The Health Care Crisis in The United States and Why Nurse Practitioners Can Solve It

Abstract

The Affordable Care Act health care reform is a current hot topic in the United States and is quickly becoming a reality. A main focus of this act is access to care. There is a large population of underserved citizens in this country without access to health care, let alone primary care. It has been shown that primary care access directly affects one’s overall health. Nurse practitioners are an alternative to traditional primary care physicians. Not only are the services equal to traditional physicians, they can provide that care at a lower cost. Financial concerns are a deciding factor in whether individuals seek care on a regular basis or not. Implementing more nurse practitioners as primary care providers is a sound answer to the health care crisis that is current in this country. The purpose of this paper is to illustrate the importance of nurse practitioners to primary care as well as personal motivations for perusing the profession.

Political Perspectives

Almost everyone working in the health care field is aware that there is legislation both passed and being written for health care reform. This has been a cause of great anxiety, argument, and uncertainty throughout the health care field. These reforms refer to the Patient Protection and Affordable Care Act (ACA) of 2010 (Fiscella, 2011). In Fiscella’s article he describes the six domains in which the reform is focused: “access related to insurance coverage and costs, strengthening primary care, improvements in health information technology, changes in physician payment, adoption of a national quality, and improved disparity monitoring and accountability” (p. 78). These are unsettling to many providers and are hard to digest particularly with the financial crisis currently in this country. While the financial crisis had made us more aware of spending in all areas of our lives, it has also strengthened the feeling of personal viability and thus has people focused on their own livelihoods, not particularly the greater good.

The United States is unique in the health care world; as there is no centralized government control over health care. There are government coverage programs for special populations under Medicare, Medicaid, coverage for Native Americans, and Veterans. Aside from those who qualify for these programs there is no universal health coverage. This leaves a large gap of people who do not have access to care due to lack of insurance. A goal of the reform acts is to provide insurance and health care coverage for the country’s population. Many in the world are covered under government health plans; however most in this country fear it for various reasons. The main focus of the Affordable Care Act is access to care; by adding financial coverage the number of those who will have access to care will greatly improve. By expanding and requiring insurance coverage to all, and estimated 32 million uninsured Americans will soon have health insurance coverage. By providing this coverage it opens access to care without fear of astronomical costs paid out of pocket. “Lack of health insurance is a major contributor to health care disparities.” (Fiscella, 2011) This statement is found across the research and articles surrounding reform despite what side of the argument; for or against, the author is. Without coverage problems compound until a major health crisis or even death is achieved, making the care needed complex and exponentially more expensive.

In order to achieve access, we must also improve primary care. In the article, Nurse practitioners as an underutilized resource for health reform, by Bauer (2010), states that “The United States simply does not have enough primary care physicians to coordinate patient care.” With the influx of newly insured Americans seeking care and the revitalization to primary care the reform hopes to have, there is a provider shortage. Nurse practitioners may be crucial to fill this gap. Bauer states using nurse practitioners is “one of the most cost-effective and feasible reforms to solve America’s serious problems of cost quality, and access to care.” (p. 231). In 1981, the U.S. Office of Technology Assessment analyzed and published the comparison of care from nurse practitioners and physicians (Bauer, 2010, p. 229). Since the publication it has become a hot topic and been reinforced from study after study that in comparable settings and within their scopes of practice the outcome from care is comparable if not the same. This point should be brought to the forefront of the access to care problem put forth by the Affordable Care Act.

Nurse practitioners can provide the same services as family practice physicians for primary care at up to a fraction of the cost with comparable outcomes; this would both satisfy the reform goals of access, improving primary care, and improving disparity. One particular way to do so was through accountable health organizations (ACO’s). ACO’s would group providers together to provide collaborative care. This would give providers “a measurable formula of accountability for providers relative to the health and wellness of a given population of patients they serve” (Barber, 2011). By motivating providers, such as nurse practitioners acting as primary care for patients, the idea would be to establish better health throughout a community as well as provide fee-for-service care at an affordable rate. This too is a controversial idea as it would change the current model of primary care.

While the focus of the media has been on opposition to the Affordable Care Act, perhaps the focus should be shifted to the good some of these changes will do. According to healthcare.gov, “chronic diseases, such as heart disease, cancer, and diabetes, are responsible for 7 of 10 deaths among Americans each year, and account for up to 75% of the nation’s health spending- and often are preventable.” This is why the reform is so important and should be embraced by the American public, not shunned. If you mention ‘reform’ to most people they appear to focus on certain aspects, and that is a feeling of health insurance being forced upon them or something else our country just cannot afford to support. There is strong evidence to support that by seeking primary care, many chronic illnesses will be either prevented or caught in early stages, making treatment less costly. One benefit of the reform that has already been enacted as of September, 23, 2010, is the provision that evidence based preventative care is now covered without deductible, coinsurance, or copayment for those with individual health insurance. This is one step in the right direction to better health for those with insurance who deferred primary care for fear of high deductibles and coinsurance (healthcare.gov). For these reason reform is needed; to help Americans in spite of financial status, race, or location have access to primary, preventative care. It is not about government gaining more control, but a healthier America.

Nurse practitioners will fill a large gap in providers where there is a shortage of primary care physicians available. This will satisfy the need for providers as well as financial responsibility; “A study in Tennessee found that costs at nurse practitioner-managed practices were 23% below the costs of care delivered by other primary care providers; inpatient hospitalization rates were 21% lower.” (Bauer, 2010, p. 230) The same article state that in over one hundred published reports, in no case was the care received reported as inferior.

When speaking of the nurse practitioner, many confuse or even blur the role of them with the role of physician’s assistant. Both are similar in task and schooling, however the practice elements vary, as well as their scope. Both roles began at around the same point in history, related to a physician shortage and uneven amounts of primary care doctors throughout the country (aapa.org). The origins of the nurse practitioner role were born in the mid 1960’s by Dr. Loretta Ford and Dr. Henry Silver at the University of Colorado. According to Miller, et. al, nurse practitioners are not physician extenders, but counterparts that have expanded nursing roles to include; “health promotion, illness prevention, and provision of care for those with minimal access to health care.” They are prepared to give primary care in clinics as well as the ability to specialize in various specialties. The scope of practice includes assessment, diagnosis, test and treatment orders, as well as prescribing privileges. Nurse practitioners are able to practice for the most part without physician supervision, but their exact scope varies by state; however, many work alongside physician providers and serve as an extension of their care and a peer (Miller, 2005).

Nurse practitioners and physician’s assistants have common duties and tasks; however the physician’s assistants must practice under the supervision and co signature of a physician. According to the American Academy of Physician Assistants the practice of physician assistant also came about in the mid 1960’s to attempt to alleviate the same physician shortage. The idea of the physician assistant was to be a partner or supervised by the physician, but also be able to assess and diagnose. Physician’s assistants are not necessarily trained as nurses first, as they can typically hold and Bachelor of Science degree prior to the physician’s assistant program and closely follow the medical model similar to medical school and residencies.

Historical Perspectives

From their inceptions in the 1960’s both the nurse practitioner and physician’s assistant have become vital roles in the medical field. Now, as then, there are gaps in coverage for primary care areas and a shortage of primary care physicians. With health care reform focusing in on primary preventative care and universal access for Americans, both professions will help provide care to a larger and growing population of patients that will be seeking primary care. As the focus in the United States shifts from sick care to preventative care, the number of providers needed will only increase. One barrier according to Miller et. al., is the scope and training of nurse practitioners is not well known, he cites a study done in Minnesota; “33% of persons in a rural Minnesota were unacquainted with the role [of nurse practitioner]” (p. 167). By increasing public knowledge both on the scope and availability of nurse practitioners, perhaps some of the patient bourdon would be naturally eased from physicians.

The article Reflections on Independence in Nurse Practitioner Practice (Weiland, 2008), gives a very good outline of the struggles of the nurse practitioner profession since its inception. As the profession is meant to create independence it has also naturally created competition and conflict between nurse practitioners and physicians in similar practices. Weiland states in relation to the natural competition “whereby movement in any one direction by a particular profession inevitably affects other professions” (2008, p. 347). While physicians closely follow the medical model, nurse practitioners are nurses first and have the unique ability to see the patient from both a nursing perspective as well as a professional provider by paralleling nursing’s values. By using this model the need of not only a ‘gap filler’ provider, but a new specialty has developed as a mid-level provider with the ability to work from clinics to inpatient hospitals independently. Nurse practitioners as well as physicians assistants are both regarded as mid-level providers. The autonomy of nurse practitioners however, allows them to more easily and independently fill the provider to patient ratio gap. While more people will likely seek care under the new reform, they are more than likely not going to want to wait a long amount of time for an appointment. In contrast to waiting for an appointment, the number of providers currently available will not even be able to satisfy the likely number of potential patients. As more and more people seek care the ability to accept new patients by current providers will then diminish. Each practicing provider can only care for so many patients; this is where the need for more primary care providers in this country comes in.

Role implementation

To increase the numbers of providers in this country, physicians are not the only answer. Many studies have shown the number of physicians focusing on primary care or family practice have decreased in favor of more lucrative specialties. Having specialists is a necessary option for quality care; however, primary care is a necessity and will become even more focused on with the current reform. “Nurse practitioners can be the primary care providers of the future. They have the education, training and orientation to change their system to address true ‘healthcare’ rather than ‘illness’ care.” (Counts, p. 13).

Being nurses prior to practitioners, the bedside manner and focus of nurse practitioners is unique. The focus does tend to be preventative, focusing on “healthcare” as Counts says. While many physicians focus on the problem at hand, nurse practitioners care tends to be more holistic. This comes into play with the new health care reform laws, as they focus heavily on preventative care, the area where many nurse practitioners are specialized. As Buerhaus puts it,

“Because millions of Americans are expected to gain health insurance in the coming years, the media’s interest in the health workforce has increased and has even focused on whether restrictive state practice acts are constraining opportunities for nurse practitioners to fill the gap in primary care” (2010, p. 346).

Nurse practitioners scope of practice abilities varies from state to state; in order to satisfy the number of providers needed, perhaps some states need to become less restrictive and allow independent practice. As access to care and a focus on primary preventive care becomes the norm, more providers will be needed, thus building their own patient bases separate from physicians in the same geographical area. Also, being lower cost, the ability to place nurse practitioners throughout the community and schools to serve vulnerable populations that are typically underserved is a viable option to improve access.

The Affordable Care Act also contains provisions to allow reimbursement of nurse practitioner services to the same rate as physicians are paid. As more nurse managed clinics develop, the right to higher reimbursement will develop. This is counteractive to the reform issue to cost-effectiveness; however, it increases numbers of available care providers. The Affordable Care Act will be providing bonuses to primary care physicians to eliminate payment differences between Medicare and Medicaid; it is unclear whether this will be carried over to nurse practitioners as well (Fiscella, 2010). This is where there is a grey area with reform, as nurse practitioners are not mentioned in many publications specifically. Some assume they fall under primary care providers, but their scope varies state to state. The cost of underutilization of nurse practitioners costs billions annually; the “denial of primary care status” is among this underutilization (Weiland, 2008). Only time will tell how nurse practitioners are recognized through the reform process and implementation. Again, by educating the public on the scope of practice and training behind nurse practitioners, the utilization rates will increase resulting in better overall public health.

In nearly every setting that physicians and nurse practitioners practice, there is some sort of overlap. “With physician shortfall projections hovering at 63,000 by 2015, the promise of 32 million more Americans gaining health insurance, and a patient population rapidly aging and saddled with chronic disease, hospitals are scrambling to line up caregivers” (Frellick, 2011). The midlevel providers, nurse practitioners and physician’s assistants will be filling in the gaps more and more. On another angle, the same article states that this will free up the more medically trained physicians for higher risk procedures. When comparing nurse practitioners and family physicians there is a large difference in amount of schooling; classroom hours vs. clinical hours, the physicians have more in each area. However, in order to be accepted into the masters of nursing to pursue the nurse practitioner degree; typically years of nursing experience are required, which may fill this gap in schooling with real world experience. For either profession the continuing education requirements vary by state. Each is a licensed provider and must continue to practice as well as keep up with continuing education credits each year or take a licensing exam again. While physicians are higher paid, the patient experience with nurse practitioners is a draw and a skill to use for negotiations.

“Of more than 100 published, post-U.S. Office of Technology Assessment (OTA) reports on the quality of care provided by both nurse practitioners and physicians, not a single study has found that nurse practitioners provide inferior services within the overlapping scopes of license practice.” (Bauer, 2010)

The above statement refers to studies attempting to find differences in quality of care between physicians and nurse practitioners. Public education on the lack of difference is also a necessity. With studies proving the parallel in care, it should only be right that the two are viewed as equals and reimbursed and regarded in thought as so.

Naturally some physicians have felt threatened by the nurse practitioners’ ability to somewhat overlap their jobs. Once a graduate nurse practitioner passes the certification test, they are eligible to sit for the DEA examination for prescription services. Despite the possible duplication of services; the cost of the nurse practitioner services is lower than the same services provided by a physician. “A study in Tennessee found that costs at nurse practitioner-managed practices were 23% below the costs of care delivered by other primary care providers; inpatient hospitalization rates were 21% lower” (Bauer, 2010, p. 230). By nurse practitioners providing cost-effective care with lower hospital admission rates patient satisfaction scores increase not only because of those factors, but patient satisfaction scores are typically higher overall with nurse practitioners in the outpatient setting (Agosta, 2009). The lower cost of nurse practitioners has also made them more available to practice in a variety of settings from on site with employers, to schools, to wellness centers.

The exact privileges of various nurse practitioner specialties vary by state, organization, and personal confidence level. Those nurse practitioners practicing independently typically are allowed to admit to hospitals, write prescriptions up to and including controlled substances, and also bill for all services rendered under their care. All are services that parallel traditional physicians, but by a different profession. Hopefully the new health care reform laws will “get rid of out-dated scope-of-practice variances and reform advanced practice nursing by disseminating best practices across the country and creating incentives for their adoption” (Frellick, 2011, p. 49). The same article makes a very valid point that not one model will work across the board; every health care system and states vary in what they allow within the scope of practice. With reform potentially providing incentives to providers for primary care goals potentially through ACO’s, overall improved health throughout the population will result and variations of standards of care will become uniform.

Personal Perspectives

The draw of independence is what drives a lot of nurses to further their education to nurse practitioners. “Nurse practitioners define independence as being free from regulation imposed by another profession” (Buerhaus, 2010, p. 346). This speaks to the point of autonomy and independence nurse practitioners can have. The ability to practice as a provider as well as maintain nursing skills is attractive to current nurses seeking to further their education. Of course they can always work collaboratively with a physician and other care givers, but it is not a must. Nurse-managed clinics are becoming more common and are a cost effective solution to the reform act where assessing cost and being financially responsible are being brought to the forefront of quality care. In a time of health care reform and financial instability a nurse-managed clinic is a viable and attractive option to increasing the numbers of primary care providers available to the public.

In an interview from Nursing Economics it was said that nurse practitioners have been taking over rural practices of retiring family physicians and are well receipted in the community. The percentage of insurance companies that are paying for nurse practitioners as primary care providers is increasing over time; in 2004 20% of insurance carries covered nurse practitioners as primary care providers and in 2009 it was up to 52% (Buerhaus, 2010, p. 347). As reform comes into law, the coverage for nurse practitioners is only expected to grow as they are a cost effective option and study after study has found that the outcomes from nurse practitioners and physicians of the same specialty have the same outcomes and recoveries (Bauer, 2010). Using this reasoning the reimbursement rates and coverage from insurance companies will begin to level with those of physicians, in ratio to level of expertise in my opinion. Nurse practitioners must start fighting the current billing practices of being an “incident to” physician care; and bill as a provider separately to ensure independence (Counts, p. 14). By doing so not only will the reimbursement for their services be fair, it will also reinforces their independence and difference from traditional physicians.

As the playing field becomes more level, physicians who have been fighting the advancement and autonomy of nurse practitioners will be overtaken by those who feel this is the answer to future health care. There is a sense of competition between these two groups for clientele in areas that have practices in close proximity. Like any business it is a free market and I believe people will ultimately make their own decisions, but with the reform, education on the nurse practitioners capabilities should be made known to the public. Some feel that politically through the recent changes and very public debates the nurse practitioner has been made out to be a “substitute” for traditional physicians and this is not the case at all (Weiland, 2008). Like any free market, health care will always be a source of innovation, competition, and income.

Using this free market to better the health of the community should be kept in all providers’ foresight. As people choose products to fit their family’s needs, they will soon be able to do this with health care due to increased access; some will choose the more expensive “brand name” option, i.e. traditional physicians, and some will choose something comfortable, yet affordable, and be able to continue to buy it, the nurse practitioners. Some people prefer to see their physician once a year, have everything taken care of no matter what the cost. Others would rather see their practitioner more often and build a working relationship because they are able to afford to do so. This is where nurse practitioners have the advantage and it has been found that nurse practitioner visits are typically longer; with higher patient satisfaction afterward, as well as patients felt they could go more often, for the little things, to keep on top of their health because it is affordable (Agosta, 2009).

Keeping all these points of autonomy, affordability, and high patient satisfaction in mind; why not become a nurse practitioner? While working on an inpatient hospital unit, following doctors’ orders, day in and day out, it starts to feel like an assembly line. Repetitive tasks are common nursing practice, while caring for different patients and occasionally a different diagnosis. The patient care side is what I love about nursing; including building new relationships, getting to know people, and helping them improve their through holistic care. What I did not like was having to call for an order to get an extra blood sugar because something was not quite right, or calling the physician in the middle of the night because someone had low output, knowing very well that they just needed more intravenous fluids. I craved autonomy. Being able to use my bedside nursing skills while diagnosing and treating my own patients, as well as being their primary care provider is what I have truly always wanted to do.

I feel that this class of nurse practitioners currently studying will be entering the field at a very critical tipping point. I will graduate in 2014; this is when reform is scheduled to become law and fully in effect. Being in school during the initiation phases gives us the ability to have access to the most current research, be in class for discussion as things happen, and learn with the changes as they roll out. As more nurse practitioners enter the market with this background thinking that they are the route to change primary care delivery in the United States, I think the stronger the movement will become. The greatest advertising is word of mouth. The more people that are using mid-level providers as their primary care resource, I believe the more the idea will catch on and thus become a norm. My goal as a practicing nurse practitioner is to educate the public on our capabilities as well as grant access to those who did not have the option of even having a primary care provider before. By providing quality primary care to larger numbers of people, the healthier the general population will potentially become.

Granting access is my main goal as a future provider. No one should have to go without health care due to cost. Health is a right, not something that only the rich or employed are allowed. Right now a lot of literature seems to be focused on providing care to rural areas, but I really think the focus should be universal. The rural population is at a disadvantage simply by distance, but the same is true for someone who lives in a suburb with no public transportation to their local clinic. Again, access to care is a very important part of the reform laws that we need to support and educate our patients about. Many people will hear access and simply think physical location, but the number of available providers as well as a diverse field of providers also speaks to access. Finding a primary care practitioner or physician is not a one size fits all case. Matching individuals to a provider that fits their own personality and needs is a must as well. I feel that nurse practitioners tend to be more in tune with their patient’s holistic needs; such as psychological needs as well as social in addition to physiological health simply due to their initial nursing background.

Focusing on family-centered primary care is important to me as a future nurse practitioner. Once people have access to care; be it physical or financial, the next main focus is on the importance of the primary care that people now will have access to. To focus on the whole family, not only an individual, health behaviors and problem areas can be treated more effectively. Having children as well as their parents under one providers care gives insight to family health and dynamics. Also, by treating and following the family as a unit, I believe a better rapport can be achieved as well as improving support systems within a family.

Relationships between providers are also important within a community. “Expectations are that nurse practitioners and other primary care providers; such as nurse practitioners, specialist advanced practice nurses (APNs), and physician assistants will increasingly fill primary care service gaps,” (Street, 2010, p. 438). Street also mentions that physicians who work in coordination with nurse practitioners have more positive attitudes toward them (p. 438). By working side by side, each other’s work becomes recognized and appreciated. Doing so in a primary care, family practice environment would help the holistic care aspect by providing a range of provider types and different backgrounds and attitudes. Collaboration between physicians and practitioners allows for ideas for care coming from both a medical background as well as nursing.

Having family centered holistic care ensures that primary care does not solely focus on the illness portion of health, but also the health aspect and healthy families. I believe family practice is a very important specialty as to build relationships with the entire family in order to treat each individual. “Comprehensive skills in patient assessment, as described by the participants, were central to all nurse practitioner practice,” (Carryer, 2006). By first having nursing skills, assessment, and intuition, then building the provider aspect on top it builds a holistic provider to give holistic family care.

Personally, my transition from emergency nursing to primary care seems that it will be fairly smooth in relation to patient base. In the emergency room we deal with minor illnesses to major trauma. “Nurse practitioners are capable of dealing with minor illnesses” up to doing “work autonomously and make independent diagnoses and treatment decisions,” allowing for effective substitution for physicians (Perry, 2005). This is day to day practice of many nurses in the emergency room having to make fast decisions and collaborate with physicians in an instant; however, as nurses, we must receive official orders and diagnoses from the physicians. In the future working as a nurse practitioner, I will be able to autonomously make these treatment orders directly from the nursing and medical diagnoses. Not only can this take place emergently, but all of these skills can carry over to primary care or urgent care where many nurse practitioners work. Having a strong emergency assessment skills background, I believe I will transition to an effective and efficient nurse practitioner regardless of setting. Being comfortable in preforming a thorough assessment allows me to become more familiar with the patient’s background and their holistic needs in primary care to keep them well, not solely focus on illness.

Regarding this transition, my main concern is that nurse practitioners will not be brought to the forefront as the reform makes it seem as if they will. I am a strong believer that they, as a profession, are an unrecognized gem. By gaining more recognition will allow the nurse practitioners as a profession build more into physician-like collaboration in research and innovation as well. This recognition should also allow more research to surround the nurse practitioners as a profession.

“The ability to describe those explicit complexities of human interaction occurring at the NP-patient interface is of tremendous professional significance within the diverse healthcare arena today. Data regarding the specific elements of the NP-delivered primary health care that can be demonstrated to favorably impact general patient satisfaction in such a setting is severely lacking in the literature (Agosta, 2009)

While there are many studies surrounding nurse practitioner skills and abilities in comparison to physicians, there is not a lot of research and innovation surrounding them as their own profession. By doing this type of research it will not only open up new research avenues, but also give patients more options for care with true evidence based practice; not just practice based of similar skills of a similar profession.

In conclusion, nurse practitioners are going to be a vital role to health care reform in the United States. They will provide accessible care, affordable care, and fill a large physical gap in primary care providers. By either independent practice, or in collaboration with a physician or group or ACO, nurse practitioners have been proven to be an effective resource with proven care that is on