Once a month, Andrea Brassard puts on her white lab coat and heads to a health care office in Maryland, where nurse practitioners are able to practice independently—that is, without physician oversight. She sees patients, diagnoses diseases, prescribes medications, orders tests, makes referrals to specialists, and teaches and counsels patients about health and illness.
In short, she does all the things she was trained to do as an advanced practice registered nurse (APRN). And she does it from the unique patient-centered perspective—and lower cost—of a nurse.
Although Brassard, R.N., D.N.Sc., M.P.H., F.N.P., has a full workload at AARP as a strategic policy adviser for the Center to Champion Nursing in America (CCNA), a joint initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation (RWJF), she carves out a few hours a month to keep up her practice as a nurse practitioner. It is as a clinician, she says, that she is able to see most clearly the critical role APRNs play in providing access to affordable, high quality primary care—and that vision helps inform her health care policy work at AARP.
Consumer demand for APRN-provided care is growing thanks to a shortage of primary care physicians, the soaring cost of health care, and a population that is aging and living longer with more acute and chronic conditions. Demand is projected to intensify in a few short years; in 2014, more than 30 million Americans will be able to access health care coverage under last year’s health reform law and are predicted to flood health care markets. That will place even greater demands on the already stretched-thin workforce of primary care providers.
“There aren’t enough primary care physicians now, and the shortage will only grow by 2014,” said Winifred Quinn, M.A., Ph.D., director of legislation and field operations for CCNA.
Advanced practice registered nurses, whom studies show deliver care that is as safe and as effective as primary care physicians, are a “big part of the solution” to that problem, she said.
APRNs are registered nurses with graduate-level education who are trained in preventing, diagnosing and treating illness, prescribing medication, and referring patients to specialists. Two of the four types of APRNs—nurse practitioners and certified nurse-midwives—provide primary care. Certified registered nurse anesthetists provide anesthesia and also administer another primary care service: pain management. Clinical nurse specialists focus on chronic care management.
There are currently more than 158,000 nurse practitioners practicing in the United States, more than 35,000 nurse anesthetists and more than 18,500 certified nurse-midwives, according to CCNA. In addition, an estimated 60,000 registered nurses are educated and credentialed to practice as clinical nurse specialists.
APRNs practice in settings ranging from hospitals to community health centers to school-based health clinics, and they are especially valued in rural and underserved areas, where primary care physicians are hardest to find.
Barriers to Practice Impede Growth of APRNs as Primary Care Providers
Despite growing demand for services provided by APRNs, they face restrictions that prevent them from practicing to the full extent of their education and training.
In some states and the District of Columbia, nurses can practice freely. But in others, “scope of practice” laws require nurse practitioners who diagnose, treat and prescribe medication to have some degree of physician involvement, ranging from a written collaborative agreement to on-site supervision. Critics say these types of regulations increase costs and duplicate and delay care for consumers.
The government isn’t the only sector getting in the way, experts add. Nearly half of all private insurance companies do not reimburse nurse practitioners for primary care services, according to the National Nursing Centers Consortium (NNCC). NNCC Chief Executive Officer Tine Hansen-Turton, M.G.A., J.D., is working to ensure that all insurance companies contract with nurse practitioners, a goal she says is necessary to accommodate the massive influx of patients in 2014.
Fortunately, movement is going in the right direction, she said. In 2002, only 20 percent of insurance companies contracted with nurse practitioners, Hansen-Turton said. “We’ve moved the needle pretty significantly in a relatively short period.”
Meanwhile, major insurance companies are jumping on board. Last year, Aetna changed its policy regarding reimbursement for nurse practitioners. It now recognizes nurse practitioners as primary care providers and reimburses them at 85 percent of the physician rate. These changes also applied to certified nurse-midwives, registered nurses and physician assistants.
“Nurse practitioners contribute to the accessibility and affordability of health care, which aligns directly with Aetna’s mission,” said Aetna’s Chief Nursing Officer Susan Kosman, R.N., B.S.N., M.S. The insurer is a member of CCNA’s Champion Nursing Coalition, a broad coalition of groups that have a stake in ensuring that all Americans have access to a highly skilled nurse when and where they need one. “We believe that more nurse practitioners are needed now and in the future to meet increasing demand for the type of health care services they provide,” Kosman added.
Aetna’s support is good news, Hansen-Turton says. “Any national health insurer that changes its policy always carries a lot of weight.”
Another auspicious omen came last year, when President Obama signed health reform into law, Quinn said. The law includes key incentives to promote an increase in nurses with graduate degrees and to collect critical data on the nursing workforce. But observers say it is unclear how effective those provisions will be in stimulating growth in the field. A provision establishing a commission to collect data on the nursing workforce, for example, has yet to receive federal funding, and another provision designed to stimulate the growth of APRNs could be stymied by language included in the law that would limit its effectiveness, she said.
“It’s imperative for the Medicare Graduate Nursing Education pilot program to be successful so that there are enough advanced practice registered nurses to help fill the primary health care gaps,” Quinn said.
She and others said one clear step forward is last year’s groundbreaking report by the Institute of Medicine (IOM) that calls on nurses to contribute as essential partners in the redesign of the nation’s health care system and a concomitant campaign supported by RWJF to implement the report’s recommendations.
Called The Future of Nursing: Leading Change, Advancing Health, the report says nurses should practice to the full extent of their education and training; achieve higher levels of education and training through an improved education system that promotes seamless academic progression; and be full partners, with physicians and other professionals, in redesigning health care. It also calls for better data collection regarding the nursing workforce.
“In order to meet the health care needs of individuals across the life span, it’s important to have rules and regulations in place that allow nurses and APRNs to safely function within their full scope of practice,” said Lucie Agosta, Ph.D., R.N.C., President of the Louisiana State Board of Nursing, co-chair of LSBN’s Advanced Practice Registered Nurse Task Force, and a member of the Louisiana Action Coalition, one of 15 groups around the country that is exploring implementation of the IOM report recommendations. Reviewing existing “scope-of-practice” laws and proposing revisions aimed at removing barriers to practice—one of the Louisiana Action Coalition’s key priorities—will help improve health and health care in Louisiana and around the country, Agosta said.
Added Brassard: “We see advanced practice registered nurses leading change, and that will certainly advance health.”
To ensure implementation of the recommendations in the IOM report, RWJF and CCNA are collaborating to implement the Future of Nursing: Campaign for Action, rallying support across the country and the health care spectrum, engaging consumer leaders, prominent officials and groups representing government, business, academia and philanthropy.
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