One Small Step to Improve Healthcare

Government should let nurse practitioners do more.

For several years now the country has been arguing over Obamacare, which sought to fix just about everything that's wrong with health care all at once. To put it gently, the effort failed. In the meantime, the nation has missed opportunities to make changes that are smaller—and better.

For instance. One single, simple change could …

1. Help alleviate the shortage of doctors in areas where doctors are too scarce.

2. Lower the cost of routine health care.

3. Get more medical care to more people, in more convenient venues.

4. Enable doctors to spend more time with their sickest patients.

5. And even help mitigate income inequality.

The change? Relax state regulations to let advanced-practice nurses do more.

Advanced-practice nurses have master's degrees or doctorates and advanced training in diagnosis and treatment. But their "scope of practice" is limited, and in many states—including Virginia—they are forbidden to practice medicine independently. In those states APRNs can practice only under the supervision of a doctor who will periodically check behind them, review charts, and so on.

Doctors tend to like this arrangement, for the obvious reason: It limits competition—especially because, while nurses are required to collaborate with a doctor, a doctor is not required to collaborate with nurse practitioners. If too few doctors in a given area care to collaborate with APRNs, well, tough luck.

This is not what doctors tell you for public consumption, of course. The party line from medical societies is that giving nurses more freedom to treat patients would be dangerous. As the Medical Society of Virginia put it in a letter to the Department of Veterans Affairs—which recently expanded the scope of practice for some nurses precisely to alleviate long waits for treatment—"education and training differences are stark between nurse practitioners… and physicians." Hence, "physicians are best equipped to treat complex and chronically ill patients."

Of course, many patients do not have complex ailments and are not chronically ill. But doctors do indeed receive more training than nurses. What's more, their training is different. While doctors generally focus on identifying and solving problems, nurses tend to look at a broader set of issues—such as how an ailment affects the patient's life in other areas, and how to help the patient cope with such effects.

But the fact that doctors receive more training does not lead to the conclusion that doctors give patients better care. To the contrary: A large amount of research on the subject shows that patients often do better under the care of APRNs.

A meta-study published in the Journal for Nurse Practitioners, for example, found that "outcomes for NPs compared to MDs … are comparable or better for all 11 outcomes reviewed. A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs."

Perhaps it is inevitable that a nursing journal would publish results favorable to nurses. But figures from the National Practitioner Data Bank show that APRNs in states where they can practice independently actually have fewer malpractice reports than those in states where they can't.

What's more, a 2010 report by the National Health Policy Forum cites a federal study that found APRNs "could furnish certain types of basic care of an equivalent quality to that provided by physicians and were better than physicians at tasks requiring patient communication and education. Subsequent studies have reached similar conclusions and have additionally found higher levels of patient satisfaction in care encounters with nonphysicians."

And: The average cost of a visit to a nurse "is 20 percent to 35 percent lower than the cost of a physician office visit." That's a significant difference for the uninsured or those with high deductibles.

And because APRNs make in the neighborhood of $100,000 a year—compared to $186,000 for primary care physicians and $340,000 for specialists—shifting some business from high earners to moderate earners who charge less might chip away at wealth disparties. (Protecting earnings is, after all, frequently the main objective of those who defend market-entry barriers.)

***

Six years ago the Institute of Medicine also looked at scope-of-practice regulations. Its No. 1 recommendation: "Remove scope-of-practice barriers."

The IOM said scope-of-practice rules for APRNs "are related not to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work." Also, "most studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures. Moreover, the studies suggest that NPs may provide improved access to care."

Two years ago the Federal Trade Commission likewise examined scope-of-practice regulations and issued its own report: "Competition and the Regulation of Advanced Practice Nurses." Among its findings:

• "There is increasing agreement among health authorities that APRNs could safely provide an even broader range of primary care services, if regulatory and reimbursement policies would permit them to do so."
• "Scope-of-practice restrictions may eliminate APRNs as an important source of safe, lower-cost competition."
• "Expanding APRN practice is widely regarded as a key strategy to alleviate provider shortages, especially in primary care. … The United States faces a substantial and growing shortage of physicians, especially primary care physicians, which has significant consequences for basic health care access for many American consumers."
• "Reduced access has the greatest impact on America's poorest citizens, including Medicaid beneficiaries. Physicians are less likely to practice in low-income areas or to participate in state Medicaid programs."
• "Relative to primary care physicians, APRNs are more likely to practice in underserved areas and care for large numbers of minority patients, Medicaid beneficiaries, and uninsured patients."
• "In addition, the shorter and less costly education and training requirements of APRN practice suggest that APRNs may be able to meet fluctuations in demand more quickly or efficiently."
• "The kinds of supervision requirements examined (by the FTC) do not appear to be justified by legitimate health and safety concerns."

No need to beat this dead horse any further. The case seems pretty clear. Congress and the states (including Virginia) could make health care less expensive, less scarce—and in some cases better—by letting nurses perform more of it.

So why don't they?

This column originally appeared in the Richmond Times-Dispatch.