Carla K. Johnson, AP
With a looming shortage of primary care doctors, 28 states are considering expanding the authority of nurse practitioners. These nurses with advanced degrees want the right to practice without a doctor's watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called Doctor.
For years, nurse practitioners have been playing a bigger role in the nation's health care, especially in regions with few doctors. With 32 million more Americans gaining health insurance within a few years, the health care overhaul is putting more money into nurse-managed clinics.
The medical establishment is fighting to protect turf. In some statehouses, doctors have shown up in white coats to testify against nurse practitioner bills. The American Medical Association, which supported the national health care overhaul, says a doctor shortage is no reason to put nurses in charge and endanger patients.
Nurse practitioners argue there's no danger. They say they're highly trained and as skilled as doctors at diagnosing illness during office visits. They know when to refer the sickest patients to doctor specialists. Plus, they spend more time with patients and charge less. “We're constantly having to prove ourselves,” said Chicago nurse practitioner Amanda Cockrell, 32, who tells patients she's just like a doctor, except for the pay.
Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85 percent of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60.
The health care overhaul law gave nurse midwives a Medicare raise to 100 percent of what obstetrician-gynecologists make — and that may be just the beginning. States regulate nurse practitioners and laws vary on what they are permitted to do:
- In Florida and Alabama, for instance, nurse practitioners are barred from prescribing controlled substances.
- In Washington, nurse practitioners can recommend medical marijuana to their patients when a new law takes effect in June.
- In Montana, nurse practitioners don't need a doctor involved with their practice in any way.
- Many other states put doctors in charge of nurse practitioners or require collaborative agreements signed by a doctor.
- In some states, nurse practitioners with a doctorate in nursing practice can't use the title of Dr. Most states allow it.
The AMA argues the title Dr. creates confusion. Nurse practitioners say patients aren't confused by veterinarians, chiropractors or dentists using the term.
The best U.S. study comparing nurse practitioners and doctors randomly assigned more than 1,300 patients to either a nurse practitioner or a doctor. After six months, overall health, diabetes tests, asthma tests and use of medical services like specialists were essentially the same in the two groups.
“The argument that patients' health is put in jeopardy by nurse practitioners? There’s no evidence to support that,” said Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health.
Other studies have shown that nurse practitioners are better at listening to patients, Needleman said. And they make good decisions about when to refer patients to doctors for more specialized care.
The American Medical Association is fighting proposals in about 28 states that are considering steps to expand what nurse practitioners can do. “A shortage of one type of professional is not a reason to change the standards of medical care,” said AMA president-elect Dr. Cecil Wilson. “We need to train more physicians.”
Massachusetts, the model for the federal health care overhaul, passed its law in 2006 expanding health insurance to nearly all residents and creating long waits for primary care. In 2008, the state passed a law requiring health plans to recognize and reimburse nurse practitioners as primary care providers.
That means insurers now list nurse practitioners along with doctors as primary care choices, said Mary Ann Hart, a nurse and public policy expert at Regis College in Weston, MA. “That greatly opens up the supply of primary care providers,” Hart said. But it hasn't helped much so far. A study last year by the Massachusetts Medical Society found the percentage of primary care practices closed to new patients was higher than ever. And despite the swelling demand, the medical society still believes nurse practitioners should be under doctor supervision.
The group supports more training and incentives for primary care doctors and a team approach to medicine that includes nurse practitioners and physician assistants, whose training is comparable. “We do not believe, however, that nurse practitioners have the qualifications to be independent primary care practitioners,” said Dr. Mario Motta, president of the state medical society.
The American Nurses Association hopes the 100 percent Medicare parity for nurse midwives will be extended to other nurses with advanced degrees. “We know we need to get to 100 percent for everybody. This is a crack in the door,” said Michelle Artz of ANA. “We're hopeful this sets the tone.”
In Chicago, only a few patients balk at seeing a nurse practitioner instead of a doctor, Cockrell said. She gladly sends those patients to her doctor partners. She believes patients get real advantages by letting her manage their care. Nurse practitioners' uphill battle for respect makes them precise, accurate and careful, she said. She schedules 40 minutes for a physical exam; the doctors in her office book 30 minutes for same appointment.