Nurse Practitioners, Doctors in Tug-of-War Over Patients
Christy Blanco’s health clinic is sitting empty. A nurse practitioner in El Paso, Tex., Blanco says she has all the necessary equipment and a doctorate in nursing practice that prepared her to perform routine physical exams and treat diabetes, asthma, high blood pressure, and many other common ailments. About 50 miles away in Las Cruces, N.M., dozens of nurse practitioners at clinics like Blanco’s are busy caring for patients. The only difference is that in Texas, nurse practitioners are required to contract with a doctor to sign off on medical charts; the physician must also spend 1 out of every 10 days at the clinic. In New Mexico, no doctor is necessary. “I just want to get started,” says Blanco, who’s tried for nearly two years to recruit a physician for her clinic, which will specialize in care for low-income women. “I’m trying to work for the poor,” she says. “I’ve spent thousands of dollars of my own money. I have a waiting list of patients, and I have to tell them I can’t practice.”
Blanco is one of the nation’s 155,000 nurse practitioners caught in a tug-of-war with doctors over who will provide basic primary care for the 30 million U.S. citizens set to get health insurance under the 2010 Affordable Care Act. The nurses say they can do their jobs just fine without doctor supervision, and they’re lobbying lawmakers in as many as 34 states to get restrictions lifted.
Nurse practitioners must complete a master’s or doctoral program in nursing practice—which adds two years or more beyond the four years of school required to become a registered nurse and includes training in diagnosing acute and chronic illnesses, pharmacology, and health-care ethics. Depending on the course of study, they can provide basic primary care or specialize in such fields as pediatrics, women’s health, or cardiology. They do not typically perform surgery or invasive procedures such as colonoscopies or tumor biopsies.
The U.S. faces a shortage of more than 13,000 physicians, a gap expected to grow to 130,000 by 2025, according to the Association of American Medical Colleges. That could leave 7 million Americans living in areas without enough primary-care doctors, concludes a February study in the journal Health Affairs. Yet doctors’ groups, led by the American Medical Association, are fighting efforts by nurse practitioners to take on more responsibility, arguing that care will be compromised unless doctors supervise. “Physicians, physician assistants, nurses, and other health-care professionals have long worked together to meet patient needs for a reason: The physician-led team approach to care works,” writes AMA President Jeremy Lazarus in an e-mail.
“Doctors are under a lot of pressure financially and feel like they are losing some of their patient volumes and traditional position as captain of the ship,” says John Rowe, a physician and former chief executive officer of Aetna who is now a professor of health policy and management at Columbia University. At the same time, “Nurses find it demeaning and unprofessional to be in a situation where they are restricted from doing what they know they can do.’’
States regulate how much oversight nurse practitioners must have. In 16, including Colorado, New Hampshire, and Washington, they can evaluate and diagnose patients, order diagnostic tests, and prescribe drugs. That means they can start a practice or work out of a clinic with no doctor on staff. The remaining states have a patchwork of regulations. In Florida and Alabama, nurses can’t prescribe certain drugs for pain, insomnia, or attention deficit disorder that are considered controlled substances. In New York, they need a written collaboration agreement with a doctor, and there’s a limit on how many each doctor can work with, effectively creating a cap on the number of nurse practitioners.
That may soon change. New York Governor Andrew Cuomo intends to do away with doctor collaboration agreements for primary-care nurse practitioners. Lawmakers in at least 10 other states, including New Jersey and Massachusetts, are considering legislation that would allow them to operate independently.
In Iowa, physicians sued the state in 2010 after it allowed nurses with advanced training to perform a procedure called a fluoroscopy, which takes pictures of the inside of the body. The doctors said nurses weren’t properly trained in the procedure, which involves radiation. The case is now before the Iowa Supreme Court after a lower court sided with the doctors. Physicians sued Colorado when the governor allowed nurse anesthetists, who administer surgical anesthesia, to work without physician supervision. An appeals court sided with the nurses last year. Nurse anesthetists prevailed in a similar suit in California, where the state Supreme Court said in 2012 that it wouldn’t review a challenge by doctors.
Doctors’ advocacy groups are lobbying state politicians across the country to leave the laws as they are. Elizabeth Dears, a senior vice president for the Medical Society of the State of New York, said in testimony to lawmakers that removing doctor oversight of nurse practitioners “would seriously endanger the patients for whom they care.” This claim, echoed by lobbyists for doctors in other states, is contradicted by at least two high-profile studies. A 2009 report by Rand Corp. found no evidence that nurses provide lower-quality care. A 2010 study of nurse practitioners published by the Institute of Medicine, a division of the National Academy of Sciences, recommended an end to state laws requiring doctor supervision.
“Doctors will tell you, ‘We trained longer, and by the way we were smarter to start with because it is harder to get into med school,’ ” says Columbia University’s Rowe. “You could take an example of someone like me: I trained in internal medicine at Harvard. Trained at NIH. Came back through Mass General. Fellowship in kidney disease. I was chief of geriatrics and a professor of medicine. Do I know more than a nurse? Of course I do, but I don’t know more about providing core primary care.”
In Texas, Blanco says she’s thinking of moving to New Mexico, where she could open a clinic and start seeing patients as soon as she registered with the state. Leaving home is the last thing she wants to do, but she can’t afford to sit idle. “We’re spending money and making no profit,” she says. “It is a business.”