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
 Dermatology, up 7 percent
 Emergency medicine, up 18
percent
 Obstetrics-gynecology, down
16 percent
 Diagnostic radiology, up 34
percent
 Pediatrics, down 8 percent
 Pathology, up 122 percent
 General surgery, down 4
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
“nurses…particularly effective at improvisation, invention….”
NY VNA, circa 1900, VNA Coll.
Loretta Ford Collection
Innovative Experiments:
1965: Duke University PA
Program
Charles Hudson
Thelma Ingles
Who shall provide care?????
Nurse
Doctor
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
Doctor
Nurse
Borderlands
Doctors
Nurses
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; 280:788-94 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
 AMA
Between organizations and
 AAFP
individuals
 AAP
 Osteopaths
Investigations by state boards of medicine,
Prosecution of physicians who collaborated,
Political lobbying
Demand for evidence
NP Policy Research
 GMENAC Report – 1980
 OTA Report - 1986
 complement vs.. substitute
 High quality of care
 nursing has independent
sphere of practice
 Patient satisfaction
 quality primary care
accepted by patients

cited Kaiser study (75%
all visits)
 need for Medicare &
Medicaid reimbursement
 Good potential for managed
care
 Barriers - physician
resistance, legal
restrictions, lack of
reimbursement, limited
coverage for health
promotion/preventive care
NP Policy Reports - 1990s
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 - 1986
 Naylor et al., 1994 - 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 1987- 2002??? (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”
(2008) Health Affairs
(Berenson, et.al.
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