health care

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.

NEXT: KC Johnson and Stuart Taylor, guest-blogging about "The Campus Rape Frenzy: The Attack on Due Process at America's Universities"

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

    BREAKING NEWS: Reason contributor wants poor people TO DIE.

    1. The FDA is right on that, furiously writing up that new regulation to protect the poor chillins from these rogue nurses.

  2. And why can’t I see my animal-vet for people-med-care? If it’s MYYYY friggin’ body? Or is it Government Almighty’s body?!?!?

    1. “Well, my doctorate’s in English, but that seems like a mighty fine pulse to me.”

      1. Well-written.

    2. “Or is it Government Almighty’s body?!?!?”

      Is that a real question? Try getting caught with a scheduled substance that was given a fancy new name and NOT prescribed to you because your doctor determined that it’s right for you we gotta push this shit harder.

    3. I don’t see a problem with going to the vet when you’re a little hoarse. Maybe you have a frog in your throat.

      1. I’m reporting you to the proper authorities for your extreme pun-ishment of the H&R commenters (I was going to use Commentariat, but according to my Googling, it’s the news media).

    4. The only choice you’re allowed to make with your body is abortion. Everything else is to be decided by Top. Men.

      1. And that’s only because the pro-abortion side isn’t strong enough to make it mandatory.

    5. If there’s a gerbil stuck in my ass, should I go to an animal-vet, or to people-med-care? Asking for a friend.

      1. Neither, just go to the shelter and get a cat.

      2. Hoover Outlet

      3. Just get a friend with a match.

      4. Is this an old-lady-who-swallowed-a-fly situation? If so, I would recommend stuffing a snake or a fox up your ass as well, to dispose of the gerbil.

        1. It stinks in this foxhole.

      5. Hi EDG reppin LBC,

        I’m not sure as to whether I should:

        ‘A) Commend you for your tolerance of alternative lifestyles, w/respect to your friend with the gerbil up his or her ass, or,

        ‘B) SJW-style condemn you for your tolerance of intolerance!

        To make my choice, I must ass… Um, ask…

        Was the gerbil paid prevailing wages or “fair” wages? If not, why not?

  3. It amazes me how much doctors hate hate hate nurse practitioners. Every time I’ve gone (or taken kids) to an NP because a doctor wasn’t open, and I follow up with the doctor, he immediately rolls his eyes on hearing it and insists on questioning every decision they made. I’ve had two doctors tell me opposite things, but there is professional courtesy there- “Well, the other doctor may have seen this and justifiably worried about the implications…”

    Yet, even when the doctor and NP agree, I get a lecture about how, “in this situation the nurse was correct, but they probably missed a couple key issues that we need to follow up on.”

    Frankly, half of what doctors do is the sort of data filtering through libraries of information that machine learning does every day. They are realizing this. They used to be special because very few people took the time and expense to become vast storehouses of medical information. But technology is quickly making them obsolete, and they are fighting tooth and nail to stay relevant.

    1. What’s needed isn’t to replace doctors with machines but to integrate doctors and machines.

      1. No, replacing doctors with machines and letting you manage your own healthcare is exactly what needs to be done.

    2. The day doctors are replaced by computers for a net savings with improved results will be a wonderful day, and cannot come soon enough.

      1. Web-based diagnostics somewhat make me skeptical.

        Everything’s cancer apparently.

      2. Shut up you racist bigot monster!

        /FDA /AMA

        1. Don’t forget “deplorable.”
          (remember: even if they aren’t Trump fans, you are supposed to say they are so the correct team cheers you on)

    3. Without all of the diagnostic machines, you can diagnose something just as well as any doctor with only a search engine at your disposal. Once small inexpensive diagnostic equipment comes along, doctors are irrelevant. It’s the FDAs job to make sure that doesn’t ever happen.

      1. You misspelled AMA.

    4. They also question other doctors’ decisions as well. In fact, they can get so belligerent that the only way they are happy is to run the competition out of town! And, don’t be a surgeon in a small town. All of the other, non-surgeon, doctors question that you can actually have a better education in science than they do! In this state, an NP can practice in a remote office with one visit a week from a “supervising” physician. And, if a doctor works one of those “satellite clinics”, the other doctors’ groups will figure out how to get him out, so they can implant their own NP or junior partner to funnel business, and profits, into their group practices. Been there! Done that! Competition, above all, to pad their own pockets! The almighty dollar is their God!

  4. Hm… would I prefer being ministered to by a nurse with maybe twelve other patients or a doctor with forty. Fractions were always my weakest suit.

    (Waiting for Groovus to happen along and mock my ass-pulled numbers.)

    1. So you like gang-bangs, huh?

      1. Pornographer: [Shows Bernard a video] This is the latest. Set in a women’s prison. ?25.

        Bernard: Do you have anything with nurses?

        Pornographer: Yeah, sure, all sorts.

        Bernard: What kinds of nurses?

        Pornographer: Well, ones with big tits!

        Bernard: No, I’m more interested in nurses who do paperwork, filing, that sort of thing.

        Pornographer: That’s very specific. Oh, how about this? [Shows him another video] “Administrative Nurses”, ?40.

        Bernard: Sorry, that should say “Senior Administrative Nurses”, that’s really the only thing I’m interested in.

        [The pornographer lifts his thumb to reveal the video’s full title, “Senior Administrative Nurses”]

        Bernard: Well, maybe we could sit down, open a bottle of wine and watch it together?

  5. Yeah, the medical industry is just almost hopelessly fucked up at this point. I don’t see any hope for it to be fixed without a technical revolution that makes the current system obsolete. Also, probably will have to close down the FDA so they won’t totally fuck that up too.

    1. It’s a strangehold, with rent-seeking the only purpose or goal.

      1. Exactly that.

    2. The doctors’ labor union, the AMA, controls medical legislation.

  6. Hinkle made it all the way through the first page without a single mention of Trump. Too busy chattering libertarian thoughts on healthcare.

    Hinkle is my new favorite.

    1. I agree, he definitely trumps most of the other writers here.

  7. The government spends all of this time obsessing about the cost of healthcare. Yet it does nothing to increase the supply of health care and in fact often takes efforts to restrict it. There are some odd quirks to health care as a commodity. It is however not immune to supply and demand and the best way to drop the price of it is to increase the supply of it. It is really that simple.

    1. Government obsesses about corporate profits, while ignoring the fact that people in the industry are paid ridiculously inflated salaries.

      But nobody is allowed to talk about that. If you do then you hate doctors and nurses and such.

      1. I may be wrong, but I’d read once that Johnson had to woo doctors into supporting Medicaid by essentially letting them fix the prices. That would seem a fatal flaw if one is terribly concerned about limiting costs.

    2. Not only are they working against increasing the supply, they’re also actively working to increase the demand (“healthcare is a human right”). It’s a bad situation.

  8. I’ve always enjoyed dealing with NPs. They spend more time with you, ask more questions, and seem to actually give a shit.

    Doctors tend to always be in a rush, ask questions grudgingly, and don’t appear to give a shit.

    1. I’ve had similar positive experiences with PAs. I wonder how they fit into this discussion. They seem to be allowed to do a lot of stuff.

  9. Combo-breaker!

  10. Between stifling certificate of need regulations and limiting what advanced nurses can do, Virginia seems like a pretty awful place to be a consumer of medical services.

  11. As a Radiologist who interprets exams ordered by both doctors and mid-level providers, I guarantee the NPs and PAs order way more exams and way more useless exams than their doctor counterparts. They have less training and confidence, so rely on imaging. The fact is, everyone could significantly reduce the number of imaging exams ordered and this would greatly reduce healthcare costs, as well as my income.

    Secondly, in professions where there are no true ways to measure success like healthcare, teaching, police work; a start to ensuring best practice is by making it difficult to enter the profession. Although, there are studies claiming to measure outcomes, they are always flawed in substantial ways; because, there is no legal way to perform true double-blinded case controlled studies in much of healthcare, teaching and police work. Flawed studies are not “the best available data”, they are flawed and always should be disregarded as such.

    1. Secondly, in professions where there are no true ways to measure success like healthcare, teaching, police work; a start to ensuring best practice is by making it difficult to enter the profession.

      Bullshit. Fuck you, slaver.

    2. Decades ago, the US Air Force studied dental health of incoming recruits, and compared USA states with tough dental laws v/s lax dental laws (licensing, etc.). Recruits from the “lax” states had better dental health…

      I bet USAF is forbidden to do such studies now any more!

  12. It’s hard to sell reforms like this to the gen’l public. “This country can afford 1st class care!” “This would be lowering the standard of care. It must be, else why would they say it lowers costs?” “Let’s focus on delivering more care, not spreading it thinner or substituting 2nd best.” “For all I’m paying, I expect a real MD!”

  13. Is this a government problem, or an AMA problem?

  14. Professional monopoly is the problem. Laws such as prescription laws increase the cost of health care. The AMA was organized back in 1847 with the express purpose (like any labor union) of increasing the income of doctors. The way this was done was through lobbying Congress to pass laws favoring what the AMA wanted. The same thing has been done by every profession and occupation seeking to increase incomes of its members. Just like organized labor has done.

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