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NP, physician groups disagree over scope of practice

Wednesday September 19, 2012
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The American Academy of Nurse Practitioners criticized a new report by the American Academy of Family Physicians that stated independent practice authority for NPs could splinter care and undermine the effort to move to patient-centered medical homes.

In the report, "Primary Care for the 21st Century," the AAFP stated that the U.S. healthcare system can meet the nationwide need for primary care providers by implementing physician-led PCMHs.

The AAFP laid out research supporting the potential of team-based care to transform primary care in the United States. The report focuses on the need to use such an approach to improve quality and cost efficiency in the U.S. healthcare system.

The AAFP also cautioned against substituting nurse practitioners for physicians as a stop-gap answer to the primary care physician shortage. It said such a solution "flies in the face of multiple studies that demonstrate the best, most efficient care is provided by teams of health professionals in the patient-centered medical home led by physicians, not independent practice by a single health professional."

The PCMH model improves the quality of care because it capitalizes on the unique expertise of each member of the patient’s healthcare team, according to Roland Goertz, MD, MBA, chairman of the AAFP Board of Directors. In doing so, it expands access to services while ensuring each patient is under the care of a physician.

Research has demonstrated that teams of health professionals in the PCMH improve quality; reduce unnecessary tests, procedures and hospitalizations; and result in lower patient-care costs, according to the AAFP.

"Wholesale substitution of non-physician healthcare providers for physicians is not the solution, especially at a time when primary care practices are being called upon to take on more complex care,’ Goertz said. "Patients need access to every member of their healthcare team — starting with a primary care physician, nurse practitioners, physician assistants and all other professionals who provide healthcare.

"Creating a system in which some patients have access to only a nurse practitioner is endorsing two-tiered care. That doesn’t happen in the physician-led patient-centered medical home, and we believe all Americans should have access to this quality of care."

Do the disparities matter?

Patients understand and care about the disparities in training, according to the AAFP. It cited a study by the American Medical Association, which stated that more than nine of 10 respondents to a recent survey said a physician’s years of education and training are vital to the best patient care, especially in emergency and complicated situations. And three of four patients said they prefer to be treated by a physician.

Education and training of physicians and APRNs are substantially different, and physicians and nurses are not interchangeable, said Goertz, who added: "Their levels of knowledge and skills are complementary, but they are not equivalent."

Primary care physicians complete 21,700 hours of education and clinical training over 11 years, compared to NPs’ 5,350 hours of education and clinical training over five to seven years, the report noted. All family physicians complete a four-year undergraduate degree and a four-year medical school program. They must pass two tests given by U.S. Medical Licensing Examinations to earn their medical degree before beginning their three-year primary care physician residency training.

The result is a health professional who "brings breadth and depth to the diagnosis and treatment of all health problems, from strep throat to chronic obstructive pulmonary disease, from stress headaches to refractory multiple sclerosis," according to the report.

Although 11 states and Washington, D.C., do not require a master’s degree to be a nurse practitioner, most NPs are RNs who have completed their nursing education through a one-and-a-half- to three-year MSN program, according to the report. Their training gives them expertise in epidemiology and community health and in treating patients who require basic preventive care or treatment of straightforward acute illness or uncomplicated, previously diagnosed chronic conditions.

"Together, the physician and nurse practitioner comprise an extraordinary team of professionals whose expertise supports and complements each other in the patient-centered medical home," Goertz said.

The AAFP report is available at www.aafp.org/online/en/home/membership/initiatives/nps/patientcare.html.

AANP responds

Angela Golden, RN, DNP, FNP-BC, FAANP, said the AANP strongly supports PCMHs and team-based care models, but took issue with other conclusions in the AAFP report.

"AANP believes that AAFP’s efforts to link these evolving models of care with the licensure of nurse practitioner practice are misdirected and out of step with today’s environment," Golden said.

The AAFP’s position runs contrary to recommendations from the Institute of Medicine and National Council of State Boards of Nursing regarding scope of practice, Golden said. In its 2010 report, "The Future of Nursing: Leading Change, Advancing Health," the IOM stated that "regulatory and institutional obstacles — including limits on nurses’ scope of practice — should be removed so that the health system can reap the full benefit of nurses’ training, skills and knowledge in patient care" in the wake of rising demand for healthcare services.

Golden added that the requirement for physician leadership of a healthcare home is inconsistent with requirements set by the National Committee for Quality Assurance, URAC and the Joint Commission, "each a well-known and respected organization currently accrediting patient-centered healthcare homes led by NPs."

"More than 100 studies analyzing care provided by both NPs and physicians have demonstrated that NPs have the same or better patient outcomes when compared to physicians," Golden said. "Making full use of the NP workforce is a critical piece of a multi-pronged solution to address the urgent need for healthcare access in our nation.

"The ongoing attempts by the AAFP to limit the ability of NPs to practice to the full extent of their education and training only serves to increase the already overwhelming hardships placed on millions of Americans who are struggling to gain access to high-quality healthcare."

Golden noted that NPs complete MSN or DNP programs and "provide a variety of critical health services, including evaluating patients, making diagnoses, ordering and interpreting diagnostic tests, writing prescriptions and managing acute and chronic health conditions — including the oversight of patients with multiple and complex chronic illness.

"NPs are providers of choice for millions of individuals and families. They are especially educated and prepared to care for vulnerable populations such as the elderly, the medically underserved and those who live in rural areas that have more acutely experienced the primary care provider shortage."


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