Nurse Practitioners, Midwives Play Integral Roles in Primary Care

By Andrew Schwartz on December 21, 2009

Naomi Schapiro, who directs the ambulatory care Pediatric Nurse Practitioner program at UCSF, examines a patient.

This past summer, with a group of nurses at his side, President Barack Obama spoke about the critical role that nurses can play in health care reform.

For a profession often relegated to the shadows of the health care debate, the broad daylight of a White House event was a rare moment to showcase what nurses do.

Kathleen Dracup

“From birth to death, patients receive a majority of their care from nurses; one out of three Americans will see a nurse practitioner for primary care in the coming year,” says Kathleen Dracup, RN, DNSc, FNP, FAAN, dean of the UCSF School of Nursing. “Yet aside from a few isolated moments, I see little in the health care debate acknowledging the integral role nurses play in primary care or in a health care system striving for lower costs and improved quality.”

Primary care is especially ripe for leveraging the skills nurses bring to the table. If, as expected, 47 million people enter the system in 2013, most experts believe there will be nowhere near enough primary care physicians to serve them; there is already a shortage.

Nurse practitioners (NPs) and midwives – the advanced practice nurses trained to deliver primary care – point out that because their training requires fewer years, they can more quickly fill the expected void. Moreover, most research confirms that primary care NPs and midwives achieve patient outcomes equal to or better than their physician counterparts, and sometimes do so at a lower cost.

Despite this, the exact role primary care nurses will play in health care reform remains unclear. Some physician groups are unwilling to cede patients and income. An arcane, inconsistent, state-by-state system often limits NP and midwife scope of practice and reimbursements. There is meager federal support for nurse training, as opposed to that of physicians. And there is the hard reality that nurses have fewer resources and less influence than other groups lobbying lawmakers in the health care debate.

Determined to overcome those barriers, many nursing leaders have been making a blunt public case about where and why they can help meet the expanding need and, in many cases, improve care and free up physicians for what they do best.

Working with Aging Boomers

One of the first groups where nurses see an opportunity is the rapidly growing population of older adults, who often present with a complex mix of chronic conditions that demand careful clinical oversight. Gerontological NPs already play a central role among this population in settings that include long-term care, skilled nursing facilities, assisted living facilities, and hospice and palliative care.

There is also a push in some circles toward NPs making home visits to older adults who would prefer to “age in place,” but can’t get into a provider’s office because traveling is physically difficult or too expensive. Lynda Mackin, co-director of the Gerontological Advanced Practice Nursing program at the UCSF School of Nursing, believes that gerontologically trained NPs bring a particularly useful skill set to these situations.

“In primary care home visits, NPs do the type of evaluation people normally receive in a doctor’s office, only more thorough because they see things that you can’t see in an office visit,” says Mackin. “This is an area where nursing training makes a difference. It’s not that physicians can’t do the same, but their training drives them in a different direction.”

She notes, for example, that because a home visit presents a clearer picture of the physical and social environment and available resources, the NP can create a more comprehensive and tailored geriatric care plan. “Older people tend to be more relaxed in their own home, so NPs can better evaluate things like their cognitive state and the effect of symptoms on their daily activities,” says Mackin.

Is such an approach sustainable? Home visits often take more time than office visits, and today, many such visits are paid out of pocket or supported by philanthropy because providers judge them as unsustainable under current Medicare reimbursement guidelines. Yet the approach might actually save money. The Department of Veterans Affairs runs a home visit program and has calculated that the success of its program in averting hospitalizations and nursing home placements reduces the total cost per patient per year by 24 percent.

Even if the reimbursement issues can be resolved, however, the challenge will be expanding the resource pool to meet expanding needs. Unless there is more money available to support the hiring of new faculty or help talented, midcareer nurses return to school, the ability to expand that resource pool is limited.

Helping Cancer Survivors

For many patients, advances in cancer treatment have made this once-acute illness more of a chronic condition. Today, there are nearly 12 million cancer survivors, many of them older adults, living full lives.

Most of those survivors receive primary care from their oncologists, their primary care physicians or both. The problem is that most oncologists don’t have the time to deliver primary care and most primary care physicians don’t have the time or training to deliver primary care with an oncology slant. According to Theresa Koetters, who co-directs the Advanced Practice Oncology Nursing program at UCSF, these patients need someone who has the time and training to deliver both.

“One reason is these patients worry all the time,” says Koetters. Those in remission often don’t know how to identify early signs of recurrence, or what to look for or report. Patients who are not in remission want to better understand how to improve their quality of life or be kept abreast of emerging treatment information.

“For these patients, it can be scary to go back out to regular primary care,” says Mary Lou Ernest, who worked for years as a clinical trial coordinator, responsible for cancer patients on experimental therapy, before returning to school at UCSF and graduating in 1993 as a gerontological NP. For the next 16 years, she provided follow-up care to cancer patients at the UCSF Helen Diller Family Comprehensive Cancer Center.

Both Ernest and Koetters note that the typical primary care provider sees his or her patients only once a year for a physical, lab work, screening and education. “An oncology-focused primary care provider would probably see a breast cancer survivor twice a year or more, looking to do a breast and axillary exam because of the higher risk for other cancers or for the original cancer to return,” says Koetters.

For patients with significant family histories or genetic indicators of cancer, oncology NPs can use their experience and training to more expertly screen for early warning signs. And because oncology NPs are typically first trained as adult, family or gerontological nurse practitioners, they can effectively screen for or manage more traditional primary care concerns such as diabetes, heart disease and arthritis – and help avert unnecessary and invasive tests. For the patients, staying connected to their oncology care gives them the type of reassurance that can improve their quality of life.

“Some of this has been going on already,” says Ernest. Although the Cancer Center’s survivorship program still refers patients back to their primary care providers, Ernest believes that, over time, there will be more reasons for oncology NPs to become these patients’ primary care providers.

“There is an acute shortage and we don’t need duplicate services,” she says. “We shouldn’t underestimate what the primary care people bring to the table, but they have to consider a broader perspective, and it may not be fair to expect them to have oncology in their bag of tricks.”

Koetters notes that in theory, oncology NPs providing primary care could produce revenue for oncology practices while freeing medical oncologists to use their expertise for the sickest of the sick. “Part of the challenge, though, is getting this service under the right umbrella in terms of reimbursement,” she says. Ernest notes that sometimes follow-up care can involve longer appointments than the 10 or 15 minutes primary care appointments are typically allotted. Current reimbursement levels hardly cover the shorter appointment, much less a longer one.

Then there is the inevitable tension over “stealing patients.” Even if traditional primary care providers are willing to cede monitoring of the cancer itself, they will still want to treat the earaches, sore throats and arthritis. Koetters understands, but believes that argument may disappear in the face of 47 million more people entering the system. “There will be more than enough work to go around,” she says.

Humanizing Childbirth

Health care reform is yet one more reason for midwives to continue their long-running crusade to increase patient access to midwife services and to expand and standardize their scope of practice in the United States. “The single greatest diagnosis code for hospital admissions is childbirth and it can be costly,” says Amy Levi, who directs the Midwifery/Women’s Health Nurse Practitioner program at the UCSF School of Nursing.

Levi and the American College of Nurse-Midwives would argue that increased use of midwives is one sensible way to help reduce childbirth costs without sacrificing quality. “In terms of consumption of resources, midwives shy away from gratuitous use of technology,” she says. “That gets cost savings without compromising outcomes.”

Research generally confirms that midwife care is at least as safe as care from physicians, the cost is better and women tend to be satisfied with their care, according to Joanne Spetz of the Center for the Health Professions at UCSF.

Midwives approach childbirth as a normal physiological process, not a condition that in every case demands that a woman and her child be monitored by complex medical devices and, at the slightest indication, must undergo inpatient medical treatment. Though Levi knows well that there are many situations during childbirth that require skilled physicians and medical technology to resolve, she and her professional colleagues believe that medical technology is often overused and unnecessary.

Another reason Levi believes midwives fit neatly into the visions of health care reform is that many are trained to work with those patients who will be entering the system anew. In her program at UCSF, the focus of the training is on providing culturally competent care for underserved populations. Levi herself delivers babies at San Francisco General Hospital, San Francisco’s hospital of last resort and one of the best public hospitals in the country.

“Most nurse practitioners and midwives did not go to school to become high wage earners, but to provide service and care to individuals,” she says. “If reform reduces barriers to using midwives, there can be less cost and ubiquity of services.”

Today, however, some of those barriers still stand. Many states require a referral from an obstetrician-gynecologist before insurance will pay for a midwife, and midwives themselves need agreements with physicians who, when necessary, can provide the medical services that midwives cannot.

“We are always looking to increase the numbers of our physician colleagues who are supportive and collaborative,” says Levi. “Slowly, inroads are being made. But I think it’s slow because our numbers are small and we are still seen as alternative providers in the marketplace.”

Managing Chronic Diseases

“Nearly everyone agrees that [under any version of health care reform] health care service delivery needs to be more collaborative and patient-centered,” says Suzan Stringari-Murray, who directs the Adult Nurse Practitioner program at the UCSF School of Nursing. “That’s why nurse practitioners are in the best position to step into any of the models.”

There are multiple reasons why this is so. For one, NP training is patient-focused, rather than disease-focused, with an emphasis on psychosocial factors, managing illness, navigating the system and patient education. Other disciplines have begun to recognize how valuable this training is to maintaining health, but NPs are already experts in these areas. Numerous outcome studies – including a definitive one published in the Journal of the American Medical Association in 2000 – have established that NPs do as well as physicians in managing primary care patients, often with less utilization.

“Schools like ours have worked hard to adapt to health system and community needs and train NPs in a fundamental skill set that can move among various settings,” says Naomi Schapiro, who directs the ambulatory care Pediatric Nurse Practitioner program at UCSF.

A central part of that skill set is managing chronic illnesses like diabetes, asthma and hypertension that have come to dominate health care service delivery. This is not only an area that NPs are trained specifically to do, but, says Ellen Scarr, who directs the Family Nurse Practitioner program at UCSF, chronic disease management is the type of care that many physicians prefer not to do.

A second area ideally suited to NP training is working with young adults, the population least likely under the current system to have health insurance. “If insurance does become available to this group, the only places that will settle for what will likely be lower reimbursement are the community clinics – settings that many NPs work in because of their commitment to working with these poor and underserved populations,” says Scarr.

A third skill set where NP training is particularly apt is in managing patient education and prevention for children and adolescents. Research has shown that those types of services are among the most effective components of adolescent care. Schapiro notes, however, that expanding that role will depend on how reimbursement is structured.

“Because the changes need to be revenue-neutral, maybe rather than being reimbursed for every test that’s ordered, we can reimburse pediatricians and NPs for motivational interviewing or educating adolescents about risk-taking behaviors,” she says.

But Schapiro worries that even if those changes occur, it may be difficult to sustain these types of pediatric services. “Today, Medi-Cal and Medicaid reimbursement is often less than the cost of care,” says Schapiro. “It’s so low practices are barely hanging on or they’re folding.” People often cite these reimbursement concerns as a reason that fewer and fewer medical students opt for primary care, and it is certainly a consideration for NPs as well.

Training Enough Providers

Leaving aside the political fights, even if lawmakers agree that NPs and midwives are ideally suited to the various visions of health care reform, three key questions remain. How can you train enough providers to meet the need? What constitutes fair reimbursement? And will the system allow NPs and midwives to practice to the full extent of their training?

The first question – Can you train enough providers? – is very much on the minds of those who run graduate nursing programs.

“The success of health care reform might depend, in part, on providing the next generation of nurses with federal funding for nursing education, particularly of advanced practice nurses,” says Dracup. “Medicare has always supported nursing education costs at a relatively small amount, compared to its support for graduate medical education for physicians ($9 million as compared to $9 billion per year).

“While nursing education and patient care needs have changed tremendously since 1965, Medicare’s policy remains frozen in time. If we modernize Medicare’s support of nursing education, we can produce the additional highly skilled advanced practice nurses needed to enable cost-saving, quality-enhancing delivery system reforms such as transitional care and increased primary and preventive care.”

Scarr believes that if such funding materializes, some of it needs to be targeted at clinical faculty and training sites. “Practicing clinicians are the ones who can credibly teach clinical management, and schools need a management plan for clinical educators, rather than requiring clinical faculty to scramble to write training grants,” Scarr explains. Today, most hard money faculty positions are reserved for researchers and full-time professors.

“We also have to incent clinics because preceptors are very valuable,” she says. “My program has close to 70 students, who need 80 to 160 clinical hours per quarter, and it is not easy to find sites.”

Spetz points out that another important aspect of education will be creating a culture that encourages people in primary care to work where the need will be. “We will need NPs to work in underserved communities, so you need to provide that training,” she says. “Just look at the rural problem. NP programs tend to be housed at major nursing schools, which are mostly in urban areas. We do a good job here focusing on underserved urban populations, but rural is a tougher nut to crack.”

Paying Providers Fairly

A second major hurdle to incorporating NPs more extensively under health care reform will be resolving a complicated maze of reimbursement concerns. “Payment rules for NPs can be so complex it might require another degree to figure them out,” says Spetz.

Consider that for Medicare, NPs are technically free to bill the Centers for Medicare and Medicaid Services, but whether they can do so directly – or under a physician’s practice – depends on which state they practice in. Some states don’t allow direct billing for NP services at all.

Moreover, the amount of reimbursement for NPs varies from state to state. In some states, the Medicare or Medicaid fee is set at 85 percent of the physician fee. But if an NP is working in a physician’s office, the office can sometimes bill the service under the physician’s ID without specifying who performed it, allowing the office to collect the full 100 percent. That may or may not get to the NP, who is likely working on a straight salary.

With private insurers, there is even more variation. Some states have clear statements about how NPs must be reimbursed under private insurance; other states say nothing about it at all.

The lack of standardization is certainly part of the problem, but NPs also are in a strange Catch-22. On the one hand, they argue that they can deliver cost savings through a stronger focus on preventive care, an expertise in managing chronic illness that can reduce utilization and, in the case of midwives, less use of medical technology. On the other hand, there is the current reality that for the same services, NPs receive less reimbursement than physicians.

The lower reimbursement rates may register positively with some policymakers looking to reduce costs, but many NPs believe that with reimbursement rates already low for primary care services, they should not have to settle for the lower rates.

Dracup agrees. “The payment differential has no analytic foundation, and many health care practices won’t be able to survive with that differential rate,” she says.

Differing State Regulations

A third hurdle will be what are called scope-of-practice rules, which again vary by state and, in many cases, add unnecessary administrative burdens for physicians and nurses.

For a nurse practitioner to provide primary care to patients, some states require physician oversight and some states require physician consultation, but in other states, no physician involvement is required. Also, different states require different licensing and education levels.

“Within those guidelines, there are differing regulations about how or even if NPs can make diagnoses or prescribe controlled substances,” says Spetz. “Clearly, there are spaces where NP care is inappropriate – and good NPs know their limits – but with so much variation, it’s hard from a policy standpoint to ensure the limits.”

Malpractice laws complicate this picture. Spetz says that when physicians are sued, they are sued individually. But in some states, if an NP or a midwife is working in a doctor’s office and there is a lawsuit, the nurse, the practice and the supervising physician all get sued. That drives malpractice premiums higher and reduces the number of settings where NPs and midwives can realistically work.

Catherine Dower, Spetz’s colleague at the Center for the Health Professions, conducted a thorough study of the scope-of-practice guidelines and concluded, in the executive summary of her report Overview of Nurse Practitioner Scopes of Practice in the United States (December 2007):


“Preventing professionals from practicing to the full extent of their competence negatively affects health care costs, access and quality. NP practices are impeded by scope of practice laws, financing and reimbursement mechanisms, malpractice insurance policies and outdated practice models. The professions and the public are ill-served when practice authorities differ dramatically among states.”


She suggested that policymakers should consider expanding the NP scope of practice to match their competence, adopt uniform scope-of-practice laws to reduce variability among states and increase the number of NP programs to reflect growing demand for primary care.

“Primary care delivery has changed dramatically in the past 50 years, and for the better,” says Dracup. “We are living longer and more comfortably, and nurses and nurse practitioners are often the people who have provided the primary care in partnership with primary care doctors. If regulations around nurse practitioners and midwives are updated and outdated views of primary care change, that will provide one very promising pathway toward effective health care reform.”

Photo by Elisabeth Fall/fallfoto.com

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