Nurses, Advanced Practice Nurses: Workforce for the

21st Century

Julie Fairman, PhD, RN, FAANProfessor

RWJ Investigator in Health Policy

Director, Barbara Bates Center for the Study of the History of

Nursing

Health Reform Dilemmas

Payment

Access

Quality

Cost

Provider Supply

Increasing specialization

Family practice, down 51 percent

Internal medicine, down 18 percent

Obstetrics-gynecology, down 16 percent

Pediatrics, down 8 percent

General surgery, down 4 percent

Dermatology, up 7 percent

Emergency medicine, up 18 percent

Diagnostic radiology, up 34 percent

Pathology, up 122 percent

Anesthesiology, up 150 percent

Is your facility currently seeking physicians?

No: 14%

Yes: 86%

If yes, what type? (check all that apply)

Primary care . . . 81%

2007 Physician and Nurse Supply Survey,Council on Physician and Nurse Supply

Not Enough Primary care physicians

NY VNA, circa 1900, VNA Coll.

“nurses…particularly effective at improvisation, invention….”

Loretta Ford Collection

Innovative Experiments:

1965: Duke University PA Program

Charles HudsonThelma Ingles

Nurse

Doctor

Who shall provide care?????

Dietician, Social Worker, etc.

Who Should Provide Care:

Ms. Shade is a 56 year old woman with a 4 year history of Non-Insulin Dependent Diabetes Mellitus. She has a 10 year history of smoking more than 1 pack per day. She is on a fixed income due to a past disability related to arthritis, another chronic illness. Her current weight is about 25% over the recommended limit for her height, and she also suffers from high blood pressure. On her last visit to her health care provider, her blood pressure was 149/85, her fasting blood glucose level was above normal, around 140 mg/dl, and her hemoglobin A-1C, was elevated at 9 percent. Her feet were still in pretty good shape, warm with palpable pulses bilaterally, and showed no signs of the typical changes accompanying uncontrolled diabetes. At this visit Mrs. Shade requested and received information about a weight loss and low salt diet plan, an exercise plan that was appropriate for low income people, referral for county transportation resources, referral to a community-based “Quit Smoking” program, and correct use of a recently purchased glucometer and home blood pressure set.

Other healthprofessionals

NurseDoctor

NursesDoctors

Borderlands

Context

The American healthcare system is fragmented and difficult for many patients to navigate.

The average Medicare patient sees seven different doctors, according to the New England Journal of Medicine.

Patients with multiple chronic conditions may see up to 16 physicians annually.

It’s easy for important aspects of a patient’s medical history or personal care preferences to fall through the cracks.

A lack of care coordination leads to medical errors, higher costs, and unnecessary pain for patients and their families.

Resident Match Program 2009

Facts on US Nurses

Most numerous health care workers

Shortages driven by demand and context

Largest supply in world

U.S. needs more BSNAiken et al. (2003) JAMA

Variation in basic preparationBSN, AD, Diploma

U.S. Nurse Shortage

By 2020, the demand for RNs will be 2.8 million equaling a shortage rate of 29%

Bureau of Health Professions, July, 2002

Registered Nurses

Licensed by state

Licensing Exam- NCLEXLondon, Hong Kong

726 per 100,000 persons

Most employed in hospitals

8% with advanced degrees

88.4% white, 94.3% women

HRSA Health Professions Workforce Nursing Reports

Advanced Practice Nurses2004

Nurse Practitioners

Clinical Nurse SpecialistsSpecialty Care & Mental Health

Nurse Anesthetists

Nurse Midwives

Interlocking cases that addressed historical questions

Relationship between private and public initiatives in practice and education

Political rhetoric of the professional organizations

Influence of gender , race, and class in the generation of new roles and knowledge

Influence of the patient

The importance of personalities

Workforce

Nurse Practitioners46, 328 (1992)63, 191 (1996)85, 000 (2000)141,209 (2004)

Clinical Nurse Specialists25, 000 (1995)72,521 (2004)

2004 Nurse Sample Survey

Policy Implications

Individual-generated patient demand for different models of care can move ideas forward to coalesce to health policy changes.

These changes can be piecemeal and at times inadequate to support large scale reform in the delivery system.

Greater access for patients to nurse practitioner models rests on real and virtual boundary disputes

Policy implications

Develop delivery models organized around the care needed rather than around the type of practitioner who will deliver it.

Look to the large available pool of primary nurse practitioners to work as partners and collaborators rather than ancillaries.

What do NPs do?“Patient Centered”

Assessment

Diagnosis

Treatment

Case Management/coordination of care/integration

Continuity and secure transmission across the health system

Emotional support

Access

“Whole Person”…Family and Community focus

Limitations to Access

Scope of practice

Payment

Competition vs.. Collaboration

Licensure/Certification

Autonomy

Prescriptive authority

U.S. Health Care WorkforceSelected Primary Care Clinician Supply

Source: Cooper RA, et al JAMA 1998; 280:788-94 and COGME’s Eighth Report, November 1996.

Clinically significant questions focused on health policy issues :

How do we decide who provides particular types of care at particular times and places?

Difference in response

Between organizations and

individuals

AMA

AAFP

AAP

Osteopaths

Investigations by state boards of medicine, Prosecution of physicians who collaborated,Political lobbyingDemand for evidence

NP Policy Research

GMENAC Report – 1980 complement vs..

substitute nursing has independent

sphere of practice quality primary care

accepted by patients cited Kaiser

study (75% all visits) need for Medicare &

Medicaid reimbursement

OTA Report - 1986 High quality of care

Patient satisfaction

Good potential for managed care

Barriers - physician resistance, legal restrictions, lack of reimbursement, limited coverage for health promotion/preventive care

NP Policy Reports - 1990s

1995 GMENAC Report Joint meeting Integrated Requirements Model Need for 12-24% increase in NPs

1997 HRSA Report on NP Preparation Access to primary care Increase in NP program support

Societal Acknowledgements

HCFA removed Medicare requirement of physician supervision for nurse anesthetists

NPs in all states can dispense drug samples

Harvard Business Review - resistance to NPs is “flawed logic,” “disruptive technology”

IOM identifies NPs as primary care providers

Medicare identifies NPs as primary care providers

State reform initiatives: NPs as key components

Health reform bills: all include NPs as primary care providers

NP Outcome Studies

OTA Report - 1986

Naylor et al., 1994 - Transitional care model

Mundinger et al., 2000 (RCCT)

Larkin (2003)- patient days, days on ventilators, complications

Laurent, Reeves, Hermens, et. al. (2006) – Cochran data Base Review (substitution of physicians by nurses)

Medicare Payment Percentage

For virtually all services in all settings, Medicare will cover PAs, APNs at 85% of the physician fee schedule

Services are billed at the full rate. Use of the PAs/APNs provider number triggers the 85% payment

[Medicare Transmittal AB-98-15]

“It’s the delivery system, stupid”

4/5 Americans with health insurance cannot find a primary care provider

NYT 2009 Major source of bankrupt individuals; medical bills

Main increase in Medicare expenditures 1987- 2002??? (Thorpe and Howard, Health Affairs 2006)

Many models tried: CCM Disease Management Case Management Guided Care Geisinger’s Personal Health Navigator (Paulus, et.al. (2008)

Health Affairs

Consider:

Not enough primary care physicians

Why not NPs?

Culture/structure: “tyranny of the urgent” (Berenson, et.al. (2008) Health Affairs

Where do NPs fit in current health care reform debates?

Senate and House bills House “Affordable health Care for America Act” passed

by 5 votes Senate “Patient Protection and Affordable Care Act” in

debate with political issues such as abortion, public option going to be key

Demonstration projects Medical home Regional consortiums

Funding for primary care education

Companion bills: Faculty support

Proposed Medicaid changes

Increase patient pool

Funding for FQHC/safety net clinicsNurse managed clinicsBirthing centers

Other changes:

Medical home language:

from physicians to physicians, nurse practitioners, and physician assistants

What’s Not Addressed

Scope of practice

Licensure

Equitable pay for equitable services

Making Room in the Clinic

Modern health care depends upon:

Nurses, physicians, and patients working together

finding common ground

putting patients first

knowing how to use the skills and knowledge of providers across time and place