Nebraska has become the 20th state to lift restrictions on nurse practitioners (NP), granting them the authority to evaluate patients; diagnose, order, and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications.
This move by Nebraska is one of the ways government reforms can reduce the cost of health care, says Jessica Smith, director of research for the Platte Institute for Economic Research in Omaha, Nebraska.
“A nurse practitioner won’t be as expensive as a doctor, and this will provide more options to access quality care when needed,” said Smith.
With the new law, Nebraska joins Alaska, Arizona, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Iowa, Maine, Minnesota, Montana, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, Vermont, and Wyoming in granting NPs full practice authority.
New Opportunities for NPs
NPs have been around for 50 years, and states are now considering how they can better use their health care workforce to increase access and lower costs for health care, says Tay Kopanos, vice president of state government affairs for the American Association of Nurse Practitioners.
NPs must have the following qualifications and credentials in most states: A Bachelor of Arts Degree in Nursing, a Registered Nurse License, graduate nursing education, certification from the National Board, and a licensure from a state agency. This amounts to six or more years of academic and clinical preparation.
With an increase in the population, aging baby boomers, and the newly insured under Obamacare, millions of new patients will be entering the health care system, Kopanos says. This presents opportunities for NPs, whose numbers are expected to rise from about 171,000 in 2013 to about 244,000 by 2025.
“Granting full practice rights to NPs is a no-cost, no-delay solution for states that opt to, unlike other options that require new schools, new residency programs, or telehealth infrastructure that increase state budget spending,” Kopanos said.
Kopanos says another benefit is in states where NPs have full practice authority, more are working in rural and underserved areas, meaning those states are better able to provide earlier preventive health care services and access to primary care.
Retailers such as CVS Health and Walgreens Boots Alliance have hired thousands of NPs, Kopanos says. Nationally, Walgreens has 1,200 practitioners at more than 420 clinics, and CVS has 2,700 practitioners in 960 clinics.
Nebraska’s new law will also allow nurse practitioners to open their own clinics, Kopanos says.
Must Understand Limitations
There is a shortage of physicians in many areas of the United States and in various specialties, creating special obstacles and opportunities, says Dr. Roger Stark, a health care policy analyst at the Washington Policy Center and a retired physician.
“Nurse practitioners can serve as physician-extenders as long as they practice within their scope of training,” Stark said. “They can replace physicians only in medical areas of their competency. NPs can make straightforward diagnosis and do basic treatments without supervision. The critical thing for NPs—like with any doctor—is to know when to refer a patient for more specialized care.”
We don’t know yet whether the use of NPs will generally be greater in rural areas, Stark says, but NPs will have a role wherever there is a real shortage of doctors.
While many applaud the easing of restrictions on NPs, the American Medical Association (AMA) argues physicians should continue to lead health care teams.
“We encourage physician-led health care teams that utilize the unique knowledge and valuable contributions of nurse practitioners, physician assistants, and other health care clinicians to enhance patient outcomes,” AMA said. “Innovative physician-led team models used by some of the nation’s top health care systems across the country are achieving improved care and patient health, while reducing costs.
“The AMA looks to these systems as evidence that physician-led, team-based models of care are the future of American health care,” said AMA. “Patients win when each member of their health care team carries out the role for which they are educated and trained.”
Need to Scrutinize Training
Because of gender and political agendas, NPs end up with a truncated medical education that does not include hospital rotations, says Dr. John Dale Dunn, an emergency physician, attorney, and policy advisor to The Heartland Institute, which publishes Health Care News. They also have very limited exposure to diagnostic situations, which means they are more likely to make mistakes on occasion, due to a lack of experience.
“We need to be asking what types of training NPs are getting and if they should be treating sick people without getting training with sick patients,” said Dunn. “Are they doing clinical rotations in hospitals with sick patients? Do they get any courses in pharmacology? It’s not the routine cases but the ability to distinguish the non-routine cases that matters, otherwise, medicine would be nothing more than a cookbook.”
Tough cases present some risks in having NPs care for patients independently and prescribe medicine, Dunn says.
“Most of the time it will probably be OK, but it will not save money in the long-run because they will overprescribe tests, etc.,” said Dunn.
Ken Artz ([email protected]and.org) is managing editor of Health Care News.