Nurses, Advanced Practice Nurses: Workforce for the 21st Century Julie Fairman, PhD, RN, FAAN Professor RWJ Investigator in Health Policy Director, Barbara Bates Center for the Study of the History of Nursing

Health Reform Dilemmas Payment Access Quality Cost Provider Supply

Increasing specialization Family practice, down 51 percent Internal medicine, down 18 percent Obstetrics-gynecology, down 16 percent Pediatrics, down 8 percent General surgery, down 4 percent Dermatology, up 7 percent Emergency medicine, up 18 percent Diagnostic radiology, up 34 percent Pathology, up 122 percent Anesthesiology, up 150 percent

Is your facility currently seeking physicians? No: 14% Yes: 86% If yes, what type? (check all that apply) Primary care... 81% 2007 Physician and Nurse Supply Survey, Council on Physician and Nurse Supply

Not Enough Primary care physicians

NY VNA, circa 1900, VNA Coll. “nurses…particularly effective at improvisation, invention….”

Loretta Ford Collection

Innovative Experiments: 1965: Duke University PA Program Charles Hudson Thelma Ingles

Nurse Doctor Who shall provide care????? Dietician, Social Worker, etc.

Who Should Provide Care: Ms. Shade is a 56 year old woman with a 4 year history of Non-Insulin Dependent Diabetes Mellitus. She has a 10 year history of smoking more than 1 pack per day. She is on a fixed income due to a past disability related to arthritis, another chronic illness. Her current weight is about 25% over the recommended limit for her height, and she also suffers from high blood pressure. On her last visit to her health care provider, her blood pressure was 149/85, her fasting blood glucose level was above normal, around 140 mg/dl, and her hemoglobin A-1C, was elevated at 9 percent. Her feet were still in pretty good shape, warm with palpable pulses bilaterally, and showed no signs of the typical changes accompanying uncontrolled diabetes. At this visit Mrs. Shade requested and received information about a weight loss and low salt diet plan, an exercise plan that was appropriate for low income people, referral for county transportation resources, referral to a community-based “Quit Smoking” program, and correct use of a recently purchased glucometer and home blood pressure set.

Other health professionals NurseDoctor

NursesDoctors Borderlands

Context The American healthcare system is fragmented and difficult for many patients to navigate. The average Medicare patient sees seven different doctors, according to the New England Journal of Medicine. Patients with multiple chronic conditions may see up to 16 physicians annually. It’s easy for important aspects of a patient’s medical history or personal care preferences to fall through the cracks. A lack of care coordination leads to medical errors, higher costs, and unnecessary pain for patients and their families. Resident Match Program 2009

Facts on US Nurses Most numerous health care workers Shortages driven by demand and context Largest supply in world U.S. needs more BSN Aiken et al. (2003) JAMA Variation in basic preparation BSN, AD, Diploma

U.S. Nurse Shortage By 2020, the demand for RNs will be 2.8 million equaling a shortage rate of 29% Bureau of Health Professions, July, 2002

Registered Nurses Licensed by state Licensing Exam- NCLEX London, Hong Kong 726 per 100,000 persons Most employed in hospitals 8% with advanced degrees 88.4% white, 94.3% women HRSA Health Professions Workforce Nursing Reports

Advanced Practice Nurses 2004 Nurse Practitioners Clinical Nurse Specialists Specialty Care & Mental Health Nurse Anesthetists Nurse Midwives

Interlocking cases that addressed historical questions Relationship between private and public initiatives in practice and education Political rhetoric of the professional organizations Influence of gender, race, and class in the generation of new roles and knowledge Influence of the patient The importance of personalities

Workforce Nurse Practitioners 46, 328 (1992) 63, 191 (1996) 85, 000 (2000) 141,209 (2004) Clinical Nurse Specialists 25, 000 (1995) 72,521 (2004) 2004 Nurse Sample Survey

Policy Implications Individual-generated patient demand for different models of care can move ideas forward to coalesce to health policy changes. These changes can be piecemeal and at times inadequate to support large scale reform in the delivery system. Greater access for patients to nurse practitioner models rests on real and virtual boundary disputes

Policy implications Develop delivery models organized around the care needed rather than around the type of practitioner who will deliver it. Look to the large available pool of primary nurse practitioners to work as partners and collaborators rather than ancillaries.

What do NPs do? “ Patient Centered” Assessment Diagnosis Treatment Case Management/coordination of care/integration Continuity and secure transmission across the health system Emotional support Access “Whole Person”…Family and Community focus

Limitations to Access Scope of practice Payment Competition vs.. Collaboration Licensure/Certification Autonomy Prescriptive authority

U.S. Health Care Workforce Selected Primary Care Clinician Supply Source: Cooper RA, et al JAMA 1998; 280: and COGME’s Eighth Report, November 1996.

Clinically significant questions focused on health policy issues : How do we decide who provides particular types of care at particular times and places?

Difference in response Between organizations and individuals AMA AAFP AAP Osteopaths Investigations by state boards of medicine, Prosecution of physicians who collaborated, Political lobbying Demand for evidence

NP Policy Research GMENAC Report – 1980 complement vs.. substitute nursing has independent sphere of practice quality primary care accepted by patients cited Kaiser study (75% all visits) need for Medicare & Medicaid reimbursement OTA Report High quality of care Patient satisfaction Good potential for managed care Barriers - physician resistance, legal restrictions, lack of reimbursement, limited coverage for health promotion/preventive care

NP Policy Reports s 1995 GMENAC Report Joint meeting Integrated Requirements Model Need for 12-24% increase in NPs 1997 HRSA Report on NP Preparation Access to primary care Increase in NP program support

Societal Acknowledgements HCFA removed Medicare requirement of physician supervision for nurse anesthetists NPs in all states can dispense drug samples Harvard Business Review - resistance to NPs is “flawed logic,” “disruptive technology” IOM identifies NPs as primary care providers Medicare identifies NPs as primary care providers State reform initiatives: NPs as key components Health reform bills: all include NPs as primary care providers

NP Outcome Studies OTA Report Naylor et al., Transitional care model Mundinger et al., 2000 (RCCT) Larkin (2003)- patient days, days on ventilators, complications Laurent, Reeves, Hermens, et. al. (2006) – Cochran data Base Review (substitution of physicians by nurses)

Medicare Payment Percentage For virtually all services in all settings, Medicare will cover PAs, APNs at 85% of the physician fee schedule Services are billed at the full rate. Use of the PAs/APNs provider number triggers the 85% payment [ Medicare Transmittal AB-98-15]

“It’s the delivery system, stupid”

4/5 Americans with health insurance cannot find a primary care provider NYT 2009 Major source of bankrupt individuals; medical bills Main increase in Medicare expenditures ??? (Thorpe and Howard, Health Affairs 2006) Many models tried: CCM Disease Management Case Management Guided Care Geisinger’s Personal Health Navigator (Paulus, et.al. (2008) Health Affairs

Consider: Not enough primary care physicians Why not NPs? Culture/structure: “tyranny of the urgent” (Berenson, et.al. (2008) Health Affairs

Where do NPs fit in current health care reform debates? Senate and House bills House “Affordable health Care for America Act” passed by 5 votes Senate “Patient Protection and Affordable Care Act” in debate with political issues such as abortion, public option going to be key Demonstration projects Medical home Regional consortiums Funding for primary care education Companion bills: Faculty support

Proposed Medicaid changes Increase patient pool Funding for FQHC/safety net clinics Nurse managed clinics Birthing centers Other changes: Medical home language: from physicians to physicians, nurse practitioners, and physician assistants

What’s Not Addressed Scope of practice Licensure Equitable pay for equitable services

Making Room in the Clinic Modern health care depends upon: Nurses, physicians, and patients working together finding common ground putting patients first knowing how to use the skills and knowledge of providers across time and place