DiversityNursing Blog

By SABRINA TAVERNISE

www.nytimes.com 

There are just a handful of psychiatrists in all of western Nebraska, a vast expanse of farmland and cattle ranches. So when Murlene Osburn, a cattle rancher turned psychiatric nurse, finished her graduate degree, she thought starting a practice in this tiny village of tumbleweeds and farm equipment dealerships would be easy.

It wasn’t. A state law required nurses like her to get a doctor to sign off before they performed the tasks for which they were nationally certified. But the only willing psychiatrist she could find was seven hours away by car and wanted to charge her $500 a month. Discouraged, she set the idea for a practice aside and returned to work on her ranch.

“Do you see a psychiatrist around here? I don’t!” said Ms. Osburn, who has lived in Wood Lake, population 63, for 11 years. “I am willing to practice here. They aren’t. It just gets down to that.”

But in March the rules changed: Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now 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 do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments.

“I was like, ‘Oh, my gosh, this is such a wonderful victory,’” said Ms. Osburn, who was delivering a calf when she got the news in a text message.

The laws giving nurse practitioners greater autonomy have been particularly important in rural states like Nebraska, which struggle to recruit doctors to remote areas. About a third of Nebraska’s 1.8 million people live in rural areas, and many go largely unserved as the nearest mental health professional is often hours away.

“The situation could be viewed as an emergency, especially in rural counties,” said Jim P. Stimpson, director of the Center for Health Policy at the University of Nebraska, referring to the shortage.

Groups representing doctors, including the American Medical Association, are fighting the laws. They say nurses lack the knowledge and skills to diagnose complex illnesses by themselves. Dr. Robert M. Wah, the president of the A.M.A., said nurses practicing independently would “further compartmentalize and fragment health care,” which he argued should be collaborative, with “the physician at the head of the team.”

Dr. Richard Blatny, the president of the Nebraska Medical Association, which opposed the state legislation, said nurse practitioners have just 4 percent of the total clinical hours that doctors do when they start out. They are more likely than doctors, he said, to refer patients to specialists and to order diagnostic imaging like X-rays, a pattern that could increase costs.

Nurses say their aim is not to go it alone, which is rarely feasible in the modern age of complex medical care, but to have more freedom to perform the tasks that their licenses allow without getting a permission slip from a doctor — a rule that they argue is more about competition than safety. They say advanced-practice nurses deliver primary care that is as good as that of doctors, and cite research that they say proves it.

What is more, nurses say, they are far less costly to employ and train than doctors and can help provide primary care for the millions of Americans who have become newly insured under the Affordable Care Act in an era of shrinking budgets and shortages of primary care doctors. Three to 14 nurse practitioners can be educated for the same cost as one physician, according to a 2011 report by the Institute of Medicine, a prestigious panel of scientists and other experts that is part of the National Academy of Sciences.

In all, nurse practitioners are about a quarter of the primary care work force, according to the institute, which called on states to lift barriers to their full practice.

There is evidence that the legal tide is turning. Not only are more states passing laws, but a February decision by the Supreme Court found that North Carolina’s dental board did not have the authority to stop dental technicians from whitening teeth in nonclinical settings like shopping malls. The ruling tilted the balance toward more independence for professionals with less training.

“The doctors are fighting a losing battle,” said Uwe E. Reinhardt, a health economist at Princeton University. “The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”

Nurses acknowledge they need help. Elizabeth Nelson, a nurse practitioner in northern Nebraska, said she was on her own last year when an obese woman with a dislocated hip showed up in the emergency room of her small-town hospital. The hospital’s only doctor came from South Dakota once a month to sign paperwork and see patients.

“I was thinking, ‘I’m not ready for this,’ ” said Ms. Nelson, 35, who has been practicing for three years. “It was such a lonely feeling.”

Ms. Osburn, 55, has been on the plains her whole life, first on a sugar beet farm in eastern Montana and more recently in the Sandhills region of Nebraska, a haunting, lonely landscape of yellow grasses dotted with Black Angus cattle. She has been a nurse since 1982, working in nursing homes, hospitals and a state-run psychiatric facility.

As farming has advanced and required fewer workers, the population has shrunk. In the 1960s, the school in Wood Lake had high school graduating classes. Now it has only four students. Ms. Osburn and her family are the only ones still living on a 14-mile road. Three other farmhouses along it are vacant.

The isolation takes a toll on people with mental illness. And the culture on the plains — self-reliance and fiercely guarded privacy — makes it hard to seek help. Ms. Osburn’s aunt had schizophrenia, and her best friend, a victim of domestic abuse, committed suicide in 2009. She herself suffered through a deep depression after her son died in a farm accident in the late 1990s, with no psychiatrist within hundreds of miles to help her through it.

“The need here is so great,” she said, sitting in her kitchen with windows that look out over the plains. She sometimes uses binoculars to see whether her husband is coming home. “Just finding someone who can listen. That’s what we are missing.”

That conviction drove her to apply to a psychiatric nursing program at the University of Nebraska, which she completed in December 2012. She received her national certification in 2013, giving her the right to act as a therapist, and to diagnose and prescribe medication for patients with mental illness. The new state law still requires some supervision at first, but it can be provided by another psychiatric nurse — help Ms. Osburn said she would gladly accept.

Ms. Nelson, the nurse who treated the obese patient, now works in a different hospital. These days when she is alone on a shift, she has backup. A television monitor beams an emergency medicine doctor and staff into her workstation from an office in Sioux Falls, S.D. They recently helped her insert a breathing tube in a patient.

The doctor shortage remains. The hospital, Brown County Hospital in Ainsworth, Neb., has been searching for a doctor since the spring of 2012. “We have no malls and no Walmart,” Ms. Nelson said. “Recruitment is nearly impossible.”

Ms. Osburn is looking for office space. The law will take effect in September, and she wants to be ready. She has already picked a name: Sandhill Behavioral Services. Three nursing homes have requested her services, and there have been inquiries from a prison.

“I’m planning on getting in this little car and driving everywhere,” she said, smiling, behind the wheel of her 2004 Ford Taurus. “I’m going to drive the wheels off this thing.”

By Alvin Tran

More than 27 million Americans will soon gain health coverage under the health law. But who will treat them all?

With such a large coverage expansion, and with an anticipated shortage of primary care physicians available to serve them, some states have or are considering allowing so-called advanced practice nurses -- those with advanced degrees -- to treat more patients. David Hebert is at the issue’s center. Hebert, a veteran health care lobbyist and former CEO of the American College of Nurse Practitioners, is the first CEO of the American Association of Nurse Practitioners (AANP) -- a new group with 42,000 members recently formed from the merger of the American College of Nurse Practitioners and the American Academy of Nurse Practitioners.

Hebert says that despite doubts from some doctor groups, nurse practitioners are honing their craft in patient care and research to position themselves to help care for this new influx of patients, and they’re doing so without sacrificing the quality of care.

KHN's Alvin Tran sat down recently with Hebert to discuss the changing role nurse practitioners may soon have, as well as some physicians' efforts to stop them.

Here are edited excerpts of that discussion:

Q. As of 2012, 18 states and the District of Columbia allow nurse practitioners to diagnose, treat patients and prescribe medications without a doctor’s involvement. What is the biggest impediment to expanding to other states? How are you planning to expand that to the other states?

Well, the problem is that there are certain states that require physicians' supervision of nurse practitioners or there may well be some kind of restrictive collaborative agreement that is imposed upon the nurse practitioner. Often times, that makes it very difficult for nurse practitioners to practice. Sometimes there may be a physician who is unwilling to supervise. Other times you may have an issue where the physician chooses to not form a collaborative agreement with nurse practitioners. So, part of the issue is that we have anticompetitive regulations in place.

There are a number of things that we want to do at the federal level. We are hopeful that legislation is going to be reintroduced this Congress that will allow nurse practitioners in Medicare to admit patients for home health care. Right now, the admission can only be done by a physician. Given the fact that we've had research indicating that it would be cost effective, we can get people out of nursing homes and hospitals quicker. It really makes good public policy sense. Particularly, if you got a situation in a rural area where the nurse practitioner and the patient is waiting for the physician to sign the order to admit into home health.

Same thing is true on hospice. We've not been able to get legislation passed that allows nurse practitioners to admit to hospice. We’re not currently permitted by statute to formaccountable care organizations on our own. That opens up a lot of possibilities for safe and effective, cost effective health care.

Q. Physicians groups, including the American Medical Association, have opposed efforts to expand the scope of practice of nurse practitioners and raised concerns of patient safety, contending that physicians' extended training makes them more qualified to handle such issues. How do you make sure that patients are protected?

There have been studies over the years that shows that our outcomes are the same or better than primary care physicians. The fact is that it’s a total red herring. Nurse practitioners have been practicing safely and providing great outcomes for decades.

Q. Medicare’s reimbursement rate for NPs is 85 percent of the physician rate for the same services. Should these rates be the same for both providers?

One hopes that, when all is said and done, whether they're working with a physician or billing on their own, it should be 100 percent of what a doctor is paid because the fact is, they're providing the same services that a physician is providing. Quite frankly, it doesn't make any sense.

Q. What role do you think NPs will have once the federal health law takes effect in 2014?

I think that once you have a full implementation of the expanded Medicaid provisions of the ACA, you’re going to see increased demand for primary care. Unless there’s someone there to provide that care, the intent of the ACA will not be fulfilled. You’re going to see a lot of patients who may be insured or have coverage under Medicare and Medicaid, but may not be able to get services.

I think the major challenges will be to look at regulations that artificially restrict a nurse practitioner’s ability to practice within their scope. If patients want to choose a nurse practitioner, they should be free to do so.

Q. Your tenure as CEO began last month, what’s at the very top of your 'to-do list'?

We are looking at rebranding and a more enhanced public relations campaign. We're looking at increasing membership. Right now we’re about 42,000 members and there are 155,000 nurse practitioners in this country. So, we have room for growth. We’re going to be spending some time ramping up our association activities.

Source: Kaiser Health News

 By Katie Bascuas / Nov 27, 2012

Two nurse practitioner trade associations are joining forces to better advocate for their members and to help their members better advocate for patients.

Beginning next year, nurse practitioners will have a single, collective body representing them in Washington, DC, as well as promoting education and research in the field.

As of January 1, 2013, the American Academy of Nurse Practitioners and the American College of Nurse Practitioners will merge to form the American Association of Nurse Practitioners, both organizations announced last week.

“We felt like it was the right time for there to be one national nurse practitioner organization representing all specialties at the national level,” said Angela Golden, president of the American Academy of Nurse Practitioners. “This new organization gives us the opportunity to have that one strong, unified voice to move good quality patient care forward.”

The new association will also make it easier for nurse practitioners interested in joining a professional organization but confused by which one to join.

“I think the members will continue to see the same strong organization that they’ve come to expect, but nurse practitioners will not have to decide anymore, ‘Do I have to pay membership to two organizations,’” Golden said. “There’s one organization with their best interest at heart, moving things forward.”

By aligning resources and working together, “we’re going to be able to have the best of both worlds,” said Jill Olmstead, former president of ACNP. One of the biggest benefits includes a stronger legislative platform.

“I’m hoping that this will actually give the average nurse practitioner the opportunity to become more involved within their profession and advocate for improved access to patient care,” Olmstead said. “Nurse practitioners are wonderful at advocating for their patients, and I think the organization is trying to help inspire [them] to advocate for their profession.”

With the growing shortage of primary care doctors and new healthcare care laws creating a large contingent of newly insured Americans, nurse practitioners are becoming increasingly pivotal players in the U.S. healthcare system.

“Whether it’s one organization or not, nurse practitioners are so focused on the patient care, and as healthcare reform comes in,” Golden said, “our focus has to stay where it always has been and that’s on our patients.”