Paging Dr. Nurse: The Growing Role of Non-traditional Care Providers

The need for more providers to deliver primary care is unquestioned, but can non-MDs deliver the same quality of care independent of physician sueprvision?

One interesting effect of the recession on healthcare: the nursing profession is now more educated.

According to the Greater Cincinnati’s Health Council’s Bi-annual Nursing Supply and Demand study, which gathered regional data from 13 hospitals and nursing schools, and compared it to “the Council’s 2006 and 2008 Supply and Demand studies,” the economic downturn caused a large number of nurses to put off retirement (“The 2010 RN turnover rate of 8.48 percent is the lowest recorded in the last deacde…”) which knocked the 2010 vacancy rate down to a scant 2.5 percent. “Experienced nurses gained the hiring edge over new nurse graduates.”

This was reflected in the rapid increase in the number of nurses with bachelor’s (from 33 to 41 percent) and master’s degrees (from three to 12 percent) between 2008 and 2010.

“Hospitals in our region are beginning to demand more specific degree requirements in order to adapt to changing health care trends and meet changing patient care needs,” said Mary Duffey, executive director of the Council’s Health Care Workforce Center.

In addition to tougher educational standards, nurses are now expected to graduate into a job market in which fewer opportunities are available in the hospital setting. Whereas in 2008, “99 percent of…new graduates who elected to remain in the Cincinnati area and were hired into a health care organization were hired into a hospital…that percentage dipped to 80 percent [in 2010] as more new graduate nurses were hired into health care settings outside the hospital.”

The Council cites health care reform legislation as a strong motivating force behind the continuance of this trend in coming years, meaning that, in large part, these “settings outside the hospital” will be centers which emphasize primary care. Health care reform was not only about giving greater numbers of people access to affordable insurance, but eliminating costly burdens weighing on the system by getting an early handle on chronic conditions and preventing minor illnesses and injuries from spiraling into life-or-death emergencies.

When considering this in light of a more educated nursing workforce, it isn’t much of a stretch to suggest that an increasing number of nurses will be the primary point of contact for patients in the delivery of health care. Certainly if many states have their way, that will undoubtedly be the case: as many as 28 are considering an expansion of the role of the nurse practitioner.

A quick look at the shortage of primary care physicians just in medically underserved areas (7,189 according to the Department of Health and Human Services) leaves no doubt as to the need for some kind of supplementary work force in primary care. Factor in the 30 million people that will be added to health insurance rosters in the coming years, and the need is magnified immensely.

Unfortunately this has become a point of contention rather than a moment for collaboration.

Nurse practitioners seem to want to seize this opportunity to be declared de facto primary care physicians. After nurse midwives were given equal Medicare reimbursement to OB/GYNs under health reform legislation, Michelle Artz, Chief Associate Director, Department of. Government Affairs, American Nurses Association advocated extending that further. "We know we need to get to 100 percent for everybody. This is a crack in the door," she said in conversation with the Associated Press. "We're hopeful this sets the tone."

MDs, meanwhile, seem to want to quash the idea of nurse practitioners as their equals altogether. The AMA in response to an Institute of Medicine report on the future of nursing: “A physician-led team approach to care—with each member of the team playing the role they are educated and trained to play—helps ensure patients get high quality care and value for their health care spending.”

There is common ground to be found here somewhere that respects the professional abilities and sensibilities of PAs, NPs, and PCPs, while balancing the need of patients to have ready access to quality care…but where?

This is a complicated situation with no easy answers, but we know that you’ve got suggestions.

  • If NPs and PAs were required to study longer and gain more clinical experience, would PCPs warm up to the idea of sharing roles with them?
  • Is it absolutely necessary that PAs and NPs practice independently of PCPs?
  • Is this simply a new reality that PCPs must adjust to?
  • Is the focus on this “sibling rivalry” misguided? Are opinions as divided as they seem?

Tell us what you think. Your colleagues want to know.