The case for cooperative health care delivery

I was somewhat saddened to read "Two bills would remove limits on nurses ability to practice," by Melissa Miller, in the Feb. 1 Southeast Missourian. I was saddened because it was obvious that advanced practice registered nurses Bell and Keser have never had the benefit of a true collaborative practice.

APRNs (most of whom are nurse practitioners) are effective and valuable members of the health care team. They are often better in preventive care, education and counseling than physicians and are competent in treating common medical conditions within the limits of their training.

Interestingly, the two practices profiled in the article are not the norm for Missouri. The only reason these nurse practitioners "must pay physicians substantial fees in order for them to collaborate with them" is because they are already, essentially, operating an independent practice. In most cases primary care nurse practitioners work in the same location as their collaborating physicians in a dynamic team setting where more complex care is delegated to the physicians, and everyone works to the level of their ability and competence.

The supporters of the APRN independent practice bills (HB 1371 and SB679) make some assumptions that I would like to address.

1) Nurse practitioners have adequate training to provide comprehensive primary care services.

APRN training consists of four years attaining an undergraduate degree, then one and a half to three years in a master's program, some of which can be completed online.

At the point of certification, a new nurse practitioner has acquired between 500 and 1,500 hours of clinical training. Contrast this with a newly graduated family physician, who proceeds through four years of college, four years of medical school and then three years of an accredited residency program, totaling more than 15,000 hours of "hands on" clinical training before being allowed to practice autonomously.

A 2004 survey of nurse practitioners published in the Journal of the American Academy of Nurse Practitioners concluded that, "Our results indicate that formal NP education is not preparing new NP's to feel ready for practice."

Nurse practitioners are trained to recognize and treat common health problems such as strep throat and ear infections. They are trained to monitor certain chronic conditions such as hypertension and, as mentioned, they do an excellent job educating patients about chronic conditions, medications, nutrition and exercise. However, as our population ages the complexity of problems presenting to a primary care office has dramatically increased.

Primary care physicians are trained to diagnose and treat the more difficult cases. They are taught to be the leader of the medical team which directs patients through an increasingly sophisticated health care system.

2) Nurse practitioners will decrease the cost of health care.

Because their income is less than that of primary care physicians, it has been assumed that allowing nurses to practice independently will result in a reduction in health care spending.

A study in the journal Efficient Clinical Practice compared the utilization of medical services of three groups; APRN's, resident physicians and attending physicians. These researchers showed that nurse practitioners ordered more tests and consulted more than less experienced physicians, who used these expensive services more often than experienced physicians.

This should come as no surprise. A less knowledgeable clinician when confronted with a more difficult problem will be inclined to order more tests and/or consult more readily with a specialist due to his or her uncertainty. This increased utilization of medical services by nurse practitioners would more than make up for any lowering of fees paid to NPs by third-party payers.

3) Nurse practitioners are more likely to locate in rural or underserved areas.

NPs are no more or less likely to locate in underserved areas than primary care physicians. Extensive research studying the geographic distribution of physicians and APRNs has failed to show any significant migration of APRNs into underserved areas in states which have allowed independent practice.

A study commissioned by the AHRQ (Agency for Healthcare Research and Quality) released on Feb. 6, 2012, has determined that 22.5 percent of family physicians and 27.8 percent of nurse practitioners currently practice in rural areas. (This figure does not include the general internists and pediatricians practicing primary care in rural locales.) Additionally, APRNs are increasingly drifting into more lucrative opportunities in medical specialties. Barely half (52 percent) of nurse practitioners currently work in primary care.

The AAFP (American Academy of Family Physicians) believes that patients are best served in a medical home in which a team of primary care physicians, APRNs, nurses, therapists and other health care professionals work together.

I employ two excellent nurse practitioners who work, literally, right down the hall from my office. We discuss the more difficult cases several times a day. I appreciate the special skills they contribute to our practice. But a nurse practitioner's training, education and clinical expertise cannot replace that of a primary care physician.

Better cooperation between APRNs and physicians under the present system should be our goal, not independent practice.

Michael Wulfers, MD, practices family medicine in Cape Girardeau and is a past president of the Missouri Academy of Family Physicians.