]

Rodney Lester, PhD, CRNA, president of the AANA, understands the critical role CRNAs play in meeting the healthcare needs of rural communities. “If it weren’t for CRNAs, people living in rural and medically underserved areas simply wouldn’t be able to maintain access to the services they need requiring anesthesia—for example, trauma stabilization, diagnostic procedures, and emergency surgeries related to obstetrics, orthopedics, and a myriad of acute conditions,” Lester says.

Hospital medical bylaws reflect this geographic difference in access to services. In the 29 states where physician supervision of CRNAs is not required by law, the medical bylaws of rural hospitals typically don’t require supervision.  However, urban hospital bylaws, which are far more restrictive, tend to require physician supervision. As Witkowski explains, “Some bylaws in urban hospitals with plenty of physician coverage can be so limiting that [CRNAs] wouldn’t be able to make any independent judgments at all. CRNAs would do well to read their hospital’s bylaws and address those that are too restrictive.”

The Future of Physician Supervision

The future of the physician supervision requirement is anyone’s guess. Publicly, the ASA frames physician supervision of CRNAs in terms of patient safety rather than interprofessional turf, and it hailed the Bush ruling as a major victory. But from Gunn’s perspective, “CRNAs have always worked collaboratively with physicians, so supervision is neither necessary nor appropriate.”

Some believe the new ruling may be a violation of the original Medicare Act. Glen Maxey (D-Austin), a healthcare consultant who represented Travis County in the Texas legislature from 1991 to 2002, believes the January ruling shouldn’t have been rescinded. “When Medicare was passed in 1965,” Maxey says, “a fundamental principle of the program was that it wouldn’t interfere with state law regarding the regulation of healthcare professionals. Since the January 2001 ruling would have deferred to the states on supervision, it should have been allowed to stand.”

Thirty years ago, the Catholic order of the Franciscan Sisters of Mary decided to send Sister Angela to the Texas Rio Grande Valley, one of the poorest, hottest regions in the United States. Sister Angela was finishing her master’s degree in maternal nursing and nurse midwifery at Columbia University and passed the board exam to become credentialed as a certified nurse midwife (CNM). By 1972 when she reached Raymondville, a small town near the southern tip of Texas, she nwas ready to take on her new responsibilities as a nurse at Su Clínica, a federal migrant health center.

She quickly discovered the difficulties local women faced in obtaining health care. “Most of the women labor as seasonal farm-workers, making between $1 and $3 per gunnysack filled with picked onions, cucumbers, turnips—whatever is in season,” she explains. “They have no health insurance or car, and there is no public transportation. Consequently they become isolated, staying in their colonias.” At the time the local women—who typically marry young and have numerous children—had another reason to worry. “The local clinics did not offer maternity care. If a woman wanted a hospital delivery, she had to find a ride, travel 25 miles on rough, rural two-lane highways stopping through small towns to get to the Harlingen hospital [the only hospital with an obstetrician in the region].” This was unacceptable to 32-year-old Sister Angela. “These women desperately needed a birthing center,” she said, “and I promised myself that it would happen.”

Gaining Ground for CNMs

In the meantime, Sister Angela faced some formidable obstacles to establishing the first nurse midwifery clinic in the state. “From the moment I set foot in Texas, I knew I was going to have a horrific fight on my hands,” she recalls today. The Texas Board of Medical Examiners had declared that when CNMs were delivering babies, they were practicing medicine. Sr. Angela was heavily involved in the fight against this assertion, and an opinion was requested from the Texas Attorney General’s office, which issued an opinion (H1293) in 1978 that clearly stated that CNMs were not practicing medicine by delivering babies, thus clearly defining the legal base for nurse midwives to practice in Texas.

The next obstacle was the issue of direct reimbursement. “As luck would have it, the sole physician on the Texas Medicaid Advisory Committee was an obstetrician who frequently declared, ‘over my dead body will nurse midwives ever receive Medicaid reimbursement for delivering babies in Texas,’” she said. Six years into her fight, Sister Angela was approached by an attorney who offered to represent the clients of her birth center in a class-action lawsuit that would require Medicaid to pay for nurse midwifery. “After just one letter from [the attorney], the doctor lost his steam,” said Sister Angela. “The taste of victory was sweet in 1989 when I received the first Medicaid provider number issued for a CNM in the State of Texas.” Today, all 50 states allow direct Medicaid reimbursement to CNMs.

In 1986, Sister Angela served on the Texas Department of Health advisory committee that wrote the original Texas Birth Center Rules and Regulations, and assisted with their revision 10 years later. She is currently helping to update them. She helped write the National Association of Childbearing Center’s “Standards for Birth Centers” and serves as site visitor to birth centers seeking accreditation based on those standards. Her efforts have not gone unnoticed. A frequent television and radio guest as well as a keynote and commencement speaker, in 1990 she was awarded the most prestigious honor that a CMA can receive, the Hattie Hemschemeyer Award for outstanding contributions to midwifery and maternal and child health. On September 10, 2002, she was inducted into the Texas Women’s Hall of Fame, sharing the honor with former recipients the late former Congresswoman Barbara Jordan, former Governor Ann Richards, former First Lady Barbara Bush and astronaut Sally Ride.

Breaking Ground for the Women of Texas

In 1980, Sister Angela began looking for medical and financial support. Funding came through private grants, contributions from the local diocese, and the sponsorship of three Catholic orders. Help often came from unexpected directions. “An electrical contractor passionately wanted this birth center to open,” she recalls, “He’d call his friends to help, so that construction was free or at a huge discount.”

In 1983, on four acres of former cucumber fields, Sr. Angela opened the Holy Family Birth Center, with one sister to manage the office, two CNM sisters, and two RN sisters. News of the clinic spread by word of mouth and since then, the complex has expanded significantly. Today its bright yellow buildings are home to a clinic, a classroom, a chapel, six birthing suites, and a residence for staff, fellows, students, and visitor. Seven RNs, four CNMs, two fellows, and two volunteers deliver services. Over 20 years, more than 5,000 babies have been delivered at the center, which is accredited by the Commission for the Accreditation of Birth Centers. With the U.S. infant mortality rate at 7.0 deaths per 1,000 births (1999 data),1 the birth center rate is only 1.3 per 1000; 0.7 per 1000 if lethal anomalies are excluded. Her victory for nurse midwifery in Texas has had a ripple effect nationwide. Today there are over 160 freestanding childbearing centers located throughout the United States.

“At our center, if the patients don’t have Medicaid, they are happy to work off their bill with in-kind services such as doing laundry, mowing, trimming bushes, cleaning, or driving,” said Sister Angela. “We’re a family-friendly place. If the volunteers have babies they are breast-feeding or young children, they’re welcomed at the center with open arms.”

Birth center volunteers and clinical fellows routinely describe their work as a life-changing experience. “I like the fact that I’m crossing all the lines—doing public health, childbirth education, health teaching, clinic work, labor and delivery, antepartum, well-baby clinics, home visits,” explains Shaanti Abbruzzese, a University of California at San Francisco nurse midwifery graduate who recently completed a fellowship. “I’ll never look at maternal care the same again.”

To learn more, visit www.holyfamilybirthcenter.com.

REFERENCE

1. National Center for Health Statistics. New CDC Report Shows Decline in Infant Mortality Rate in 1999 Analyzes Patterns of Infant Mortality. Centers for Disease Control and Prevention. 2002. http://www.cdc.gov/nchs/releases/02facts/99infant.htm.

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.

Will the economically disadvantaged babies that I have so lovingly and painstakingly cared for over the years have access to medical treatment for the fevers, sore throats, and earaches of childhood without their parents’ resorting to emergency rooms?

Your August 13 editorial, “Nurses’ Lib,” was right on mark in supporting the proposal of Hillary Rodham Clinton’s Task Force on Healthcare Reform to remove barriers constraining advanced practice nurses (APNs) from serving as primary care providers. These nurse practitioners are well prepared and suited to fill the void created by the shortage of primary care physicians to treat common ailments.

If national healthcare reform results in basic health care becoming universal for all Americans, many more providers of primary care will be needed to care for the 37 million people who are now uninsured.

Nurse practitioners have repeatedly demonstrated their ability to increase access to primary health care while preserving quality and reducing costs.

Abstract

In this millennial age, if national health-care reform results in basic health care becoming a fundamental right for all Americans, many more providers of primary care will be needed to care for the 35 million or so people who are now uninsured. A fundamental principle of the health-care reform effort is to utilize human resources to their fullest potential. Advanced practice nurses (APNs) have demonstrated their ability to increase access to primary health care while preserving quality and reducing costs. Limitations on APNs’ scope of practice, prescriptive authority, and third-party reimbursement impair their successful integration into the delivery of health care. These limitations are embodied in statutes and regulations and are directly amenable to legislative reform at both the state and federal levels. The President’s Task Force on Health Care Reform is recommending removal of these barriers. This article will examine the salient terms and issues, their history, political obstacles, state legislative activity, and specific recommendations for immediate action to grant APNs full legal, prescriptive, and reimbursement authority. Regulation reform to enable APNs’ effective deployment not only will better this nation’s health, but also will be the single most significant step of this century to further the profession of nursing.

Introduction

As the millennium approaches, the United States (US) is on the verge of major health-care reform. While swallowing scarce national resources, our health-care system[i] produces unenviable results and major inconsistencies. In 1992, 838.5 billion dollars were spent on health care, biting more than 14 percent out of our gross national product.[ii] From 35 to 37 million Americans[iii], or approximately 14 percent of the population[iv], are uninsured. Our health-care system is inherently inconsistent: We have the highest birthweight-specific survival rate of any country in the world, yet we rank 19th worldwide in infant mortality rate[v], i.e., state-of-the-art medical technology allows us to save a 500-gram infant[vi], yet the mother of that infant may not have had access to basic, minimal prenatal care.

At this writing, the President’s Task Force on National Health Care Reform has adjourned, having met its charter. In the beginning, stakeholders were numerous and vociferous even to the point of suing for entry to meetings, yet nurses had a voice on the Task Force. Approximately 20 nurses were key participants in the process, as members of working groups, technical advisory groups, and as reviewers of the final report.[vii] As expressed by Task Force representatives Ira Magaziner, Senior White House Advisor, and Donna Shalala, Health and Human Services Secretary, fundamental principles of health-care reform include guaranteed access to primary and preventive care for both children and adults, continued quality of care, cost-containment, and elimination of barriers to practice for advanced practice nurses. If the recommendations of the Task Force regarding deployment of advanced practice nurses are addressed, regulations constraining APNs’ proven ability to provide primary and preventive health care will become a matter of national debate.

If national health-care reform defines basic health care as a fundamental right for all Americans, many more providers of primary health care will be needed. Even now, when health care is considered by many to be a privilege[viii], there is a shortage of providers. A fundamental principle of health-care reform is to make the fullest use of human resources. Primary care, the type of care required by most Americans, is provided by nurse practitioners (NPs) or physicians, and the current shortage of these providers results in delayed and more costly care. If advanced practice nurses were used to their full potential, an estimated 6.4 to 8.75 billion dollars would be saved annually.[ix] Reasons for the shortage are complex; they include economic disincentives for physicians and legal barriers for nurse practitioners.

With regard to the physician shortage, practicing primary-care physicians are aging and retiring from practice, and replacement opportunity is diminishing.[x] There is a clear economic disincentive and disinterest in specializing in this type of care. Indeed, this specialty is among the lowest-paying; in 1985 to ’86, the income of family and general practice physicians was 32 percent less than the average physician.[xi] Geiger reports a “huge difference between specialty and primary care practice incomes”.[xii] The technical procedures performed by physicians who subspecialize are rewarded by third-party payers far more than the cognitive and interpersonal skills inherent in primary care. Not only is there a low percentage of medical residents specializing in primary care, but also the trend to specialize in this area is declining. The percentage of physicians practicing a primary-care specialty declined from about half in 1963 to about one third in 1986.[xiii] In 1991, only eight percent of US medical residents specialized in family practice.[xiv]

The nurse practitioner shortage is due to discriminatory laws at state and national levels which impose legal constraints to independent practice. The National Alliance of Nurse Practitioners estimates that 6,400 NP positions remain vacant.[xv] Legal limitations on APNs’ scope of practice, prescriptive authority, and third-party reimbursement impair their successful integration into the delivery of health care.[xvi] These barriers prevent large numbers of APNs from working efficiently and discourage them from staying in the field. Since all three barriers to practice are embodied in statutes and regulations, they are directly amenable to legislative reform at both the state and federal levels.[xvii]

This article explores the complex issue of regulatory constraints on advanced practice nursing and makes specific recommendations for immediate legislative reform. Removal of practice constraints will promote access to cost-effective, high-quality primary health care, thus bettering this nation’s health.

Term/Concept Clarification

Intelligent, productive public debate on this issue must be based on a clear understanding of the salient terms and concepts.

What is primary care?

Primary care is the type of care usually sought at the initial contact with the health-care system for the treatment of common (acute and chronic) illnesses. Primary care is basic, general health care which is ideally offered in an outpatient (ambulatory) or community setting.[xviii] This care is client-oriented and considers psychosocial as well as biological needs. The care is comprehensive, continuous, coordinated, and is considered to be holistic in its scope. Effective practitioners of primary care inherently possess enhanced interpersonal and cognitive skills, which have largely been undervalued by payers. Prevention is emphasized, utilizing measures such as screenings, assessments, and immunizations.[xix]

Who are advanced practice nurses?

APNs provide primary care to children and adults in a variety of settings such as community health centers, public health departments, hospitals and hospital clinics, school and college student health centers, business and industry employee health clinics, NP offices, physician offices, health maintenance organizations, nursing homes and hospices, home health-care agencies, and the Armed Forces and Veterans’ Administration facilities.

APNs are registered nurses whose formal education and clinical preparation extend beyond the basic requirements for licensure, resulting in either a certificate or master’s degree. APNs are prepared and experienced in delivering holistic care which integrates the physical and psychosocial components of patient health status, thus correcting for expensive and ineffective fragmented care. Care provided by APNs emphasizes early intervention and ongoing management of patient health status, enabling patient needs to be met effectively. Specialties of advanced practice nurses include certified nurse midwives (CNMs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs), and nurse practitioners. Various APN subspecialties include neonatal, pediatrics, women’s health, family practice, adult health, psychiatric/mental health, school/college health, and geriatrics. APNs assume high levels of responsibility for patient care and safety, such as the duty of the psychiatric/mental health clinical nurse specialist to warn third parties of homicidal intentions of the patient.[xx] Certified nurse midwives and nurse practitioners have a central role in providing primary care.

CNMs have received advanced preparation in midwifery. CNM practice includes the independent management of care of normal newborns and women–antepartally, intrapartally, postpartally (including family planning), and/or gynecologically. They practice “within a health care system which provides for medical consultation, collaborative management, and referral”.[xxi]

CRNAs provide anesthesia for dental, surgical, and obstetrical procedures. Although CRNAs are not primary caregivers, their technical services are needed for procedures recommended by primary-care providers. CRNAs are the sole anesthesia providers in approximately 30 to 35 percent of all hospitals, 85 percent of which are located in rural areas.[xxii]

Nurse practitioners are prepared to perform a wide range of professional nursing functions including obtaining medical histories, performing physical examinations, providing prenatal care and family planning services, providing well-child care including screening and immunizations, providing health maintenance care for adults such as annual physical exams, promoting positive health behaviors and self-care skills through education and counseling, and collaborating with physicians and other health professionals as needed. NPs are also prepared to perform certain functions traditionally performed by physicians, including the diagnosis and management of common acute health problems such as infections and minor injuries, as well as common chronic diseases such as diabetes and hypertension. NPs may order and interpret diagnostic studies such as lab work and x-rays, and prescribe or recommend prescriptions for medications and other treatments.

Whereas physician practice has traditionally been based on “curing” (diagnosing, treating, and prescribing), nursing has taken on the responsibility of “caring”, and APNs may be said to combine caring with curing. APNs are committed to establishing basic health care for all, health promotion and maintenance, increased quality of care, and the promotion of informed consumers.

How does the quality of care of APNs compare with that of physicians?

Health-care effectiveness is based on three criteria: quality, access, and cost. Hundreds of effectiveness studies have been underway for more than 20 years to study care provided by APNs. Interestingly, systematic study to evaluate care provided by physicians was not undertaken until recently, 1989, when the current perceived health-care crisis[xxiii] prompted policymakers and payers to inquire into the quality and cost-effectiveness of services actually rendered. According to Louis Sullivan, previous Secretary of Health and Human Services, “The problem is, for many medical treatments, we don’t know what works and what doesn’t, and for whom it works and for whom it doesn’t”.[xxiv]

The most comprehensive study to date of APNs was undertaken by the Office of Technology Assessment (OTA) in 1986 in response to a request from the Senate Committee on Appropriations.[xxv] This exhaustive study analyzed numerous studies assessing quality of care based on measures of process (what a provider does to and for a patient) and outcome (the result of patient care, i.e., health status) as well as on patient satisfaction and physician acceptance. The study concluded that, within their areas of competence, care provided by NPs and CNMs was equivalent to that provided by physicians. The OTA study also found that relating to patient satisfaction, NP and CNM care was superior to that of physicians, especially with regard to shared control[xxvi], 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.

A 1988 study by the Institute of Medicine (IOM) concluded that NPs and CNMs “are particularly effective in managing the care of pregnant women who are at high risk because of social and economic factors”.[xxvii] This same IOM study recommended “increased use of [CNMs] and obstetrical nurse practitioners; state laws and physicians themselves should support hospital privileges for CNMs and collaboration between physicians and [CNMs and NPs]; eventually, large interstate variations in the laws governing the use of such midlevel[[xxviii]] practitioners should be eliminated….”[xxix]

Barbara Safriet writes, “The quality of care provided by NPs and CNMs is crucially important for two reasons. First, their effective deployment depends upon their ability to render care that is safe and effective; only when that issue is settled do questions of relative cost and access become relevant. Second, the most often articulated basis for physicians’ opposition to these…providers has been concern about their ability to provide such care…however, virtually all of the studies to date have demonstrated that the quality of care rendered by NPs and CNMs is at least equivalent to that provided by physicians for comparable services.[xxx]

A Little History

A brief look at history promotes an understanding of the legal struggle APNs have endured to provide the primary health care for which they are prepared. History not only reveals who in America were the traditional healers and curers, but also the sociology, psychology, and political and legal maneuvering that established professional turf. Events of history have shaped the rugged course APNs have navigated.

As early as the Colonial period, women were serving as autonomous healers or general practitioners, as well as midwives.[xxxi] Anne Hutchinson, a religious reformer, was a general practitioner; Harriet Tubman, an African-American leader who guided many slaves to freedom, worked as both nurse and doctor.[xxxii] Prior to the era of industrialization and domination of medicine by men, women were an autonomous and primary healing group.[xxxiii]

In the 1800s physicians staked claim to all healing turf by establishing themselves as the legal and official medical profession. They established organizational structures designed to preserve professional dominance and autonomy.[xxxiv] Sociologist Paul Starr reflects, “By the mid-twentieth century, the strategic position of the medical profession in relation to hospitals, health insurance, and the pharmaceutical industry became pivotal in sustaining the profession’s economic position, superseding the earlier role played by their monopolization of practice….Throughout the medical system, the profession was able…to establish organizational structures that preserved a distinct sphere of professional dominance and autonomy.”[xxxv] Eliot Freidson, medical sociologist, states that the formal hierarchy created by physicians is politically supported and is fundamental to the inadequacy of health services.[xxxvi] Thus, women, the “lay” healers, were negatively valued as they were relegated to a subsidiary position. This medical division of labor was the basis of sexism in health care and contributed to the downgrading of the nurse.[xxxvii]

The perceived shortage of primary-care physicians in the ’60s and early ’70s led to the growth and development of a new health-care provider–the nurse practitioner. Access to health care became a political issue in the mid ’60s with the rise of President Johnson’s “Great Society” and the civil rights movement.[xxxviii] At minimal additional cost and educational preparation, nurses could deliver primary health-care services safely to selected populations.[xxxix] Physicians voiced little resistance, as the movement was viewed by medical doctors as a physician-controlled method of increasing their profits or providing health care for less desirable markets (poor and rural populations).[xl]

By the mid ’70s, however, a physician oversupply was perceived with immediate anti-NP sentiments reflected in the policies of the AMA and the American College of Physicians, which clearly indicated that medicine was not willing to delegate tasks in a shrinking marketplace. A physician-dominated health-care system threatened NP employment and halted expansion of NP preparation and education programs. Practice relations between NPs and physicians remained politically, legally, economically, and clinically unequal. Third-party reimbursements were seldom, if ever, made for NP services, and physician practice roles were defined and protected by statute, whereas NP roles were not. NPs were required to assume a (directly or indirectly) supervised role when performing historically defined physician tasks. In the mid ’70s, the NP movement would have died altogether had it not been for medicine’s eroding power, demands from impoverished and rural populations for health care, and pressure from government and business to cut health costs.

Various explanations arose for the continued dominance of APNs by physicians. Some commentators reduced the deferent social, political, and economic role of NPs to physicians to psychology: the passive personality of the nurse–the nurse was not assertive, or chose to be deferent. These traits were blamed on nursing education.[xli] Physician dominance has also been explained in economic and political terms. An exhaustive study by Koch, Pazaki, and Campbell of the first 20 years of nurse practitioner literature[xlii] reveals how sociology, psychology, history, politics, and economics have influenced the movement. Koch et al. concluded that the interrelated factors of labor market competition (discussed above) and professionalization have determined the course of the NP movement.[xliii] Sociologists, including Eliot Freidson, attribute the pursuit of autonomy as part of the professionalization process.[xliv]

Meanwhile, NPs, as an occupational group, strove to gain autonomy, a particularly arduous task given medicine’s control of the health-care system. In the late ’70s and ’80s the increasingly competitive health-care market in conjunction with the professional/ autonomy concerns of NPs account for APNs’ seeking autonomous practice, unfettered economic reimbursement, hospital privileges, and prescriptive authority. As Koch et al. wrote, “a clinically sound and economically viable NP profession depends on autonomous access to these political, economic and health care resources.”[xlv] In 1973, Schaefer called for nursing to organize and present a united political front on salient health policy issues to assure the future of nursing.[xlvi]

The “team” concept of NPs and physicians described in the literature of the late ’60s and early ’70s had an authoritarian/coercive potential to limit the behaviors and ideals of its members, as well as to develop conformist rather than democratic or egalitarian ideals. For example, a nurse was criticized if she was not a “team player”. During this period, NP roles were increasingly being defined in egalitarian terms in an attempt to end structured physician control. After 1980, “team” integration was rarely discussed in the literature, and the concept gave way to the notion of “joint practice”, and later to private practice.[xlvii]

It is significant that NP and CNM roles evolved historically in response to a lack of basic health services for certain populations, areas where physicians chose and continue to choose not to serve. APNs have provided a full range of care to people in rural and impoverished, inner-city areas. From the Frontier Nursing Service’s origins in 1925[xlviii] in the hills of eastern Kentucky to the inauguration of NP educational programs in Colorado in 1965[xlix], a sustained goal of APN deployment and preparation has been the provision of basic health care to populations that otherwise would have had none.

Legal Barriers to Effective Utilization of APNs

The barriers to effective utilization of APNs are the conflicting and restrictive provisions governing their scope of practice, prescriptive authority, as well as the parsimonious and fragmented state and federal standards for reimbursement. It should be noted that organized medicine, largely through lobbying, has played a central role in creating and perpetuating the states’ contradictory and constraining provisions for APN practice.[l] The states’ political support of organized medicine’s anti-competition agenda not only subjects APNs’ professional role to unwarranted diminution, but also limits the public’s access to safe and effective health care.

Scope of Practice

The states have police power to protect the public regarding health care, the premise being that not all consumers have adequate information to make safe, considered judgments about the abilities and qualifications of potential providers. Hence each state and territory has enacted licensing laws for nurses, physicians, and other health-care providers. The state restricts practice to those who have satisfied licensure requirements.[li]

Physicians were the first health-care practitioners to gain legislative recognition of their practice. In the mid to late 1800s a very highly organized effort was made to obtain physicians’ exclusive right to practice.[lii] Through statute they broadly defined their scope of practice to include curing: diagnosing, treating, and prescribing. The all-encompassing definition was invariably accompanied by a provision which made it illegal for anyone not licensed as a physician to carry out any acts included in the definition. Thus, the medical profession positioned itself to totally and legally occupy the health-care field. Nursing has had to “carve out” tasks or functions from the medical scope of practice to seek legislative recognition for its professional role. Efforts to regulate nursing while accommodating this historical medical preemption phenomenon have been painfully difficult.

In the early 1900s, the first state nursing laws enacted registration or certification of nurses. In the 1930s, mandatory licensure of registered nurses created a potential for interprofessional conflict. Conflict was avoided, however, by nursing’s narrowly defining its independent functions only as the supervision of patients, observation of symptoms and reactions, and the accurate recording of facts. The remainder of nursing’s scope of practice was dependent or complementary to the physician.[liii] To illustrate the tradition and longevity of nursing’s dependent scope of practice, Florence Nightingale’s work during the Crimean War was dependent on physicians’ willingness to allow her nurses to enter the battlegrounds to provide care to injured soldiers.[liv]

In 1955, the American Nurses Association (ANA) further developed a definition of nursing which did not require physician supervision of all nursing functions, but did prohibit nurses from diagnosing and prescribing treatments, and limited implementation of treatments and administration of medicines to those specifically prescribed by physicians.[lv] Even as states were adopting this definition, it was found to be unduly restrictive when compared with actual nursing practice. A professional consortium of medicine, hospitals, and nursing issued joint practice statements declaring that nurses could perform a number of tasks that would implicitly constitute the practice of medicine, such as performing cardiopulmonary resuscitation, starting intravenous fluids, and using defibrillators. These joint statements did not constitute law, but they did reflect a professional consensus that nursing was capable of carrying out certain traditionally medical tasks on their own initiative and without medical supervision.[lvi]

Safriet[lvii] points out that several events of history in the mid 1960s contributed to expanded roles of nursing. The birth of Medicare and Medicaid increased the number of people legally entitled to government-subsidized health care. The federal government forecast a shortage of primary-care physicians. The first formal nurse practitioner programs were established. Specialized care units such as coronary care and intensive care units were created in hospitals. The growing women’s movement emphasized autonomy for women along with a greater demand for nurse-midwife services by women who perceived medical services to be male-dominated and hierarchical. Finally, physician assistant programs for medical corpsmen returning from Vietnam demonstrated that medical tasks could be performed effectively by non-physicians.

In 1971, the federal Department of Health, Education, and Welfare issued a report stating that nursing must “encompass a substantially larger place within the community of health professions…that extending the scope of practice of nursing practice is essential if this nation is to achieve the goal of equal access to health services for all its citizens…. [F]unctions of nurses are changing primarily because nurses have demonstrated their competence to perform a greater variety of functions….”[lviii] Also in 1971, Idaho became the first state to statutorily recognize diagnosis and treatment as part of the scope of practice of APNs. Unfortunately, the statute required that acts of diagnosis and treatment be authorized by rules and regulations jointly promulgated by the Idaho boards of both nursing and medicine, and that every institution that employed NPs was to develop guidelines and policies for their practices in those settings. These added stipulations resulted in unwarranted constraints on practice.

Such has been the history of state regulation ever since. In the past 22 years, nearly all states have legally acknowledged in varying degrees the expanded roles of APNs. As with all complex public policy, forms of acknowledgment include specific designation in statutes or agency rules, statutory interpretations by attorneys general and courts, and declaratory rulings by agencies. The many years of states’ struggle with APN scope of practice has led to legislation which is unduly restrictive and perpetually contradictory.

Prescriptive Authority

The legal authority to prescribe drugs is central to APNs’ effective practice. Less than 55 years ago, not only did consumers have access to all the drugs now classified as non-narcotic prescriptive drugs, but also many nurses worked independently from physicians and made drug therapy recommendations within their normal scope of practice.[lix] The landmark 1938 Federal Food Drug and Cosmetic Act changed all that. This law terminated consumer control over choice of medications, even though such was clearly not the intent of that law.[lx] Physicians were chosen as the providers to select medications mainly because they held an established, defined position within the health-care field. Pearson notes that this assignment of prescriptive authority to physicians insulated the profession well within its hierarchical arrangement of social privilege and economic power.[lxi]

Prescription drugs include legend drugs[lxii], and narcotics or controlled substances listed on various schedules established by the federal and state governments.[lxiii] The first limited prescriptive authority was granted to APNs in North Carolina in 1975, and there are currently explicit regulatory or statutory provisions in 43 jurisdictions, with proposals pending in legislatures in several other states.[lxiv]

Safriet points out that the policy issue “is not whether these providers can and do prescribe, but rather, whether the state will acknowledge and authorize their prescribing practices.”[lxv] In states without legislative authority to prescribe, APNs still actively prescribe for their patients through one or more of the following mechanisms: 1) asking a physician to write a specific prescription for the APN’s patient, 2) calling the prescription into a pharmacy under the physician’s name, 3) co-signing the physician’s prescription pad, and 4) using protocols jointly worked out with the APN, physician colleague, and dispensing pharmacist.[lxvi] These practices are common and of ambiguous legality, but necessary given the limited availability of authorized prescribers.[lxvii]

States vary principally with regard to the degree of autonomy (professional independence in decision-making) and the range of drugs from which they are permitted to select. Many states severely limit prescriptive authority by imposing requirements for written protocols[lxviii] and physician supervision or direction, and by laying out formularies[lxix] specifying which drugs may be prescribed. Some states restrict or vary prescribing authority to certain geographic or practice settings.[lxx] Alaska, Oregon, and Washington authorize the greatest prescriptive autonomy. In these states APNs may prescribe without any physician involvement, and none of these states requires physician control of APN practice, including diagnosing, treating, and prescribing.[lxxi] These three states may thus be the testing grounds for the adequacy of the APN role to meet access, cost, and quality requirements of reasonable health-care reform.

Reimbursement

At both the federal and state levels, unjustly discriminatory reimbursement laws leave APNs reimbursed indirectly (in most instances), at a significantly reduced rate, and for a narrow range of services. APNs will not be able to practice independently or on a collegial footing with physicians without adequate reimbursement, and a substantial number of people now without care will continue to be denied access to the primary-care services ably provided by these APNs.

The reimbursement policy questions are: Relating to scope of practice, for which services will APNs be reimbursed? At what level will APNs be reimbursed for eligible services that are the same as those provided by physicians? Will reimbursement be made directly to the APN or billed through physicians?

Federal reimbursement policy is critical to the future of APNs, given the presence of Medicare[lxxii] and Medicaid[lxxiii] and the tendency of both state insurance regulators and private insurers to follow the federal government’s lead.[lxxiv] Medicare Part B services were traditionally paid on the concept of “reasonable charge payment”. Escalating costs led Congress to pass the Comprehensive Omnibus Budget Reconciliation Act (COBRA) of 1985 which directed the Health Care Financing Authority to develop a resource-based relative value scale (RBRVS) reflecting the value of physicians’ services. COBRA 1985 also directed the creation of the Physician Payment Review Commission (PPRC) to make recommendations for reform of Medicare payment to physicians.

The RBRVS was developed by William Hsiao of Harvard and replaced the reasonable charge system.[lxxv] The original Harvard/Hsiao study contemplated variation in payment among physicians based on the opportunity cost of their training.[lxxvi] The PPRC, however, in its influential 1989 report to Congress[lxxvii] explicitly rejected the differential for training costs, stating clearly that physicians should be paid the same when the service is the same. Congress reformed the system of compensating physicians under Medicare with the Omnibus Budget Reconciliation Act (OBRA) of 1989.

APNs are subjected to severe reimbursement limitations under the Act. Certified nurse midwives are covered only for services throughout the maternity cycle[lxxviii], not for family planning or gynecological care. CNM maternity cycle services are reimbursed at 65 percent of the physician fee schedule amount. Basic situations are specified in which NP services are covered under Medicare, and each requires that the NP work in collaboration[lxxix] with a physician. NP reimbursement is “capped” at a percentage of the physician fee schedule for the few NP services which are covered. OBRA 1989 specified Medicaid coverage to certain NP specialties, specifically, covering the services of family and pediatric NPs. This restrictive language is a problem in states where NP designations differ, e.g., pediatric NP is, instead, “school NP”. Finally, NPs can be directly reimbursed for services only in rural areas.

Interestingly, once the issue of payment to non-physician providers arose, the PPRC reversed its position. The 1991 PPRC report to Congress[lxxx] stated that a payment differential for services should reflect differences in opportunity (or training) costs of the providers–either ignoring or forgetting its earlier insistence on equal payment for equal services. The PPRC departs from logic in insisting on differentials for opportunity costs for one group, but not for another.

State actions determine APN reimbursement. The states have broad discretion in determining both fee levels and payment methodology for Medicaid, and most states use either fee schedules or reasonable charge reimbursement. Also, states regulate the insurance industry, and entry into private practice requires direct access to third-party, private insurers. Currently 24 states mandate by statute some level of direct third-party reimbursement for CNMs and NPs.[lxxxi] The majority of these states have mandated that any service covered for other providers shall be covered for APNs operating within their state-defined scope of practice.

One argument against expanding direct reimbursement for APNs is the increased costs to the system through greater utilization of services. If APNs are empowered and choose to practice independently, a substantial number of people now without health care will have access to health care provided by APNs whose focus is on primary and preventive care. By expanding opportunities for reimbursement, a substantial improvement in the health status of the population may be realized through availability of cost-effective, high-quality primary and preventive care. Safriet suggests that the principle question is not whether costs would increase, but whether the benefits of improved health status outweigh the potential marginal cost increase.[lxxxii]

When the inevitable health-care payment paradigm shift occurs, the authors hope that current payment methodologies will be replaced with a fair, rational payment system that promotes accountability by rewarding favorable patient outcomes, breadth of experience, and educational opportunity costs. We are not urging that APNs make, under a capitated system, the same annual income as generalist physicians, which typically is greater than $100,000 per year. The authors also do not endorse the retrospective fee-for-service payment scheme. However, while fee-for-service exists, we strongly urge that APNs be reimbursed at the same rate as other providers for the same service. Even if APNs are reimbursed equally with physicians, direct and indirect costs involved with APN practice are lower–training costs are lower, and treatment modalities used by APNs are typically less invasive and less expensive.

Political Obstacles

Political obstacles to passage of legislation empowering APNs are many and varied. For simplicity, we have divided them into three spheres–pragmatic political considerations, economic trends, and the opposition.

Pragmatic political considerations

Several practical components of the issue of APN empowerment result in a complicated and arduous legislative process.

• Familiarity The public’s familiarity with APNs has been an obstacle in the legislative realm, as legislators have difficulty passing bills that do not deal in the mainstream. There is a considerable amount of public and professional ignorance regarding APNs. Although APNs’ visibility has been somewhat low, relatively recent events have increased the public’s familiarity with APNs: the advent of managed care, which utilizes NPs extensively, and the President’s Task Force on National Health Care Reform with its recommendations to fully utilize APNs. As the term nurse practitioner or advanced practice nurse becomes a common household word, legislation will flow more easily.[lxxxiii]

• Self-service A perception of self-service may also be an obstacle. Policymakers may interpret nursing’s push for APN legislation reform as self-serving, and thus be reluctant to act.

• Conflict An appearance of intra- and/or inter-professional conflict is another political obstacle, as policymakers are hesitant to act if they sense conflict within or among professional groups. Interestingly, a lack of commitment to the role of APNs even within nursing is not unknown throughout the states, although recent attention given APNs by the President’s Task Force on National Health Care Reform has served to focus nursing on the issue. Leaders of state nurses associations (SNAs) must become thoroughly informed and versed on APN issues and serve as strong legislative advocates for APNs, even if it means temporarily destabilizing relations with medicine. SNAs must place the empowerment of APNs as a legislative priority, as it not only represents a potential of monumental significance to improve this nation’s health, but it may also be the single most important step of this century to further the profession of nursing.

• Cost Cost is another obstacle. The empowerment of APNs will initially entail increased cost as people currently without care gain access to willing and able providers. It is, however, obvious that costs of acute intervention for increased morbidity due to delayed care exceed costs of primary, preventive care, at least on a per-patient basis and perhaps on the entire patient population.[lxxxiv] Cost should be distinguished from cost-effectiveness, which is determined by a relative assessment of patient outcomes or changes in health status. The personal cost in human anxiety, suffering, and tragedy should be factored into any reasonable calculation of cost.

The President’s Task Force on National Health Care Reform appears to be acutely aware that one way to gain some control over escalating health care expenditures is to pay attention to the mix of primary-care providers and the way in which they are organized. The Task Force has expressed an awareness that APNs can and do deliver primary care far more cost-effectively than physicians while maintaining quality. The 1989 Medical Outcomes Study found that even controlling for patient mix, specialists tend to use more resources than general internists, and general internists tend to use more resources than family physicians.[lxxxv] Medical specialists charge more, and are paid more than generalists for identical services.[lxxxvi] Like the more generalist physicians, APNs prefer less invasive, less expensive treatment modalities than do specialty physicians.

A short discussion of measles should illustrate the cost savings potential of APN empowerment and health-care reform.[lxxxvii] The recent tragic measles outbreak could have been entirely prevented with proper immunization, which is emphasized in both the education and practice of RNs as well as APNs. Nurses are responsible for immunizing children in a variety of settings from neonatal intensive care units (ICUs) to the public schools. In 1990, in the Dallas, Texas metropolitan area alone there were 2,200 confirmed cases of measles.[lxxxviii] For every dollar spent on measles-mumps-rubella programs, 14 dollars are saved in medical care to treat those diseases.[lxxxix] More than 20,000 dollars per day may be spent in a typical seven to 10-day stay in an ICU to treat complications of measles[xc] (typically pneumonia or encephalitis). The deployment of APNs will allow a focus on preventive, cost-effective care.

• Crisis Whether or not APN deployment is considered to be a crisis affects regulation reform. Only about a quarter of proposed bills pass, and those that do are perceived as crisis measures. Even though there is widespread agreement that access to health care is a crisis, the literature has been replete with the health-care “crisis” for many decades.[xci] The Clinton administration, however, has placed substantive health-care reform on the legislative agenda, and Congress readies for battle. State legislatures will follow.

Economic Trends

An unstable economy has resulted in many economic trends which militate against reimbursement regulation reform for APNs. These include the trend away from direct reimbursement to individual providers, the trend toward payment for “bundled” (grouped) services, or even for capitation[xcii] as a payment methodology, and the trend toward managed care (which utilizes nurse practitioners extensively) because it is a capitative type of system. Another factor adversely affecting reform efforts are the large and increasing percentage of the population who are un- or underinsured or covered by low-pay government health programs as compared to the population covered with private pay rates. There is an approaching limit to which cost-shifting by hospitals and private providers can be accomplished for low pay/no pay services to private payers. The growing inability of consumers to pay for deductibles, co-payments, or balanced billing charges due to the changing economic status and shrinking middle class of the American public is also a factor. Business and industry concerns about the impact of their employee health-care costs on their competitiveness in a global economy is another factor.

The Opposition–Who’s Afraid of Advanced Practice Nursing?

Nursing and policymakers who support empowerment of APNs to increase access to care must have full knowledge and understanding of the opposition, whose concerns are rooted in economic considerations.

• Most physicians and their organizations Medicine perceives the APN movement as a means for nursing to gain additional autonomy and broader scope of practice. Physicians understand that there is a finite amount society can afford to pay for health care, and they will not willingly share their traditional piece of the pie with anyone. However, antitrust cases have been successfully fought against groups of physicians for restraint of trade.[xciii] It is no coincidence that APNs have most autonomy in states with serious shortages of primary-care physicians. The objections raised by physicians are based on quality and safety concerns, even though hundreds of studies, including those by the Institute of Medicine and the Office of Technology Assessment, have repeatedly repudiated such concerns.

•  Private insurance companies The perception that APN empowerment will cost private insurance companies more money, even though beneficiaries have already paid for services, ensures their opposition. Insurance companies benefit financially from patients’ not being able to take advantage of covered services, which is one reason coverage is limited to selected, named providers and other conditions are placed on payment. Like physicians, insurers continue to raise objections to APNs based on quality and safety, choosing to ignore extensive evidence to the contrary.

• Health policy analysts Health-care finance experts believe the fee-for-service system is at the root of out-of-control health-care costs. As Enthoven and Kronick write, “The dominant open-ended fee-for-service…system pays providers more for doing more, whether or not more is appropriate.”[xciv] This group is not supportive of opening up this payment methodology to other provider groups. Indeed, with this methodology, providers, as physicians have shown, raise their set charges to the limits the market can bear. Health policy analysts who call for increased access to care often will not support payment methodologies which will provide the incentive for its realization. Even though the fee-for-service payment methodology has conspicuous defects, especially with regard to incentive, APNs must work within the current system. APNs, who utilize less expensive and less invasive treatment modalities than physicians, must have the authority to directly bill through this means to be able to practice and increase the public’s access to health care.

• Employers, particularly hospitals Legislation allowing direct reimbursement of APNs may be interpreted by hospitals as a prelude to direct reimbursement of all nursing services. Hospitals may oppose such legislation since the economic benefits derived from income-generating employee subsidies to cover operation costs could be reduced.

• Legislators Even though these individuals almost universally agree on the need for increased access to health care, they may oppose proposals to empower APNs, as they perceive increased access as increasing costs to taxpayers and to other powerful constituents, such as insurance companies. Organized medicine strongly opposes measures to empower APNs, and legislators may not want to alienate this group. In 1992, political action committee Congressional contributions from the American Nurses Association amounted to more than $300,000, a modest sum compared with the American Medical Association’s contribution of nearly 3 million.[xcv]

State Legislative Activity Affecting APN Practice

A variety of approaches has been used by state legislatures to extend nursing’s scope of practice. Some opt to revise Nurse Practice Acts by deleting absolute prohibition of diagnosing and treating, adding “nursing diagnosis”, adding an “additional acts” clause, or authorizing certain specially trained nurses to perform acts of medical diagnosis and treatment. In many states physicians are required to be present when NPs and CNMs deliver care. A multitude of restrictive reimbursement schemes either refuse to pay APNs for their services or funnel their payment through physicians or hospitals and other institutions. These same reimbursement schemes allow for only a portion of the fee that would be paid to a physician, if payment is allowed at all, even though the service is exactly the same with the same quality outcome.

A state-by-state account is beyond the scope of this article, but may be found annually in the January issue of Nurse Practitioner: The American Journal of Primary Health Care. In addition, the National Council of State Boards of Nursing’s State Nursing Legislation Quarterly reports recently enacted or proposed legislation regarding the nursing profession. The following is a summary of legislation through 1992 of the states’ efforts to govern APNs’ scope of practice, prescriptive authority, and reimbursement standards.

Legal Authority

To remove the practice barrier related to scope of practice, the legislative goal is for advanced practice nursing to be regulated and administered solely by each state’s Board of Nursing (BON). APNs in 37 states are regulated by their state BONs through specific regulations. In an additional eight states, APNs function under a broad Nurse Practice Act, but with no specific title protection. In six states APNs are regulated by both the state boards of nursing and medicine, which represents a significant restriction of APN practice.[xcvi]

Prescriptive authority

In February, 1991, a federal administrative barrier was added to legal barriers that would have severely restricted APNs’ prescriptive authority and thus their effective utilization. The Drug Enforcement Administration (DEA) proposed regulations to define APNs as “affiliated practitioners” and designate these affiliated practitioners as agents or employees of “traditional” (physician) providers; NP applications for new DEA registration numbers were denied.[xcvii] This situation was untenable, as DEA numbers are necessary not only for direct patient care, but also for the provider-tracking mechanisms used by insurance companies. Fortunately, in 1992 this federal administrative barrier to prescriptive authority was removed. The DEA proposed establishing a separate category of registration for “midlevel providers”[xcviii] under which APNs would receive their own individual DEA registration numbers. Thus, APNs would be allowed to dispense controlled substances, schedules II through V as allowed by state law.[xcix]

APNs in 43 states, including the District of Columbia, have some degree of legislated prescriptive authority. Within these states there is wide disparity in degree of prescriptive autonomy. Basically, prescriptive authority for APNs can be described as independent or dependent relating to physician control. Independent prescriptive authority must meet the following three criteria: be authorized and administered by the Board of Nursing, have no requirement for physician signature, and be considered within the nursing scope of practice (not statutorily defined as a delegated medical act). Using these criteria, 22 states have statutory APN independent prescriptive authority; seven of these 22 states do not allow independent prescription of controlled substances. The remaining 21 of the 43 states have statutorily defined dependent prescriptive authority; nine of these 21 states authorize APNs to prescribe controlled substances; the remaining 12 limit APNs to prescribing noncontrolled substances.[c]

Reimbursement

APNs are eligible to receive direct third-party reimbursement, i.e., payment from private insurers, in 38 states, although only 24 states have legislatively mandated third-party reimbursement to APNs. APNs have achieved authority for the direct payment of their services under the four federal health programs: Medicare (including reimbursement for care of nursing-home and rural-area residents), Civilian Health and Medical Programs (CHAMPUS), the Federal Employee Health Benefits Program (FEHBP), and Medicaid.[ci] Medicare has been implemented for specified types of APNs in 18 states. Health Care Financing Administration (HCFA) regulations give each state Medicaid agency the option to reimburse pediatric NPs and family NPs in accordance with state policies and regulations. It is difficult to determine which states are in compliance, as many states devise confusing smoke-screens or loopholes to complicate APN reimbursement. Rules and regulations in 42 states, an increase of 17 states since 1990, enable APNs to receive Medicaid reimbursement equal to or somewhat less than that paid to physicians.[cii]

This summary of conflicting and restrictive state legislation on APN practice not only reveals the quagmire, but also shows that legal barriers are slowly but surely crumbling. Despite forward strides, APNs are still disabled from fulfilling their proven potential to enhance this nation’s health by improving access to care.

Recommendations

Federal Level[ciii]

To promote the most effective use of APNs, with regard to reimbursement, the federal government should:

• expand reimbursement to those services provided by APNs within their scope of practice.

• eliminate restrictions of certain covered APN services to specified geographic or practice settings (e.g., rural areas or skilled nursing facilities).

• eliminate any requirements that eligibility for coverage be dependent upon physician collaboration or supervision.[civ]

• eliminate narrowly circumscribing direct reimbursement to APNs.

• eliminate discrimination between and among different specialty categories of APNs for payment.

• accommodate the current trend toward “bundling” health services with provisions for payment for hospital- or institution-based APN services.

• require that the same service should result in the same payment by insurers, regardless of the specialty of the provider.

• increase funding for APN education to institutions of higher education.[cv]

With regard to the same payment for same service recommendation, APNs have been shown to deliver equivalent, and sometimes better care than that of physicians in those activities that fall within both providers’ scopes of practice. The current practice of reimbursement of APNs at a percentage of physician payment artificially elevates the status of physician providers and at the same time devalues the substantive concern for quality of outcome or health status.

• A final recommendation is for the federal government to use its influence to encourage the states to immediately remove, through regulation, existing barriers to effective utilization of APNs. Barrier removal by federal action serves as an important symbol or model for the states.

State Level[cvi]

The following actions to redefine APNs’ role and their scope of practice will clarify their authority to diagnose and treat, and will eliminate problems with prescribing. All state legislatures should:

• eliminate all reference to mixed-regulator entities, and vest sole governmental authority over advanced practice nursing in the BON. This action is consistent with licensure mechanisms governing other professions.

• amend Nurse Practice Acts to include both a specific acknowledgment of advanced practice nursing and a basic definition of APNs.[cvii] To avoid confusion, reference to specific categories of APNs should seldom be made. Mention of specific titles for an intended role by state, federal, and private insurance reimbursement provisions causes problems when those titles vary across the states.

• modify statutory definitions of the practice of registered or professional nursing to include those acts of APNs authorized under regulations adopted by the BON, and further specify that the BON is empowered to promulgate such regulations for APNs. This action would preclude challenges to BON authority by eliminating vaguely worded statutory provisions concerning the BON’s authority to adopt such rules.

• eliminate any statutory requirements for formalized APN/physician collaboration or practice agreements, as well as for physician supervision or direction of APNs.[cviii] APNs routinely collaborate with other providers, consistent with their professional ethics and judgment.

• statutorily acknowledge that APNs may prescribe drugs contained in schedules II through V of the Controlled Substances Act, or leave such specification to their BONs.

• enact nondiscrimination requirements for health insurance or health-care service plans or contracts so that covered services may be provided by qualified APNs acting within their legally authorized scope of practice. These nondiscrimination requirements should extend to payment methodology, so that direct reimbursement, if available to one provider, will be available to APNs as well at the same rate.

• extend their Medicaid regulations to reimburse APNs’ services.

• enact nondiscrimination requirements for hospitals to grant clinical and admitting privileges to APNs.

Conclusion

Access to basic health services for all Americans has proven to be an elusive goal. A fundamental principle of health-care reform is the effective utilization of qualified, competent providers. As the President’s Task Force on National Health Care Reform has discovered, advanced practice nurses have a proven ability to offer quality, cost-effective primary care, yet various state and federal statutory constraints frustrate their potential to practice. APNs must be free, accountable, and unencumbered by constraints that counteract consumer interests. APNs must be granted full legal, prescriptive, and reimbursement authority through immediate state and federal regulatory reform to facilitate their effective deployment to increase access to health care while preserving quality, reducing costs, and bettering this nation’s health.

[i] A system connotes an organized, coordinated, considered structure, which is far from accurate in describing the US health-care system.

[ii] Simon Francis, “Health and Medical Services,” in United States Department of Commerce, US Industrial Outlook 1993 (Washington, DC: United States Government Printing Office, 1993), Chapter 42, 1-6; gross national product is the total value of goods and services produced in a nation during a specific time period (e.g., a year), plus the total expenditures by consumers and government, plus gross private investment.

[iii] Pamela F. Short, Alan C. Monheit, and Karen Beauregard, National Medical Expenditure Survey: A Profile of Uninsured Americans: Research Findings 1 (Rockville, Md: National Center for Health Services Research and Health Care Technology Assessment, 1989); Emily Friedman, “The Uninsured: From Dilemma to Crisis,” JAMA, 265 (May 1991): 2491-95.

[iv] U.S. Bureau of the Census, 1990 Census of Population and Housing: United States (Washington, DC, U.S. Government Printing Office, 1992); this percentage was derived from a 1990 census population total of 248,709,873.

[v] Antoinette D. Inglis, “United States Maternal and Child Health Services Part II: A Comparison with Western Europe and Strategies for Change,” Neonatal Network: The Journal of Neonatal Nursing, 10 (Aug. 1991): 7-13; infant mortality rate is the annual number of deaths of infants under one year of age per 1,000 live births and expresses the probability of dying between birth and exactly one year of age.

[vi] 454 grams equals one pound.

[vii] Personal communication of Kathleen Hastings, nurse attorney and Task Force member from the Agency for Health Care Policy and Research, July 2, 1993.

[viii] Antoinette D. Inglis, “United States Maternal and Child Health Services Part I: Right or Privilege?” Neonatal Network: The Journal of Neonatal Nursing, 9 (June 1991): 35-43.

[ix] Len M. Nichols, “Estimating the Cost of Underusing Advanced Practice Nurses,” Nursing Economics, 10 (Sep.-Oct. 1992): 343-51.

[x] Paul G. Barnett and John E. Midtling, “Public Policy and the Supply of Primary Care Physicians,” JAMA , 262 (Nov. 1989): 2864-68.

[xi] Id., at 2867.

[xii] H. Jack Geiger, “Why Don’t Medical Students Choose Primary Care?” American Journal of Public Health, 83 (Mar. 1993): 315-16.

[xiii] See supra note 10, at 2864-65.

[xiv] This percentage is calculated from figures from Carlos J. M. Martini, “Graduate Medical Education in the Changing Environment of Medicine,” JAMA, 268 (Sept. 1992): 1097-1105; of 85,516 1991 first-year residents, 6,610 chose family practice, approximately eight percent. Only family practice residents are counted, as family practice is the only primary-care specialty which does not offer a pathway to subspecialization.

[xv] Linda J. Pearson, “1991-92 Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice,” The Nurse Practitioner: The American Journal of Primary Health Care, 17 (Jan. 1992): 14-23.

[xvi] Two additional barriers are significant and interact: malpractice insurance and admitting privileges. In relation to income, the cost of malpractice insurance for NPs and CNMs is quite costly. Similarly, a lack of malpractice insurance, or the limitations in available policies on total coverage amounts, often prevents these providers from obtaining hospital admitting privileges. These two barriers have a market-based character, and thus are not included in this discussion of regulation.

[xvii] For an exhaustive discussion on regulating the integration of advanced practice nurses into the health-care delivery system, see Barbara J. Safriet, “Health Care Dollars and Regulatory Sense: The Role of Advanced Practice Nursing,” Yale Journal on Regulation, 9 (summer, 1992): 417-487. Ms. Safriet is Associate Dean and Lecturer of Law at the Yale Law School.

[xviii] Access problems result in widespread usage of hospital emergency rooms (ERs) for primary care. Emergency rooms at any given moment may be filled with persons, especially children, seeking attention for common acute ailments such as rashes, fevers, sore throats, earaches, urinary and respiratory tract infections. Persons using ERs for primary care may have no health insurance, may have Medicaid but no provider willing to see them, or may have providers but no services outside of office hours.

[xix] This definition is adapted from two sources: a) Safriet, supra note 17, at 422, and b) U.S. House of Representatives Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce, A Discursive Dictionary of Health Care (Washington, DC: U.S. Government Printing Office, 1976).

[xx] Diane K. Kjervik, “Psychiatric-Mental Health Nurse’s Duty to Warn Potential Victims of Homicidal Psychotherapy Outpatients”, Law, Medicine, and Health Care, 9 (Dec., 1981): 11-16 and 39.

[xxi] United States Congress, Office of Technology Assessment, HCS 37, Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986) [hereinafter OTA Study].

[xxii] United States Congress, Office of Technology Assessment, OTA-H-434, Health Care in Rural America 257, 259 (1990).

[xxiii] The word “crisis” is used here with some reservation, as the term connotes a sudden change, yet the severe problems with our health-care “system” have been documented since the 1920s; see Steven Jonas, An Introduction to the US Health Care System (3rd Ed.) (New York: Springer, 1992), and Larry W. Koch, S.H. Pazaki, and James D. Campbell, “The First 20 Years of Nurse Practitioner Literature: An Evolution of Joint Practice Issues,” The Nurse Practitioner: The American Journal of Primary Health Care, 17 (Feb. 1992): 62-71.

[xxiv] Louis W. Sullivan, (From the Secretary of Health and Human Services), “The Need for Medical Treatment Effectiveness Research”, JAMA, 266 (Dec. 1991): 3264.

[xxv] See OTA Study, supra note 21.

[xxvi] See Jay Katz, The Silent World of Doctor and Patient (New York: MacMillan, 1984) for a discussion of physician unwillingness to include patients in the decision-making process.

[xxvii] Institute of Medicine, Sarah S. Brown, ed. Prenatal Care: Reaching Mothers, Reaching Infants (Washington, DC: National Academy Press, 1988): 68.

[xxviii] Use of the term “midlevel practitioner” implies a hierarchy of providers. In providing primary care within their scope of practice, APNs are not providing a middle level of care. Use of this term is unacceptable and discriminatory as it fosters, inappropriately, the granting of physicians greater status and economic rewards. Further, nurse practitioners lose their professional identity when referred to as “non-physician providers” or “midlevel practitioners”. Such nomenclature can be likened to calling an orange a “non-apple” or “midlevel fruit”.

[xxix] See supra note 27, at 144.

[xxx] See Safriet, supra note 17, at 431.

[xxxi] Nancy R. Barhydt-Wezenaar, “Nursing,” in Steven Jonas, ed., Health Care Delivery in the United States, 3rd Ed. (New York: Springer, 1986), 90-124.

[xxxii] Id., at 91.

[xxxiii] See Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: A History of Women Healers (2nd. Ed.) (Old Westbury, NY: The Feminist Press, 1973).

[xxxiv] See Rosemary Stevens, American Medicine and the Public Interest (New Haven, Yale University Press, 1971).

[xxxv] Paul E. Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982).

[xxxvi] Eliot Freidson, Profession of Medicine: A Study of the Sociology of Applied Knowledge (New York: Dodd, Mead, 1970).

[xxxvii] See Barhydt-Wezenaar, supra note 31, at 91.

[xxxviii] Morris Schaefer and Herman E. Hilleboe, “The Health Manpower Crisis: Cause or Symptom,” American Journal of Public Health, 57 (1967): 10.

[xxxix] Loretta C. Ford and Henry K. Silver, “The Expanded Role of the Nurse in Child Care,” Nursing Outlook, 15 (Sep. 1967): 43-45.

[xl] See Koch et al., supra note 23.

[xli] Id., at 64.

[xlii] See Koch et al., supra note 23, at 68.

[xliii] Id., at 68.

[xliv] Eliot Freidson, ed., The Professions and Their Prospects (Beverly Hills, CA: Sage, 1973).

[xlv] See supra note 23, at 68.

[xlvi] Marguerite J. Schaefer, “The Political and Economic Scene in the Future of Nursing,” American Journal of Public Health, 63 (Oct. 1973): 887-89.

[xlvii] See Koch et al., supra note 23, at 68.

[xlviii] Mary Breckinridge, “The Nurse-Midwife: A Pioneer,” American Journal of Public Health, 17 (1927): 1147.

[xlix] See Ford and Silver, supra note 39, at 43.

[l] See Safriet, supra note 17, at 461.

[li] Arguments opposing licensure of health-care providers have maintained that such restrictive regulation does not necessarily protect the public. See Milton Friedman, Capitalism and Freedom (Chicago: Phoenix Books, 1962). In chapter 9, entitled “Occupational Licensure”, economist Friedman argues that the market, i.e., the “customers”, can more appropriately determine which providers can best meet their needs, not government-regulated licensure.

[lii] See Freidson, supra note 36, at 47.

[liii] Like medicine, besides defining its practice, nursing also specified the training/educational qualifications necessary for licensure, and prohibited the practice of nursing without a license.

[liv] Brenda H. Canedy, “Florence Nightingale: Woman with a Vision,” in Diane K. Kjervik and Ida M. Martinson, eds., Women in Stress: A Nursing Perspective (New York: Appleton-Century-Croft, 1979), 5-30.

[lv] “ANA Board Approves a Definition of Nursing Practice,” American Journal of Nursing, 55 (Dec. 1955): 1474.

[lvi] See Safriet, supra note 17, at 443.

[lvii] See Safriet, Id., at 444.

[lviii] U.S. Department of Health, Education, and Welfare, Extending the Scope of Nursing Practice: A Report of the Secretary’s Committee to Study Extended Roles for Nurses (Washington, DC: U.S. Government Printing Office, 1971).

[lix] Linda J. Pearson, “1992-93 Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice,” The Nurse Practitioner: The American Journal of Primary Health Care, 18 (Jan. 1993): 23-38.

[lx] Id., at 25.

[lxi] Id., at 25.

[lxii] A “legend drug” is one which can only be dispensed upon prescription and which is not classified as a narcotic or a controlled substance. Examples include anti-hypertensive medications, antibiotics, and nonsteroidal anti-inflammatory drugs.

[lxiii] See Safriet, supra note 17, at 457.

[lxiv] See Pearson, supra note 59, at 24; see Safriet, supra note 17, at 456.

[lxv] See Safriet, supra note 17, at 456-7.

[lxvi] See Pearson, supra note 15, at 16.

[lxvii] See Safriet, supra note 17, at 457.

[lxviii] Protocols, in this sense, set forth various steps to be followed in the assessment or diagnosis of a condition, and, depending upon the results for each step of the aggregate process, specifies what treatments or drug therapies are to be implemented. (From Safriet, Id., at 458).

[lxix] A formulary is a list of drugs and therapeutic agents.

[lxx] See Safriet, supra note 17, at 456.

[lxxi] Id., at 458-9.

[lxxii] Medicare, created in 1965, includes two insurance programs. Part A is hospital insurance and is available without additional charge to all eligible Social Security recipients. Part B covers a wide range of services outside the hospital, including primary and ambulatory care.

[lxxiii] Medicaid is a collaborative effort between state and federal governments designed to provide payment for medical services to certain low-income persons.

[lxxiv] Safriet, supra note 17 at 466, points out that the “follow-the-Medicare-leader” phenomenon affects the availability of reimbursement insofar as both private insurers and state insurance regulators tend to pattern their provisions on federal Medicare arrangements.

[lxxv] For a discussion of the technical methodology used in establishing the scale, see William C. Hsiao, Peter Braun, Daniel Dunn, and Edmund R. Becker, “Resource-Based Relative Values: An Overview,” JAMA, 260 (Oct. 1988): 2347-53. The important concept is that a more logical payment system can be designed which accurately reflects inputs to health services.

[lxxvi] The Hsiao study considered the compelling notion of paying a differential based on patient outcome, but concluded that methods had not been developed of measuring that dimension satisfactorily.

[lxxvii] Physician Payment Review Commission, 1989 Annual Report to Congress, at xviii (1989).

[lxxviii] Federal law defines “maternity cycle” as pregnancy, labor, birth, and the immediate postpartum period.

[lxxix] “Collaboration” is explicitly defined as a situation in which an NP “works with a physician…with medical direction and appropriate supervision…”, 42 U.S.C.A. § 1395x(aa)(6) (1992).

[lxxx] Physician Payment Review Commission, 1991 Annual Report to Congress at xx (1991).

[lxxxi] See Pearson, supra note 59, at 25.

[lxxxii] See Safriet, supra note 17, at 467.

[lxxxiii] For example, in 1992, even though the national executive and legislative branches were undisputedly in gridlock, legislation affecting the cable industry passed, partially because cable television rates are a common household concern.

[lxxxiv] See Louise B. Russell, Is Prevention Better Than Cure? (Washington, DC: Brookings Institution, 1986).

[lxxxv] Alvin R. Tarlov, John E. Ware, Sheldon Greenfield, Eugene C. Nelson, Edward Perrin, Michael Zubkoff, “The Medical Outcomes Study: An Application of Methods for Monitoring the Results of Medical Care,” JAMA, 262 (Aug. 1989): 925-30.

[lxxxvi] Roger A. Rosenblatt, “Specialists or Generalists: On Whom Should We Base the American Health Care System?” JAMA, 267 (Mar. 1992): 1665-66.

[lxxxvii] The inability to cure measles in this country may be the quintessence of a failing health-care system.

[lxxxviii] Texas Department of Health Disease Prevention (internal document),Vaccine Access Initiative and Immunization Services, (January 15, 1993).

[lxxxix] Id.

[xc] Id.

[xci] See supra note 23.

[xcii] A Discursive Dictionary of Health Care, supra note 19(b) at 23 defines capitation as “a method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person served without regard to the actual number or nature of services provided to each person.”

[xciii] Cynthia E. Northrop and Mary E. Kelly, Legal Issues in Nursing (St. Louis: C.V. Mosby, 1987).

[xciv] Alain C. Enthoven and Richard Kronick, “Universal Health Insurance Through Incentives Reform,” JAMA, 265 (May 1991): 2532-36.

[xcv] Press release, April 29, 1993, Federal Election Commission; Center for Responsive Politics, “PACs in Profile: Spending Patterns in the 1992 Election,” June, 1993.

[xcvi] See Pearson, supra note 59, at 25.

[xcvii] See Pearson, at supra note 15, at 14.

[xcviii] See supra note 28.

[xcix] See Pearson, supra note 59, at 23.

[c] Id., at 24-25.

[ci] Pamela C. Mittelstadt, “Federal Reimbursement of Advanced Practice Nurses’ Services Empowers the Profession,” The Nurse Practitioner: The American Journal of Primary Health Care, 18 (Jan. 1993): 43-49.

[cii] See Id., at 25; see also Pearson, supra note 15 at 16.

[ciii] For a more detailed discussion of recommended federal action see Safriet, supra note 17, at 478-486.

[civ] Is it appropriate for physicians to be acting as financial intermediaries for APNs? No.

[cv] Graduate medical education enjoys a long tradition of federal funding.

[cvi] For a more detailed discussion of recommended state action see Safriet, supra note 17, at 478-486.

[cvii] Safriet discusses and gives a recommended definition of APN in her (cited) work at pages 479-80.

[cviii] See supra note 104.