DiversityNursing Blog

Nurse Practitioners More In Demand Than Most Physicians

Posted by Erica Bettencourt

Fri, Jul 17, 2015 @ 10:44 AM

Bruce Japsen

Contributor: Marissa Garey

www.forbes.com 

It comes as no surprise that primary care doctors are, and have always been, highest in demand. All hospitals and health systems require family physicians, as well as other internists, to service their patients. However, recent data shows that this paradigm is shifting.

To fill the necessary vacancies in medical staff, an increasing number of health systems are looking to Nurse Practitioners and Physician Assistants. According to the Merrit Hawkins’ review, neither of these positions had been among the top 20 in-demand health professionals in 2011. While primary care doctors still rank the highest, NP’s and PA’s have progressed over the past 4 years to be placed among the top 10. Both professional areas have grown to fill critical positions in the healthcare industry.

When it comes to what a hospital or health system needs to fill the vacancies in a medical staff, primary care doctors like family physicians and internists have long been the top need.

But climbing the ranks and jumping past many doctor specialties on the demand scale aren’t physicians at all. They’re nurse practitioners and physician assistants who are filling a critical role for the health care industry, according to national doctor recruiting firm Merritt Hawkins.

The snapshot into the U.S. health care workforce from Merritt Hawkins, a subsidiary of AMN Healthcare (AHS) comes as trends in insurance payment from private health plans, employers and the government under the Affordable Care Act emphasize keeping people well. The value-based care push away from fee-for-service medicine also emphasizes the outpatient care provided by nurse practitioners (NPs) and physician assistants (PAs) working with primary care doctors.

Merritt Hawkins Top 20 Most Requested Searches by Medical Specialty resized 600

“In the team-based, population health model, primary care physicians remain recruiting target number one, but PAs and NPs are target 1A,” Travis Singleton, senior vice president at Merritt Hawkins said in a statement to Forbes. “You really can’t build patient access or patient satisfaction without them.”

To be sure, patient satisfaction and quality of care are being built into contracts insurers have with medical care providers as health plans like Aetna AET -0.78% (AET), Anthem (ANTM), UnitedHealth Group UNH -0.67% (UNH) and the nation’s Blue Cross and Blue Shield plans consolidate into larger payers and shift payments to value-based care.

For the ninth consecutive year, the family doctor was the most highly recruited doctor. Internists were second on the Merritt list followed by psychiatrists amid a nationwide shortage of behavioral health specialists.

“Combined, physician assistants and nurse practitioners were fourth on the list,” Merritt Hawkins said in its report. “Four years ago, neither NPs or PAs were among (the firm’s) top 20 assignments either collectively or individually.”

On their own, nurse practitioners ranked fifth behind hospitalists who were fourth and physician assistants were in 10th place, tied on the “in demand” scale with general surgeons. Advanced practitioners are more in demand than several specialties including general surgery, cardiology, urology and neurology.

Merritt Hawkins’ review comes from a database of more than 3,100 recruiting assignments conducted by the firm from April of last year through March of this year.

Topics: nurse practitioners, physicians, medical staff

Let The Nurses Free

Posted by Erica Bettencourt

Wed, Jun 03, 2015 @ 10:47 AM

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We wholeheartedly agree with this article that Nurse Practitioners across the country should be allowed to practice without a doctor’s consent in a variety of medical areas.

What are your thoughts about this important issue? Do you strongly agree or disagree?

In March, Nebraska became the 20th state to allow nurses with the most advanced degrees to practice without a doctor’s oversight in a variety of medical fields. Maryland recently followed suit and eight more states are considering similar legislation.

What does all this mean? Nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to order and interpret diagnostic tests, prescribe medications and administer treatments.

These changes are long overdue.

The preponderance of empirical evidence indicates that, compared to physicians, nurse practitioners provide as good — if not better — quality of care. As I’ve written previously, patients are often more satisfied with nurse practitioner care — and sometimes even prefer it.

The Institute of Medicine is unambiguously clear about this: 

No studies suggest that APRNs [Advanced Practice Registered Nurse] are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs.

In addition, see this review of the literature in Health Affairs.

In general, nurse practitioners have the skills to prescribe, treat and do most things a primary care physician can do. They generally must have completed a Registered Nurse and a Nurse Practitioner Program and have a Masters or PhD degree. In addition, there are physician assistants, registered nurses, licensed vocational nurses, emergency medical technicians, paramedics and army medics. In most states, each of these categories has its own set of restrictions and regulations, delineating what the practitioners can and can’t do.

What should each of these professionals be allowed to do? Whatever they’ve been trained to do.

The doctors counter that someone who hasn’t trained to be a doctor might miss important symptoms or clues that a physician might catch. This observation is true but trivial. Every professional might miss something that someone who is better trained might catch. A specialist might catch something a primary care physician might miss. A specialist in one field (say, oncology) might catch something a specialist in some other field (say ENT) might miss.

Perhaps more relevant to common experience, Emergency Medical Technicians riding in ambulances are treating victims of accidents and emergencies every day. Would the care be slightly less risky if we put doctors in all those ambulances? Maybe. Is anyone seriously suggesting that we do that? Of course not.

Think of health care as a large market in which everyone has to make decisions about whether the patient-provider nexus is the right fit. It’s not just the providers who have to decide whether the problem lies within their area of competence. Patients must make those decisions too. In Britain (under socialized medicine), patients make such decisions all the time. For routine problems, most Britons see a National Health Service physician. But “if it’s serious, go private” is a common bit of advice in that country.

How do professionals handle these decisions? From the most part quite well. Walk-in clinics (where nurses deliver care following computerized protocols) have been around for at least a decade. Studies show that the nurses follow best practices as well or better than traditional primary care physicians. And I am not aware of any serious, reported cases of nurses failing to distinguish between cases they are competent to handle and those they are not.

But even if a nurse did make a serious mistake, doctors make mistakes too. There is no such thing as a risk free world. We encounter tradeoffs between cost and risk every day. There is no reason for politicians (beholden to special interests) to make these decision for us.

In Texas, which has some of the most stringent regulations in the country, however, a nurse practitioner can’t do much of anything without being supervised by a doctor who must:

•Not oversee more than four nurses at one time.

•Not oversee nurses located outside of a 75 mile radius.

•Conduct a random review of 10 percent of the nurses’ patient charts every 10 days.

•Be on the premises 20 percent of the time.

These restrictions make it virtually impossible for Texas’ 8,600 nurse practitioners to practice outside the office of a primary care physician. The Texas requirement that a doctor supervising nurse practitioners be physically present and spend at least 20 percent of her time overseeing them creates an incentive for the physician to require nurses to be employees, rather than self-employed professionals. When practitioners are employed by a doctor, the physician meets state supervision requirements simply by showing up. This allows the doctor to see her own patients while generating additional revenue from patients seen by the practitioners.

These regulations have the greatest impact on the poor, especially the rural poor. The farther a nurse is located from a doctor’s office, the less likely the physician will be willing to make the drive to supervise the nurse. This means that people living in poverty-stricken Texas counties must drive long distances, miss work and take their kids out of school in order to get simple prescriptions and uncomplicated diagnoses. This problem might be alleviated if nurse practitioners were allowed to practice independently in rural areas. But, under Texas law, these practices must be located within 75 miles of a supervising physician. A physician with four nurses located in rural areas could drive hundreds of miles a week to review the nurses’ patient charts. The result is that doctors in Texas don’t receive a return on investment sufficient to induce them to supervise nurse practitioners.

If all this sounds like the reinvention of the Medieval Guild system, that’s exactly what it is. In Capitalism and Freedom, Milton Friedman argued that these labor market restrictions are no more justified today than they were several centuries ago. The proper role of government, said Friedman, is to certify the skills of various practitioners; then let consumers decide what services to buy from them.

Contributer: John C. Goodman

www.forbes.com


Topics: nurse practitioners, health, nurses, doctors, medical care

Commentary: Psychiatric Mental Health Nurse Practitioners Can Help Address Increased Demand for Mental Health Services

Posted by Alycia Sullivan

Mon, May 19, 2014 @ 03:30 PM

By Susan Chapman and Bethany J. Phoenix

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Because the Affordable Care Act requires that individual and small-group plans include coverage for mental health care that is comparable to that for general medical care, many analysts expect the demand for mental health services to dramatically increase over the next few years. In California, finding enough mental health providers to meet the demand will be a challenge, as the federal Health Resources and Services Administration has identified 128 Mental Health Professional Shortage Areas in our state.

After documenting vacancy rates for mental health professionals in county-operated mental health programs and state hospitals, the California Mental Health Planning Council suggested that one way to address this shortage is to increase the recruitment and preparation of psychiatric/mental health nurse practitioners (PMHNPs) as primary mental health providers. Given the direction of health care service delivery in the US, perhaps the most important advantage PMHNPs offer is that they are educated in an integrative practice model that stresses connections between physical and mental health and emphasizes health promotion. This is especially critical in public mental health settings, where many patients struggle to get to any health care appointment, much less multiple appointments with multiple providers.

Using PMHNPs to address shortages and increase access to care in public mental health settings, however, faces a number of challenges. To help understand and address these challenges, we are collaborating with the California Institute for Mental Health (CiMH) to conduct a Robert Wood Johnson Foundation-funded study that will include case studies in five California counties with a history of using PMHNPs. The aim is to document best practices, identify unnecessary restrictions on NP practice and formulate strategies to remove these restrictions. By the conclusion of the study in 2015, we hope to have evidence-based information for key stakeholders – from public mental health care systems to state policymakers – about how PMHNPs can help increase access to mental health services in the state.

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One thing the study will allow us to do is examine in more detail presumed barriers that have emerged both anecdotally and from prior research. To begin with, just as with primary care, there is a need to rapidly fill the pipeline by incentivizing existing and future students to work in public mental health. That’s why beginning in 2009, California’s Mental Health Services Act began funding educational stipends to PMHNP students at three schools of nursing, including UC San Francisco. The stipend requires that students “pay back” their stipend by working in a public mental health setting for the equivalent of a year of service for each year of stipend funding.

That’s a fine start, but many of our colleagues across the state are concerned that scope-of-practice laws and the lack of good practice models for PMHNPs in California appear to undermine the effort to prime the pipeline.

For example, UCSF School of Nursing faculty member Aaron Miller was educated in Oregon and says that the biggest difference between the two states is that, “In Oregon, NPs can practice without a collaborative agreement with a physician…and the scope-of-practice law in Oregon contains an explicit description of the NP’s scope of practice: assessment, diagnosis, creation of plan and treatment.” By contrast, he says, in California NPs must always have a collaborative agreement in place with a supervising physician, and in every setting they have to devise agreed-upon standardized procedures that define what the NP can do – essentially, the scope of practice. Moreover, at present, practice models in the state do not facilitate optimal billing for PMHNP services.

Ebony Anderson, one of our former stipend students, says these limitations have dampened her willingness to strike out into independent practice as a psychiatric mental health nurse practitioner.

Thus, even as many in the state recognize that NPs can provide high-quality care and organizations are starting to utilize NPs’ full scope of practice, a number of factors may be erecting unnecessary obstacles to meeting the mental health needs of many Californians – especially in areas already short on qualified providers. These factors include reimbursement challenges, the effort involved in defining acceptable scope for each setting and finding physicians willing to provide NPs with the mandated level of supervision – and bill for services under their provider numbers, if appropriate.

Our charge, among other things, is to examine how and to what degree these factors affect the state’s ability to meet expected growth in demand for mental health services. Such research is the lifeblood of policy change. Our hope is that the results of our work will enable the state to fully leverage an educational system that is training PMHNPs to deliver outstanding care but, at least at the moment, sending them into a health care system that is not yet taking full advantage of their strengths.

Susan Chapman and Bethany J. Phoenix are leading a study to examine the structural, practice and policy opportunities and barriers that affect psychiatric/mental health nurse practitioners’ ability to most effectively use their skills and expertise in public mental health settings. Chapman directs the Health Policy Nursing specialty in the Department of Social and Behavioral Sciences at UC San Francisco School of Nursing. Phoenix is vice chair of the School’sDepartment of Community Health Systems and coordinates the School’s Psychiatric/Mental Health Nursing specialty. The study is supported by the Robert Wood Johnson Foundation’s Future of Nursing National Research Agenda, which is coordinated by the Interdisciplinary Nursing Quality Research Initiative, a national program of the Robert Wood Johnson Foundation.

Source: Science of Caring

Topics: California, study, ACA, Robert Wood Johnson Foundation, nurse practitioners, CiMH

VCU dentists and nurse practitioners collaborate on patient care

Posted by Alycia Sullivan

Sat, Apr 20, 2013 @ 03:49 PM

Dominiquea Rosario sees a dentist regularly for debilitating jaw pain, but at her last two dental appointments at Virginia Commonwealth University she also saw a nurse practitioner who checked her blood sugar and blood pressure.

In a new practice model, dentists and nurse practitioners at VCU are teaming up to see patients together, with goals of increasing access to care, better understanding the connection between oral health issues and disease elsewhere in the body and lowering health care costs.

“It’s a new model … so that you can have sort of one-stop shopping,” said Nancy Langston, professor and dean of the VCU School of Nursing.

“Dentistry has always been about health promotion and disease prevention. Nurse practitioners have been about early recognition, risk reduction and health promotion. We are putting them in the same environment to see if we can truly matter in reducing risk and increasing health promotion,” Langston said.

The new VCU Neighborhood Partners Practice is being provided primarily to patients enrolled in VCU’s Virginia Premier Health Plan, a managed care plan for Medicaid enrollees.

The combined practice is located in the oral medicine suite in the Wood Memorial Building on the MCV campus.

“We’ve found when we have been looking at the literature that a lot of patients who visit the dentist haven’t seen a primary care provider in about three or four years,” explained nurse practitioner Judith Parker-Falzoi.

“There are a lot of chronic health problems that come up in the course of a dental exam that can impede the progression of their dental treatment plan,” she said.

The combined practice project is modeled after a New York University partnership in which dentists and nurse practitioners work together. VCU nursing professor Debra Lyon, chairwoman of VCU’s Department of Family and Community Health Nursing, is overseeing the VCU project.

The dental visit is the entry point.

“We are using the well-established, prevention-oriented delivery system of dentistry to see if we can harness that to apply to other disease,” said David C. Sarrett, dean of the VCU School of Dentistry. “So that patients who are coming for dental care, and if they also have other chronic issues, we can encourage them or facilitate them to pay some attention to those other things.”

At Rosario’s visit to the combined practice Tuesday, she saw dentist Bhavik Desai, an assistant professor of oral medicine and temporomandibular joint disorder, about the jaw pain and then went down the hall to see Parker-Falzoi, the nurse practitioner.

Parker-Falzoi checked her overall health, Rosario said. One item that did get red-flagged this time was her fasting blood glucose level. It came back a little high.

“I didn’t know I might have diabetes,” Rosario said later. “I had gestational diabetes a couple of years back when I was pregnant with my son,” said Rosario, whose children are ages 2, 3 and 4.

“And I was feeling … where I was craving salt, a lot of water and using the bathroom a lot.”

Rosario is scheduled for a follow-up visit with her regular primary care doctor next week.

Langston said the combined practice also promotes a more holistic look at health in training.

“Another piece of this is teaching nurses to do better assessments of the oral cavity and teaching our dental students and future practitioners to look more holistically at the human being in their chair and not just the mouth. So we will be doing some cross education,” she said.

Source: Times Dispatch

Topics: nurse practitioners, patient care, NP, dentists, collaboration

When the Doctor Is Not Needed

Posted by Alycia Sullivan

Thu, Jan 03, 2013 @ 01:36 PM

As seen in The New York Times    

There is already a shortage of doctors in many parts of the United States. The expansion of health care coverage to millions of uninsured Americans under the Affordable Care Act will make that shortage even worse. Expanding medical schools and residency programs could help in the long run.

But a sensible solution to this crisis — particularly to address the short supply of primary care doctors — is to rely much more on nurse practitioners, physician assistants, pharmacists, community members and even the patients themselves to do many of the routine tasks traditionally reserved for doctors.

There is plenty of evidence that well-trained health workers can provide routine service that is every bit as good or even better than what patients would receive from a doctor. And because they are paid less than the doctors, they can save the patient and the health care system money.

Here are some initiatives that use non-doctors to provide medical care, with very promising results:

PHARMACISTS A report by the chief pharmacist of the United States Public Health Service a year ago argued persuasively that pharmacists are “remarkably underutilized” given their education, training and closeness to the community. The chief exceptions are pharmacists who work in federal agencies like the Department of Veterans Affairs, the Department of Defense and the Indian Health Service, where they deliver a lot of health care with minimal supervision. After an initial diagnosis is made by a doctor, federal pharmacists manage the care of patients when medications are the primary treatment, as is very often the case.

They can start, stop or adjust medications, order and interpret laboratory tests, and coordinate follow-up care. But various state and federal laws make it hard for pharmacists in private practice to perform such services without a doctor’s supervision, even though patients often like dealing with a pharmacist, especially for routine matters.

NURSE PRACTITIONERS In 2012, 18 states and the District of Columbia allowed nurse practitioners, who typically have master’s degrees and more advanced training than registered nurses, to diagnose illnesses and treat patients, and to prescribe medications without a doctor’s involvement.

Substantial evidence shows that nurse practitioners are as capable of providing primary care as doctors and are generally more sensitive to what a patient wants and needs.

In a report in October 2010, the Institute of Medicine, a unit of the National Academy of Sciences, called for the removal of legal barriers that hinder nurse practitioners from providing medical care for which they have been trained. It also urged that more nurses be given higher levels of training, and that better data be collected on the number of nurse practitioners and other advance practice nurses in the country and the roles they are performing. Tens of thousands will probably be needed, if not more.

Mary Mundinger, dean emeritus of Columbia University School of Nursing, believes highly trained nurses are actually better at primary care than doctors are, and they have experience working in the community, in nursing homes, patients’ homes and schools, and are better at disease prevention and helping patients follow medical regimens.

RETAIL CLINICS Hundreds of clinics, mostly staffed by nurse practitioners, have been opened in drugstores and big retail stores around the country, putting basic care within easy reach of tens of millions of people. The CVS drugstore chain has opened 640 retail clinics, and Walgreens has more than 350. The clinics treat common conditions like ear infections, administer vaccines and perform simple laboratory tests.

A study by the RAND Corporation of CVS retail clinics in Minnesota found that in many cases they delivered better and much cheaper care than doctor’s offices, urgent care centers and emergency rooms.

TRUSTED COMMUNITY AIDES One novel approach trains local community members who have experience caring for others to deliver routine services for patients at home. Two pediatric Medicaid centers in Houston and Harrisonburg, Va., have tested this concept to see if it can reduce the cost of home care and avoid unnecessary admissions to a clinic or hospital.

The aides are trained to consult with patients over the phone by asking questions devised by experts. A supervising nurse makes the final decisions on the care a patient requires. The community aide may visit the patient, provide care in the home and send photos or videos back to the supervising nurse by cellphone.

The aides are typically paid about $25,000 a year, according to an article in Health Affairs by the pilot study’s leaders. The study concluded that the program would have averted 62 percent of the visits to a Houston clinic and 74 percent of the emergency room visits in Harrisonburg.

The aides cost $17 per call or visit, compared with Medicaid payment rates of $200 for a clinic visit in Houston and $175 for an emergency room in Harrisonburg.

SELF-CARE AT HOME A program run by the Vanderbilt University Medical Center and its affiliates lets patients with hypertension, diabetes and congestive heart failure decide whether they want a care coordinator to visit them at home or prefer to measure their own blood pressure, pulse or glucose levels and enter the results online, where the data can be immediately reviewed by their primary care doctor. The patient could consult by phone or e-mail with a nurse about his insulin dosage, but there would be no need for a costly visit to a doctor.

Taking this idea a step further, a hospital in Sweden, prodded by a kidney dialysis patient who thought he could do his own hemodialysis better than the nursing staff, allowed him to do so and then teach other patients, according to the Institute for Healthcare Improvement, a nonprofit organization in Cambridge, Mass. Now most dialysis at that hospital is administered by the patients themselves. Costs have been cut in half, and complications and infections have been greatly reduced.

HEALTH REFORM LAW The Affordable Care Act contains many provisions that should help relieve the shortage of primary care providers, both doctors and other health care professionals.

It provides money to increase the number of medical residents, nurse practitioners and physician assistants trained in primary care, yielding more than 1,700 new primary care providers by 2015. It offers big bonuses for up to five hospitals to train advanced practice nurses and has demonstration projects to promote primary care coordination of complex illnesses, incorporating pharmacists and social workers in some cases. And it offers financial incentives for doctors to practice primary care — like family medicine, internal medicine and pediatrics — as opposed to specialties.

These are all moves in the right direction, but they will need to be followed by even bigger steps and protected from budget cuts in efforts to reduce the deficit.

Topics: nurse practitioners, affordable care act, doctors shortage, retail clinics, health care reform, health care, community, pharmacists

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