Betting on Reno
(Editor’s Note: This is the fourth in a series of articles on the Athens uninsured initiative, produced by graduate students in the Health and Medical Journalism Program at the University of Georgia. Visit the previous articles by clicking on the red button to the left.)
More and more Americans, especially in rural areas, say they have no primary care doctor. And the situation may get worse before it gets better. As millions of people become newly insured in 2014 and the population grows, many are worried that those with new coverage will overwhelm the nation’s already short supply of primary care physicians.
“Fifty years ago, half of the doctors in America practiced primary care, but today fewer than one in three do,” the Senate Primary Health and Aging subcommittee reported in January. And of the 17,000 new doctors graduating from medical school each year, only 7 percent choose a primary care career.
So who will fill this growing primary care gap, especially in rural America? In many cases, the answer is nurse practitioners (NPs) – advanced practice registered nurses who have earned a postgraduate nursing degree that prepares them to practice at a more advanced level than a regular RN.
NP training is faster and less expensive than medical school, and while the number of primary care doctors is dwindling, the number of NPs in primary care settings is increasing.
“When it comes to primary care, you are seeing fewer and fewer doctors, and more and more nurse practitioners and physician assistants,” said Joshua Cole, who helps members of Nevada’s Access to Healthcare Network obtain appropriate care. Years of medical school and residency aren’t needed to diagnose an earache, he said. “That is very easy for a nurse practitioner or a physician assistant to do.”
A physician assistant (PA) practices medicine under the direction of physicians and surgeons. They are formally trained to examine patients, diagnose injuries and illnesses, and provide treatment.
A large but restricted role
For the past seven years, the Access to Healthcare Network has helped low-income adults get care without commercial health insurance or other coverage. Members of the network pay a low monthly membership fee and then can get primary care, specialized care, and a wide range of medical services at a greatly discounted rate.
Today the network operates statewide in Nevada and has about 8,000 members.
Now, health care leaders in Athens are looking to replicate the plan in northeast Georgia. The number of potential patients is huge in this area, where many people work low-wage jobs with no health benefits.
When more individuals get access to health care — whether through expanded coverage or some other program — that means more patients that someone will have to treat. That, in turn, can lead to a shortage of primary care physicians. But unlike some systems plagued by such a shortfall, the Access to Healthcare Network model has no problem allowing nurse practitioners to fill the gap.
Each of the network’s members has a designated primary care provider. While some members are assigned a physician, such as an M.D. or D.O. (osteopathic physician), some are assigned a nurse practitioner or a physician assistant. Cole says that so long as the members receive consistent, effective care, they don’t see any real difference.
For handling patients’ primary care needs, “we don’t really differentiate between M.D., D.O., nurse practitioner, and physician assistant,” he says. “As long as they are licensed in the state of Nevada to offer these services, we’ll treat them basically the same.”
Already across Georgia and the nation, nurse practitioners typically deliver the care in the expanding retail medical clinics in pharmacies, grocery stores and “big box’’ outlets.
Whether nurse practitioners can truly ease the primary care crisis, however, depends on “scope of practice” laws that vary from state to state.
In a national survey, researchers at the University of California, San Francisco found that although NPs are capable of performing a full range of primary care services, no state permits them to do everything they know how to do. Every state has some sort of restrictions
In Nevada and Georgia, a nurse practitioner is legally authorized to make a diagnosis in a setting officially supervised by a physician, but an NP cannot prescribe drugs for a patient without a physician’s written permission. Nor can NPs refer patients directly to other providers.
And while nurse practitioners serve as primary care providers for many members of Nevada’s Access to Healthcare Network, they don’t have the same independent status within the network as do physicians. The NPs cannot join the network as primary care providers on their own, but instead derive their affiliation from their supervising physicians who are signed up with it.
Political issues not settled
NPs seeking an expanded role often find opposition from state physician organizations.
The executive director of the Medical Association of Georgia, Donald J. Palmisano Jr., says his organization “believes that nurse practitioners are an important part of any physician-led patient care team, and MAG applauds nurse practitioners for the contributions that they make to the health care system in Georgia.”
But Palmisano adds: “It is important to keep in mind that there are fundamental differences between physicians and nurse practitioners. Physicians are required to complete a far more rigorous education and training program, including an undergraduate degree, four years of education at a medical school, and three to seven years in a residency program – depending on the specialty.”
Advocates for increasing the number of nurse practitioners undoubtedly will continue to fight state regulations that restrict NPs from practicing within their scope. But this effort often faces stiff resistance. Legislation to give advanced practice nurses the authority to order imaging tests failed to pass the Georgia General Assembly this year.
As states implement the universal access provision of the Affordable Care Act, they have the opportunity to reconsider scope-of-practice statutes for NPs. If state legislators take into account dwindling access to primary care, especially for rural citizens, many health care leaders believe that NPs will get the opportunity to practice what they know.
Indeed, if Georgia law allows, says Allie Chambers, executive director of the Athens Health Network, “I would not foresee a problem with having nurse practitioners, under the direction of a physician, serve as primary care providers.” The Athens Network is bringing the Nevada plan to Georgia.
Health policy expert Barbara Glickstein of Hunter College’s Center for Health, Media & Policy, also expects barriers to fall. “If you are a nurse practitioner and you have experience practicing in primary care, why couldn’t you or why shouldn’t you be working as a leader giving primary care to patients in a community?” says Glickstein, an RN.
Alyssa Sellers is a graduate student at the University of Georgia. She is currently pursuing a master’s degree in journalism and mass communication with a concentration in telecommunications.