Pri­mary dis­pute

Docs say laws al­low­ing nurses and other prac­ti­tion­ers greater lee­way en­dan­gers pa­tients; ad­vanced prac­tice nurses say they’re fill­ing a need that will only grow un­der re­form

Modern Healthcare - - Special Report - Joe Carl­son

Though it was dwarfed by the firestorm swirling around na­tional health­care re­form, the long-sim­mer­ing bat­tle be­tween nurses, doc­tors and spe­cialty prac­ti­tion­ers over who’s qual­i­fied to do which jobs has reached a new level of ran­cor and im­me­di­acy, those close to the is­sue say.

Physi­cians say state and fed­eral law­mak­ers are in­creas­ingly putting pa­tients at risk by al­low­ing lesser-trained nurses, spe­cial­ists and other “lim­ited li­cen­sure” prac­ti­tion­ers to en­croach into ar­eas of health­care where they are not qual­i­fied to pro­vide pa­tient care. The Amer­i­can Med­i­cal As­so­ci­a­tion tracked more than 300 laws in state leg­is­la­tures last year to ex­pand nurses’ pow­ers and is al­ready gear­ing up for more bat­tles this year.

Mean­while, many ob­servers say fed­eral health­care re­form will lead to a spike in in­ter­est in scope-of-prac­tice is­sues na­tion­ally, as in­sur­ance re­forms lead to more ac­cess to pri­mary care—which is one of the epi­cen­ters in the strug­gle be­tween ad­vanced prac­tice nurses and doc­tors over prac­tice rights.

Physi­cians typ­i­cally cast the de­bate in terms of the qual­ity of pa­tient care, but other ob­servers say the ar­gu­ment has deep roots in fi­nan­cial con­cerns. For ex­am­ple, more in­sur­ers than ever are al­low­ing ad­vanced prac­tice nurses, such as nurse prac­ti­tion­ers, to bill di­rectly for their ser­vices, and some are even pay­ing more than the 85% re­im­burse­ment rate that nurses have tra­di­tion­ally re­ceived com­pared with physi­cian com­pen­sa­tion for the same ser­vices.

“They’re re­ally scared that we’re go­ing to do some­thing that will take money away from them. As long as we went out and only gave health­care to poor peo­ple, no­body said any­thing,” says Dee Swan­son, pres­i­dent of the Amer­i­can Academy of Nurse Prac­ti­tion­ers. “Let’s face it: We have a cri­sis in pri­mary care in this coun­try, and it’s an area that physi­cians have not been in­ter­ested in, or there wouldn’t be a short­age.”

Ce­cil Wil­son, a Florida in­ternist and pres­i­dent-elect of the Amer­i­can Med­i­cal As­so­ci­a­tion, says such ar­gu­ments miss the larger point about pa­tient care, and whether nurses are adding new ed­u­ca­tional re­quire­ments to go along with the ad­di­tional re­spon­si­bil­i­ties they’re seek­ing.

“We’re not talk­ing about pro­tect­ing what physi­cians do, this is about pro­tect­ing pa­tient safety,” Wil­son says. “Our con­cern is that this push for ex­panded scope of prac­tice is in some ways a way to try to prac­tice medicine without get­ting an M.D. de­gree.”

As em­ploy­ers, hospi­tal ex­ec­u­tives are find­ing them­selves on in­creas­ingly un­sta­ble mid­dle ground in the scope-of-prac­tice strug­gle, as they try to bal­ance cost on one hand and qual­ity on the other.

Keith Barn­hill, an

ad­vanced reg­is­tered nurse prac­ti­tioner who

is a cer­ti­fied reg­is­tered nurse

anes­thetist, con­fers with one of his pa­tients at at Grundy County

Memo­rial Hospi­tal in Iowa.

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