Of all the complaints about the Affordable Care Act, the specter of rationing is surely the most worrisome. But the estimated 30 million more Americans expected to have health insurance Jan. 1 won’t catch providers by surprise. The nation’s health care system has been reshaping itself for some time, not just for Obamacare, but for the so-called silver tsunami of an aging health care population.
Changes in the industry will ease the crush provided that reimbursements, which drive the U.S. health care system, honor the important role nurse practitioners and physician assistants will fill in providing primary care. For their part, consumers are likely to be pleased with more accessible, patient-centered care the individuals in both professions provide, particularly if they are aware of the extensive and rigorous training and continuing education required.
Northeast Indiana is well positioned to help meet demand for providers and will be more so if the state approves IPFW’s new Doctor of Nursing Practice program, the first-ever doctoral program for the regional campus. The University of Saint Francis has been preparing physician assistants – doctoral-level providers – since it acquired the program from Lutheran College about 15 years ago. About 300 students apply each year for 25 spots in the intense program.
The nursing model
Christina Trahin, a registered nurse and instructor at Saint Francis’ Department of Nursing, exemplifies the type of provider seeking the advanced training that will help meet demand in primary care. She’s a nurse practitioner student at Saint Francis, extending four years of nursing study and 10 years of practice by another two years of graduate work and clinical experience.
Your goal in nursing is to work for people who are sick and in need, said the third-generation nurse. I basically want to be a nurse practitioner because I want a stronger influence in patients’ care.
Heather Krull, one of two certified family nurse practitioners staffing IPFW’s Center for Healthy Living: Clinic and Wellness Programs, worked as a home health aide, certified nursing assistant and RN before becoming a nurse practitioner. She said she was attracted by the autonomy the position holds in treating patients. Krull earned a doctor of nursing practice at Ball State University and now teaches in IPFW’s Department of Nursing.
At the IPFW clinic, she treats primary-care cases – basic chronic illness, infection, diabetes management and more. A collaborating physician off site reviews 5 percent of the orders she writes.
Nurse practitioners allow the physicians to take the more complex cases – the cases that need more time and more significant management, Krull said. Nurse practitioners can manage the other cases and free them up to do more.
Indiana has about 3,500 advanced practice nurses, the vast majority of whom are nurse practitioners, according to Marcia Plant Jackson, a founding member of the Coalition of Advanced Practice Nurses of Indiana. Licensing falls under the state’s Board of Nursing.
The medical model
Physician assistants are licensed by a state Physician Assistant Committee.
The University of Saint Francis is the training ground for physician assistants in this region. Its program is one of just four in the state, although the University of Evansville will begin a program in 2016.
Our graduates have jobs immediately, said Dawn LaBarbera, associate professor and chair of the Physician Assistant Studies program at Saint Francis. I get a list of available jobs every day.
Indeed, Saint Francis has had a 100 percent placement rate for its PA graduates for each of the last three years. Likewise, Saint Francis PA graduates consistently post perfect passing rates on the day-long board exam, compared to a 93 percent passing rate nationwide.
Physician assistants are not physician’s assistants; the two providers work as a team, with PAs qualified to practice and prescribe medicine.
A better model
Experts are increasingly pointing to a concept known as a medical home as a means of reducing costs and improving quality in health care. Both nurse practitioners and physician assistants are key figures in such a model, which is based on patient needs.
They typically have more time than physicians to spend with patients. The goal is to improve access to care, with extended office hours and patient/provider communication through email and phone, and to coordinate care.
The model takes a team approach, with physicians, nurses, nutritionists, pharmacists and more collaborating.
Cheryl Erickson, a board-certified nurse practitioner and associate professor at Saint Francis, said advanced practice nurses are perfect partners in such a collaboration, given that their work always has been patient-centered. The advanced training many nurses are seeking rightfully earns them a place at the table in prescribing care. Some nurses are now spending as much as eight years in education.
I’m not trying to be a mini-doc, said Erickson, who also is the family nurse practitioner for the Allen County Department of Health. I’m trying to get (patients) the best outcome. We’re going to have to play together to meet all of the population’s health care needs.
Both PAs and nurse practitioners have had to fight for expanded scope of practice. The Indiana Academy of Physician Assistants made inroads in the last legislative session with approval of a bill to expand prescriptive authority and fewer requirements involving a supervising physician. It’s a win for medically underserved counties seeking more primary-care providers.
But there is opposition. The American Medical Association opposes expanded licensing authority for nurse practitioners, arguing that care will be compromised without direct physician supervision. The powerful organization also has opposed expanded-practice efforts of physician assistants.
Physicians, physician assistants, nurses and other health care professionals have long worked together to meet patient needs for a reason: The physician-led team approach to care works, AMA President Jeremy Lazarus told Businessweek earlier this year.
What is important to note is that in Indiana we all collaborate with physicians, most notably family-practice docs, said CAPNI’s Jackson, a family nurse practitioner in central Indiana. The opposition really comes from their professional organizations. In the real world of practice, we have very good relationships with the physicians we work with.
Erickson agreed that physicians are increasingly open to collaboration, but insurance companies sometimes limit or exclude their participation in health plans. Nurses are the silent providers whose work the companies don’t recognize for reimbursement.
The irony of the Obamacare rationing scare is that the growing shortage of primary-care doctors already has patients waiting for health care. A survey conducted by The Commonwealth Fund in 2011 found that 16 percent of U.S. adults waited at least six days for an appointment when they needed to see a doctor or nurse, compared with 2 percent in the United Kingdom, where the National Health Service has been in effect since 1948.
Given the number of Americans who will have access to health care, the need for more primary-care providers is obvious. Physician assistants and nurse practitioners can fill that need, provided that state and federal lawmakers recognize that health care demands will require more providers and that professionals in both areas have proven they’re up to the task.