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Nurse Practitioners, Handmaidens No More


After years of working with a neurosurgeon and a heart surgeon, nurse practitioner Kathy Kenny opened her own medical practice last year in Chandler, Ariz., where she provides some of the same screenings and treatments that doctors do. Kenny is among 148,000 nurse practitioners who will have to pick up the slack beginning in 2014, if the Supreme Court allows President Barack Obama’s health-care law to add at least 30 million people to U.S. hospital, clinic, and doctors’ practices already suffering a shortage of physicians.

The nurses will likely see more referrals from local emergency rooms—mostly patients requiring follow-up care—as well as those with chronic conditions that need monitoring and those seeking treatment for the minor bumps, bruises, and sniffles of everyday life. “It’s controversial because some physicians feel that’s taking over their role,” says Kenny, who cares for patients with heart disease and diabetes at her Transition Clinic. “I’m not qualified for extremely complicated cases, but there’s going to be this influx of patients that need to go somewhere.”

The American Medical Association, the nation’s largest physicians’ lobby, opposes allowing anyone to practice medicine independently who hasn’t completed state requirements for medical doctors. Yet by 2015 the U.S. will be facing a shortage of about 63,000 doctors, according to the Association of American Medical Colleges. While there has been a push for more primary-care physicians, training typically takes about 10 to 15 years.

Nurse practitioners are registered nurses with advanced degrees and state certifications that can take as few as six years to obtain. “You don’t need a medical degree to provide primary care, and you haven’t needed a medical degree for almost 100 years,” says Susan Apold, health policy director at the American College of Nurse Practitioners in Alexandria, Va. Nurses don’t need anyone’s permission to give a vaccine, she says.

Nurses are less expensive than doctors. Medicare, the U.S. health program for the elderly and disabled, reimburses nurse practitioners about 85 percent of what doctors get; private insurance reimbursement can be as low as 50 percent, says Kenny, who is also a clinical associate professor at the College of Nursing and Health Innovation at Arizona State University.

According to the American Academy of Nurse Practitioners, the profession is 96 percent women. The average base salary in 2011 was $91,310. Family doctors make $175,000 to $220,196 a year, according to the Association of American Medical Colleges. That’s one reason there’s a turf war over “whose sandbox it is,” says Paul Keckley, executive director of the Deloitte Center for Health Solutions research group in Washington. “It’s going to be a very intense struggle about the value of services rendered,” he says.

The downside to nurse practitioners taking on more of a burden is that often, primary care isn’t simple medicine, Keckley says. Frequently patients have multiple conditions. Without doctors to practice with or good clinical information systems, nurse practitioners alone may be “dangerous,” he says.

Kenny says she generally will refer patients to a doctor when they require two or more medications or if someone with Type 2 diabetes fails to respond to insulin and oral medications after two to three months.

Certified nurse practitioners can prescribe medication without the supervision of a physician in 16 states and Washington, D.C., according to the National Conference of State Legislatures. While additional states are making efforts to expand the profession’s duties, it’s a “turbulent political issue,” says Kara Hinkley, a spokeswoman for the group.

Glen Stream, a doctor in Spokane, Wash., who serves as president of the American Academy of Family Physicians, says he prefers nurse practitioners to work under the same roof as doctors. “If someone like me comes in with chest pains, that could be respiratory illness, acid reflux, angina,” he says. Making the right call is “where the substantially greater depth of training is important.”

Julie Rivera, who works alongside doctors as a nurse practitioner at St. Luke’s-Roosevelt Hospital’s Adult Medicine Addiction Institute in New York, says the relationship is “very collegial.” She has a supervising physician available to consult if she has a question. In addition, she reviews her patients’ charts with a doctor every three months. “A lot of people still don’t know what nurse practitioners do,” Rivera says. “It’s kind of frustrating.”

Either alone or as part of a doctor’s practice, more patients will see a nurse practitioner, Apold says. “There aren’t enough physicians to go around.”

The bottom line: The health-care revamp calls for a bigger role for nurse practitioners to ease a shortage of doctors. Not all physicians welcome the move.

Lopatto is a reporter for Bloomberg News.

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