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Opinion and Commentary from TMA

I Won’t Take the Nurse Practitioners’ Bait

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The American Association of Nurse Practitioners (AANP) is obviously intent on picking a fight with physicians. No thanks. We’ll take the high road, fully aware of the dangers of their plans, and stick with what we know is best for our patients: the physician-led health care team. 

In a recent commentary published in USA Today, two of AANP’s allies repeated the trope that authorizing independent practice for nurse practitioners would somehow solve the shortage of physicians we all know America faces. In their misguided quest, the authors have twisted and misinterpreted the research they cite, and in the end hurt the very patients they say they want to help. 

Fleeger_MugI won’t rebut, point by point, the authors’ argument. I’ll leave it at this: My problem is not with NPs. They are an integral part of the health care team. We need them on the team to help with disease management and education. Indeed, it is hard to imagine our health care system without them. My problem is with independent practice and the false argument that this will somehow improve access to and decrease the cost of medical care for our patients. The data are clear: Regardless of whether or not they work in states that allow independent practice, the vast majority of NPs locate just where physicians do – in the big cities. Without appropriate supervision, they order more tests and consultations to compensate for a more limited diagnostic knowledge base.  

Meanwhile, members of the American Medical Association’s Scope of Practice Partnership shared an insightful slide presentation from a recent AANP meeting. I was drawn to one slide that lists AANP “Board Initiatives.” Parts of it are repeated in more detail in the AANP’s 2019 strategic plan. I call your attention to two bullet points on that slide: 

  • “Patients nationwide will have full and direct access to high-quality care and will choose NPs as their health care provider” (emphasis added); and
  • “NPs will have parity with physicians and other providers in reimbursement, payment, and government funding.” 

These kind of statements might be good for AANP membership, but they’re awful for our patients. A nurse is not a doctor. And a doctor is not a nurse or physical therapist or an audiologist or any other type of clinician on the team that has to work together on behalf of our patients. 

As I stated when I proudly took my oath to become your TMA president, “It is because we are professionals that we lead, supervise, educate, and monitor the other members of our health care team. They do not know what we know. They cannot do what we do.” 

Nonphysician practitioners work with physicians – but under our direction. That’s not a put-down. It makes little sense to create more fractionation in our already confusing health care “system.” That’s what we work for at the Texas Legislature, in the U.S. Congress, in the courts, and in regulatory agencies. That’s why we defeated more than 20 scope-of-practice expansion bills during the 2019 legislative session. Your association – and I – remain firm in this principle. (See our strong letter opposing President Trump’s plan to grant NPs payment parity in Medicare.) 

In 2013, with the full support of the nurse practitioners and physician assistants here, the Texas Legislature passed a groundbreaking law that replaced the old site-based restrictions for prescriptive delegation and supervision with a more flexible, collaborative model for physician-led, team-based care. 

Our legislators understand that our patients benefit when each member of the team brings his or her special talents, skills, and training to the bedside. They understand that the path to independence is through education, not legislation. We will not stand by and watch the AANP and their supporters try to pretend that our years of medical school training and residency do not make a difference. No one has the skills and education that physicians have that qualify us to lead the patient care team. And ultimately, we have the responsibility for our patients’ health. 

I won’t take the bait. I’ll just continue to stand up for Texas physicians and our patients. 


Expanding APRNs’ scope of practice will increase the cost of care   

• Research comparing APRNs to physicians found a 41-percent increase in hospitalizations and a 25-percent increase in specialty visits among patients treated in the same setting by APRNs.1  

• Collaborative care models, such as the patient-centered medical home, have demonstrated reductions in emergency department visits of up to 29 percent2, reductions in hospitalizations up to 40 percent3, and reduction in total medical costs by 9 percent.4  

Sources:  

1 Hemani A, Rastegar DA, Hill C, et al. “A comparison of resource utilization in nurse practitioners and physicians.” Effective Clinical Practice 1999 Nov-Dec; 2(6):258-265. 

2 Reid R, Fishman P, Yu O, et al. “A patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation.” American Journal of Managed Care, September 2009.  

3 BD Steiner et al, “Community Care of North Carolina: Improving care through community health networks.” The Annals of Family Medicine 2008;6: 361-367.  

4 Geisinger Health System, presentation at White House roundtable on Advanced Models of Primary Care, August 10, 2009.