The Nurse Practitioner Will See You Now

In 1965, the United States was in the early stages of significant political and social change. As anti-war protesters stormed the nation’s capital and U.S. astronaut Edward White became the first American to walk in space, another first was quietly taking place in Boulder, Colo. Seeing the need for expanded education and training within the nursing profession, public health nurse Loretta Ford was collaborating with pediatrician Henry Silver to co-found the nation’s first nurse practitioner program at the University of Colorado’s Schools of Medicine and Nursing. “Here she is practicing in rural Colorado, she sees a need for a new profession, a better way of doing things, something that could really enhance healthcare and bring healthcare to more people, and she created the whole profession,” said Penny Kaye Jensen, DNP, former president of the American Academy of Nurse Practitioners.¹

Ford’s program was successful, and decades later, nurse practitioner programs were cropping up all over the country. Today, the interest in and demand for the profession shows no signs of waning. According to the Bureau of Labor Statistics, the demand for all advanced practice registered nurses, including nurse practitioners (NPs), is expected to grow by 31 percent through the year 2022, faster than average for all other occupations.² In fact, in early 2015, the American Association of Nurse Practitioners (AANP) released data showing that the number of nurse practitioners licensed in the United States has nearly doubled over the past 10 years alone, rising from approximately 106,000 in 2004 to 205,000 as of Dec. 31, 2014. “The explosive growth of the nurse practitioner profession is a public health boon considering our nation’s skyrocketing demand for high-quality, accessible care,” said AANP president Ken Miller, PhD, RN, CFNP, FAAN, FAANP. “The challenge now will be right-sizing state and federal laws such that all patients will have full and direct access to nurse practitioners, and these expert and dedicated clinicians will be able to provide care to the top of their education and clinical training.”³

The Expanding Role of the NP

Ford’s original vision for the profession she pioneered essentially encompassed four key components that offered NPs the opportunity to assess, diagnose, treat and evaluate. Fast-forward to 2016: With the demand for primary care services escalating in most states, more than 16 million individuals are expected to gain health insurance coverage thanks to the Affordable Care Act. Add to that a rapidly aging population with escalating healthcare needs, and it’s easy to see why many states are considering options to expand the role of primary care providers, including expanding the scope of practice for NPs.⁴

Currently, NPs are the largest group of advanced practice registered nurses (APRNs), serving patients in a wide variety of settings under varying degrees of physician supervision.⁵ While both NPs and registered nurses (RNs) work closely with patients to monitor their health and provide care for acute and chronic illnesses, the work environments and responsibilities typically vary greatly between the two. The most significant differentiators between NPs and RNs are the educational requirements; RNs need, at minimum, an associate’s degree in nursing, while NPs require at least a master’s degree.

The working environment for NPs and RNs can also differ, with many NPs working in private practice and community clinics, while RNs largely work in hospitals and surgical settings. But, perhaps the most significant difference between NPs and RNs lies in their day-to-day duties.⁶

Typical RN responsibilities include:

• monitoring patients
• recording and maintaining records
• ordering and interpreting diagnostic tests
• communicating with patients and families about care plans
• assisting physicians with exams and treatments

Typical NP responsibilities include:

• prescribing medications and monitoring side effects and drug interactions
• taking, analyzing and interpreting patient health histories in order to provide diagnoses
• creating individualized treatment plans
• diagnosing and treating acute illnesses
• monitoring and managing chronic illnesses

A Holistic Approach to Healthcare

In addition to providing excellent primary, acute and specialty care, NPs bring a unique perspective to health services because they place an equal emphasis on both care and cure. Ford’s original vision for the profession emphasized a holistic model of care, and according to the AANP, it’s a vision that continues to be exemplified by a focus on wellness, disease prevention, education and counseling.⁶ “By providing both high-quality care and health counseling, NPs can lower the cost of healthcare for patients. For example, patients with NPs as their primary care provider have fewer instances of emergency room visits, shorter hospital stays and often have lower medication costs,” said Dr. Jensen. “This can be attributed to the fact that NPs partner with patients for their health and provide the necessary information so that they know when early intervention is needed.”⁷

This patient-centered approach to care has made NPs an increasingly preferred provider choice. A survey conducted by researchers at the University of Michigan using the U.S. Agency for Healthcare Research and Quality’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) questionnaire found that NPs outscored physicians on more than three-quarters of satisfaction questions. Of the 18 core questions, NPs had better scores than physicians on 15.⁸ In general, the findings indicated that NPs spend more time with patients, listen more closely, provide more feedback and show more respect for patients’ opinions. Researchers were quick to note that physicians also scored well on the survey, averaging 7.2 out of 10, compared with 9.8 for NPs.9 “This adds to the evidence that NPs are able to work independently,” stated researcher Susan Lyons, who is also a nurse at the university. “Patient satisfaction comes from respect and listening, fewer hospitalizations and fewer prescriptions. This is just more proof NPs can operate effectively independently without supervision by physicians.”¹⁰

These survey results are not isolated. NPs routinely outscore other healthcare providers when it comes to patient satisfaction, primarily in their ability to listen and understand patients’ concerns. A 2011 study showed only 50 percent of patients felt their physician providers “always” listened carefully, compared with more than 80 percent of patients with NP providers. Healthcare analysts agree that the trust factor between patient and provider is critical when it comes to engaging patients in their own healthcare. It is also a factor in patient compliance and consistency in scheduled follow-up and wellness visits — appointments that are critical for cost efficiency and healthcare quality.¹¹

Counting the Cost of Care

With healthcare costs on the rise, any practice model that reduces costs is worth a closer look. Several studies have demonstrated that NPs prove to be cost-effective providers. One 2009 study by the RAND Corp. projected that the increased use of NPs could save the state of Massachusetts between $4 billion and $8 billion over a 10-year period. Additional studies in California and North Carolina show comparable savings.¹⁰

Reductions in costs associated with broadening NPs’ scope of practice are being documented across the U.S. In national retail clinics, for example, NPs provide the majority of the care, and cost savings have been significant. In one study, researchers compared insurance claims data for a two-week period for 9,503 patients who visited retail and nonretail clinics from 2004 through 2007. They compared costs in states that require NPs to be supervised by or collaborate with physicians, states that allow NPs to practice independently but not prescribe, and states in which NPs are allowed to practice and prescribe independently. They found that insurance claims for a two-week period were lower after retail clinic patient visits than after visits to other settings such as doctors’ offices for the same conditions. Insurance expenditures for retail patient visits were even lower in states that allow NPs to practice independently. Payments for prescriptions were slightly higher in states where NPs are allowed to prescribe, according to the findings, but that increase in cost was mitigated by the lower cost of an NP practicing independently.¹¹

Cost of care aside, it is also less expensive to educate nurse practitioners. According to a 2011 article in the New England Journal of Medicine, “Between 3 and 12 nurse practitioners can be educated for the price of educating one physician.” By avoiding the rising costs of medical school, NPs are also able to avoid the overwhelming amount of debt typically incurred by doctors. The average primary care physician leaves school with a burden of $141,000, while an NP accrues approximately $64,000 of debt.¹²

Of course, salary thresholds for NPs are lower than those for physicians; the average income for a physician is $173,000 per year, whereas the average NP makes $89,000. This large salary difference tends to reflect a difference in patient expenses between those who visit NPs versus primary care physicians. According to the National Nursing Centers Consortium, the average patient saves 20 percent by visiting a nurse practitioner over a physician.¹³

While all states regulate the degree of autonomy NPs are allowed, state laws in select areas of the country still restrict NPs from practicing to the full extent of their training, although the tide seems to be turning. Evidence from many studies indicates that primary care services such as wellness and prevention services, diagnosis and management of many common uncomplicated acute illnesses, and management of chronic diseases such as diabetes can be provided by NPs at least as safely and effectively as by physicians.14 After reviewing the issue, an Institute of Medicine panel supported this conclusion, calling for expansion of nurses’ scope of practice in primary care.

Addressing the “Quality of Care” Debate

The trend toward NPs stepping into primary care roles is on the rise, but not everyone favors the shifting roles. Some physicians’ organizations argue that NPs cannot deliver primary care services that are as high quality or safe as those provided by physicians, citing the additional training required for a medical degree. In Virginia, for example, a 2010 proposal to expand the scope of practice for NPs was defeated after the state medical society raised safety concerns, citing NPs’ “lack of training and coursework,” and pushing instead for a greater focus on nurse education and clinical preparation.¹⁵ A medical society letter to the Joint Commission opposing the proposal stated: “Virginia must take all steps necessary to not only ensure access to care, but to ensure the delivery of quality care.”¹⁵

Virginia is not the only state in conflict about expanding the role of NPs. In Florida, NPs have struggled for years to move from restrictive practice and licensure to full practice authority, and have consistently been met with opposition. In one case, a “fact sheet” was sent to members of the Florida Medical Association opposing the Independent Advanced Practice Registered Nurse bill. The reasons cited were major differences in educational preparation between NPs and physicians; concerns regarding NPs’ ability to safely prescribe controlled substances and narcotics; shortage of physicians (should support initiatives to increase the number of physicians in the state); shortage of nurses (NPs will affect the future nursing workforce); inability to control healthcare costs (expansion of role may lead to the same NP reimbursement as physicians); and lack of physician oversight (concerns about the danger of less-qualified NPs practicing without supervision).¹⁵

Heated debates regarding these topics have brought the scope-of-practice issue to the forefront, with some legislators supporting the expanded role of NPs and others standing behind physician organizations that oppose broadening the scope of practice.

Despite a shortage of primary care providers, and the potential for NPs to step in and meet the demand for care, existing primary care physicians overwhelmingly do not support expansion of the roles and supply of NPs. A 2013 survey revealed that 70 percent of physician respondents agreed that nurse practitioners should practice to the “fullest extent of their education and training,” but many did not agree with the prospect of NPs leading medical homes or receiving equal pay for providing similar service as physicians. In addition, physicians surveyed believed they provided better quality care to patients than their NP counterparts.¹⁵

Jan Tower, PhD, senior policy advisor for AANP, was not surprised by the findings of the survey, although she agreed with the recommendation for more professional education so the two opposing groups can better understand one another. Dr. Tower also pointed out that the study was unclear as to how many of the physicians who responded actually worked with NPs.¹⁶ “The people who are most concerned about us are people who haven’t worked with us,” she said.

A Continued Rise in NP Services

The debate over the role of NPs in the healthcare delivery system in the U.S. will likely continue as the demand for healthcare services rises. Nevertheless, it remains clear that with research showing high patient satisfaction and lower cost of care, the number of NPs providing these necessary services will continue to increase.