As U.S. re­lies more on nurse prac­ti­tion­ers, we need to learn more about them

Modern Healthcare - - COMMENT - By Ti­mothy Hoff In­ter­ested in sub­mit­ting a Guest Ex­pert op-ed? View guide­lines at modernhealthcare.com/op-ed. Send drafts to As­sis­tant Man­ag­ing Editor David May at dmay@modernhealthcare.com.

Nurse prac­ti­tion­ers are as­sum­ing a more prom­i­nent role in pri­mary care. Mary­land is the latest state to al­low this group to prac­tice in­de­pen­dently, and the Vet­er­ans Health Ad­min­is­tra­tion may soon fol­low suit.

The driv­ers for this trend are clear: the ex­pan­sion of health in­sur­ance in the U.S. and our ag­ing pop­u­la­tion, both pro­duc­ing heavy de­mand for pri­mary-care ser­vices; short­ages of pri­mary-care physi­cians in many parts of the coun­try, es­pe­cially in ru­ral ar­eas; an ur­gency to lower care costs in the sys­tem; and phar­macy chains and big-box re­tail stores look­ing to use pri­ma­rycare medicine (staffed pri­mar­ily by nurse prac­ti­tion­ers) as a “loss leader,” in part to build brand loy­alty for their health-re­lated prod­ucts and ser­vices.

We could ben­e­fit from know­ing more about nurse prac­ti­tion­ers. Scat­tered stud­ies in the pri­mary-care sphere show that, in some cases, nurse prac­ti­tion­ers per­form on a par with their physi­cian coun­ter­parts. These find­ings tend to fo­cus on lower-level acute and chronic-dis­ease care, which is tra­di­tion­ally the pri­ma­rycare work to which NPs have been con­signed. We also have spo­radic stud­ies that show pa­tient sat­is­fac­tion and care uti­liza­tion among NPs com­par­ing fa­vor­ably with pri­mary-care physi­cians. But at present the over­all body of re­search lacks in­te­gra­tion and ex­am­ines a lim­ited scope of pri­ma­rycare medicine.

Ar­dent sup­port­ers of us­ing NPs may feel that enough ev­i­dence al­ready ex­ists to jus­tify in­de­pen­dent NP prac­tice in all types of pri­mary-care medicine, not just the sim­pler va­ri­ety. Spurred on by con­di­tions in the pri­mary-care en­vi­ron­ment that are driv­ing greater NP prac­tice free­doms, they may be­lieve it is bet­ter to push ahead and let the re­search catch up later. This is a mis­take. Sim­i­larly, those who as­sert that NPs can­not fully re­place pri­mary-care physi­cians must un­der­stand that the ab­sence of a large, in­te­grated body of data prov­ing oth­er­wise does not jus­tify their con­clu­sions ei­ther. Think­ing it does is another mis­take.

The fu­ture vi­a­bil­ity of pri­mary-care physi­cians de­pends on syn­er­giz­ing their own strengths with a grow­ing work­force seg­ment—nurse prac­ti­tion­ers—that thinks and acts a lot like them. Oth­er­wise, dis­rup­tive in­no­va­tions like re­tail clin­ics and ur­gent-care cen­ters will act uni­lat­er­ally and erode their mar­ket share and in­flu­ence.

It is also im­por­tant to know more about nurse prac­ti­tion­ers as a group of work­ers, i.e. the qual­ity of their ev­ery­day work lives, the types of re­la­tion­ships they es­tab­lish with pa­tients, and how they adapt to be­ing al­most ex­clu­sively salaried em­ploy­ees. There is some re­search show­ing that nurse prac­ti­tion­ers are sat­is­fied with the au­ton­omy and in­tel­lec­tual chal­lenge af­forded them in prac­tic­ing pri­mary-care medicine, but they may also be con­cerned about the po­ten­tial so­cial iso­la­tion of their jobs, fewer deep in­ter­ac­tions with physi­cian col­leagues, be­com­ing overex­tended in their work, and a lack of or­ga­ni­za­tional sup­port.

Two key is­sues bear­ing on these ques­tions are the na­ture of their work and where it is done. For ex­am­ple, as an in­creas­ing num­ber of NPs are em­ployed in re­tail clin­ics, which typ­i­cally pro­vide a lim­ited ar­ray of ser­vices for pa­tients, they might be work­ing by them­selves, do­ing highly repet­i­tive work, and ad­her­ing to stan­dard­ized care guide­lines that limit pro­fes­sional dis­cre­tion. They also may have to per­form non-clin­i­cal work as the de facto man­agers of the clinic, work they may not wish to do.

If they are work­ing in physi­cian of­fices, which most cur­rently are, their daily sched­ules can be loaded with very rou­tine pa­tient-care is­sues, free­ing up their physi­cian col­leagues to do the com­plex care that builds a strong provider-pa­tient re­la­tion­ship, and leav­ing NPs to do the more im­per­sonal, episodic pri­mary-care work. In these ways, many NPs may not get enough op­por­tu­ni­ties, in­tel­lec­tual chal­lenges, or care con­ti­nu­ity in their jobs to de­velop deep bonds with many of their pa­tients, or to cul­ti­vate the full range of skills and ex­pe­ri­ence to de­liver higher-in­ten­sity care con­fi­dently. These re­al­i­ties may un­der­mine the long-term job sat­is­fac­tion and ca­reer ful­fill­ment of NPs as a group.

Pri­mary-care medicine in the U.S. needs nurse prac­ti­tion­ers to meet its grow­ing de­mands. But we must get to know these pro­fes­sion­als bet­ter, through a lot more sys­tem­atic re­search across a range of top­ics that speaks to their fu­ture roles in an evolv­ing pri­mary-care sys­tem.

Ti­mothy Hoff, Ph.D., is a pro­fes­sor of health sys­tems man­age­ment and health pol­icy at North­east­ern Univer­sity, Bos­ton, and a vis­it­ing as­so­ciate fel­low at Ox­ford Univer­sity. He stud­ies dis­rup­tive in­no­va­tion in the U.S. pri­mary-care sys­tem.

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