Advanced Practice Nursing: The future is now

As America moves forward since the Supreme Court upheld the Affordable Care Act (ACA), communities and policy makers have questioned whether the primary care workforce can meet anticipated demand.

The federal health-care law will affect more than 32 million of the 50 million uninsured individuals in the United States. Many will be searching for health-care providers. Primary-care providers are currently in short supply throughout the nation as physicians continue choosing to practice in higher paying specialties.

As our nation continues to struggle with the primary-care physician shortage, primary-care nurse practitioner programs have steadily increased to fill this deepening gap with quality health-care providers. It is time for our profession to stand in the forefront and have our voices resonate.

Yet numerous challenges continue to restrict our scope of practice, and negative public relations campaigns from physician organizations skew the political debate, disseminating misinformation that patients are in danger of receiving substandard care from Advanced Practice Nurses (APNs). In order to break down existing barriers to APN scope of practice, we need to be actively involved and support our professional organizations. Let’s review how information affects APN professional practice and growth.

Variations in scope of practice

Inconsistencies in the scope of practice are still prevalent depending on the state where an APN is employed. These discrepancies are contrived from strong efforts on the part of some physician groups that perpetuate the misconception that APN care is substandard and hazardous to the public’s wellbeing.

For example, organizations including the American Medical Association (AMA) have provided information to state medical associations and policy makers that undercut the documented benefits of APN leaders in health-care teams. The AMA recently published a document entitled the Scope of Practice Data Series, which provocatively explicates that an APN degree does not warrant a change in a nurse’s scope of practice. Furthermore, the AMA has stated that any potential role expansion for APNs may endanger the health of patients and the public.²

Although these deleterious beliefs do not necessarily encompass the voice of the entire physician profession, this negativity continues to drive a divisive breach amid health-care professionals. To counter these efforts, APNs must publicly and politically decree our excellent performance standards, and our ability to deliver high quality outcomes for our patients, their families and the community. We should not be viewed as physician substitutes, but as part of the evolution to address the changing nature of our health-care system.

In contrast to the previously mentioned scenario, some of our physician colleagues have provided positive professional endorsements in support of the APN role within health-care teams. “I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical ‘neighborhoods,’ we gain far more from collaboration than from competition,” Jeff Susman MD, Editor-in-Chief of the Journal of Family Practice, wrote in a 2010 editorial.⁷

Teamwork and developing performance measures are the keys to mitigate tension between the APN and physician professions. Let us be clear. APNs are not contending for the physician’s role within health-care teams, but seek to work in a collegial manner for our patients, their families and the communities we serve.

Other significant factors controlling the APN’s scope of practice are the inconsistencies and barriers mandated by state-based regulatory systems. In some states, APNs are not able to certify home health-care services, order durable medical equipment, admit patients to hospitals or have prescriptive authority without a supervising physician. Yet, there is no data indicating that APNs practicing in more authoritarian states that restrict scope of practice, deliver superior care compared with those in less restrictive states, or that physician roles in less restrictive states are diminished.

The future is now. It is time to upgrade our image, and unify our profession. One way we can do this is to stop using the term “mid-level practitioner,” as it carries the negative connotation that APNs are of a lesser professional standing than physicians. Nursing is in a unique position to provide primary care using the full scope of our formal education and clinical training for patients and their families. Our continuum of practice covers a broad range of care ranging from health promotion, to disease prevention, to care coordination, to palliative care and cure. If our profession expects mutual respect and a collegial existence we cannot be “midlevel.”

The argument persists that because physicians undergo longer training periods, NPs cannot provide primary care services that are comparable. But the additional clinical training a physician receives has not demonstrated a quantifiable difference in the quality of primary care delivered. Multiple research studies indicate that primary care services and management of acute illnesses and chronic diseases can be effectively provided by an APN, with positive patient outcomes that are reflective of a physicians’ care.³

And there are cost benefits, too. Primary-care practices that changed the staffing mix and used more APNs, realized lower labor costs per visit than those that only used physicians.⁶ A cost data analysis from the Rand Corporation found that cost per patient visit was 20% to 35% lower when utilizing an APN or PA than with traditional physician visits, resulting in estimated statewide savings of approximately $4.2 to $8.4 billion from 2010 to 2020.⁵

Despite these benefits, some existing policies encourage the “invisibility” of APNs by establishing barriers that adversely affect quality-related data measurement. Currently, Medicare has a policy that allows physician practices to bill Medicare for APN services as “incident-to” the physician. Hence, the physician bills for the APN service at the 100% reimbursed physician rate through Medicare, and the APN remains in the shadow of the medical practice. If the APN bills Medicare directly, it is at a reduced rate of 85% of the physician rate.⁴ This cost savings is passed directly onto the physician practice, and not the patient or the payer.

Improving public awareness

So what can we do as professionals to raise awareness and visibility to our profession? We need to be more actively involved in our professional organizations either politically, financially or both. Ongoing media and political amplification of the high standards clinical practice APNs uphold need to be better publicized.

We have provided quality care to diverse populations for over four decades and we are clinically prepared to focus on disease prevention, health promotion, chronic disease management, education and counseling. More than 155,000 APNs are practicing in the United States and each of us needs to understand that health policy, politics and legislation determine the care that we provide.

Both the American Academy of Nurse Practioners (AANP) and the American College of Nurse Practitioners (ACNP) have responded to the profession’s need for better public awareness. The AANP has launched an aggressive, strategic National Public Awareness Campaign to address the substantial role the APN has in healthcare.

In addition, a major alignment in our professional organizations has commenced. On July 3, 2012, the AANP and the ACNP announced that their boards will consolidate to form a stronger, single professional organization. This consolidation will better position the newly formed member organization to better direct APN policy, as well as to increase public awareness and advocacy for our profession.¹

APNs have an obligation to our profession, patients and society to have our contributions to health care made public. We must be diligent in documenting evidence-based practice studies, including data comparing primary care services, patient-centered care, overall cost effectiveness and patient-care outcomes.

Furthermore, APN research contributions should not only be published in nursing journals, but also in other non-nursing journals to reach an extended professional audience. Increasing APN visibility and removing barriers to the APN’s scope of practice is contingent on our professional cohesiveness, and our continued political and public involvement.

Gilda Restrepo, RN, BSN, MSN, APN, CEN, works in Internal Medicine at the U.S. Veteran’s Administration in New Jersey, and is a doctoral student at the University of Medicine and Dentistry in Newark, New Jersey. Her opinions are her own and do not reflect those of the VA.