In 18 states, plus the District of Columbia, nurse practitioners are allowed to treat patients and prescribe medications without a doctor’s involvement. Lawmakers in a number of other states are pushing for similar changes to so-called “scope of practice” laws that determine what nurse practitioners can do for patients. Proponents argue expanding the roles of nurse practitioners can address what has become a major problem: a shortage of primary care doctors. But many physicians say a team-based approach that includes at least one medical doctor is better for patients. Please join us to discuss the role of nurse practitioners.

Guests

  • Mary Agnes Carey senior correspondent for Kaiser Health News.
  • Sandra Nattina nurse practitioner at Columbia Medical Practice in Columbia, Md., and past president of Nurse Practitioner Association of Maryland.
  • Ken Miller nurse practitioner, associate dean at The Catholic University of America School of Nursing, and president-elect of the American Association of Nurse Practitioners.
  • Dr. Reid Blackwelder family physician and president-elect of the American Academy of Family Physicians.

Transcript

  • 10:06:55

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. In many states, nurse practitioners are now allowed to own and operate health clinics without a doctor on staff. A number of other states are considering similar measures. Advocates cite votes reduce costs and expanded access to care. But critics warn of possible risks to patients. Joining me to talk about nurse practitioner care: Mary Agnes Carey of Kaiser Health News, Ken Miller -- he's a nurse practitioner and associate dean at The Catholic University of America School of Nursing.

  • 10:07:36

    MS. DIANE REHMJoining us from a studio at WUOT at the University of Tennessee in Knoxville, Dr. Reid Blackwelder, family physician, president-elect of the American Academy of Family Physicians. I know many of you will want to take part in the conversation. Give us a call, 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. Good morning to all of you.

  • 10:08:14

    MS. MARY AGNES CAREYGood morning.

  • 10:08:14

    MR. KEN MILLERGood morning to you.

  • 10:08:15

    DR. REID BLACKWELDERGood morning.

  • 10:08:16

    REHMKen Miller, if I could start with you, I think many people don't quite understand what nurse practitioners do, how they differ from registered nurses or physician's assistants. Can you explain?

  • 10:08:34

    MILLEROK. Nurse practitioners are actually registered nurses who have gone on for advanced education. They either go on for a master's degree in nursing, or they go on for a doctor of nursing practice in nursing. And what they do is they have the ability to evaluate, to diagnose, to prescribe and to treat patients who have various ailments. And many of them practice in their own nurse-managed clinics, and many of them also practice in clinics within hospital facilities. Many of them also work as acute care nurse practitioners in intensive care units and emergency rooms throughout the country.

  • 10:09:17

    REHMSo what you're saying is it's a matter of education and degree.

  • 10:09:23

    MILLERAbsolutely. It's a matter of getting advanced education for whatever specialty they decide to go into.

  • 10:09:32

    REHMAnd, Mary Agnes, I gather nurse practitioners are allowed to operate independently depending on the state that they're in.

  • 10:09:47

    CAREYThat's right. It's all regulated by the states. For the District of Columbia -- District of Columbia and 17 states, they can operate independently. But for 33 states, it's a patchwork of regulation. They may or may not be allowed to prescribe medication, for example. They may have to have a physician on staff or simply consult with a physician. So for the nurse practitioners, this is kind of a ground game in every state to figure out how much regulation they have to have in their practice.

  • 10:10:15

    REHMDo you see some states moving more in the direction of allowing nurse practitioners to operate independently?

  • 10:10:28

    CAREYWe certainly have pressure, for example, about 12 or 13 state legislatures this year that are going to be debating issues. For example, in Georgia, there's a push to allow national nurse practitioners rather to order some medical imaging. In Nevada, they would remove the requirement entirely for physician supervision. In Oregon, there's a push to allow nurse practitioners to dispense prescription drugs.

  • 10:10:52

    CAREYThe National Governors Association has been pushing for more freedom for nurse practitioners, ARP and other groups. The thought is with so many people gaining coverage under the 2010 Health Law, also known as the Affordable Care Act, and with the number of baby boomers continuing to age into Medicare, it's going to pressure on an already -- a system that already has a shortage of primary care physicians.

  • 10:11:15

    REHMDr. Reid Blackwelder, I gather some primary care physicians are really opposed to having nurse practitioners work without MDs entirely. Tell us why.

  • 10:11:35

    BLACKWELDERI think the main thing that family physicians are against is the fragmentation of our health care system and the tendency toward having little pockets whether that's independent practice in this state or isolated groups in another. That's been shown to be one of the main factors in why we're spending more in this country for health care and getting worse outcomes. So what we're really pushing and feel the data is showing makes a difference are for physician-lead teams.

  • 10:12:04

    BLACKWELDERI'm really excited about the discussions about primary care and the patient-centered medical home. But those are kind of buzzwords that are easy to misunderstand. And we're trying to help clarify how best we can bring the right care for the right patient at the right time and the right place throughout our country and not in isolated pockets from state to state with different models.

  • 10:12:26

    REHMSo would you be in favor of a standard across the country then that allowed nurse practitioners to operate on their own independently?

  • 10:12:42

    BLACKWELDERThat's a really good point. One of the things that you know about a family physician, once they've gone through undergraduate medical school and residency, it doesn't matter what school, what residency in this country, having that degree and that training, you know that the 21,000 hours of training, you know they have a bachelor's degree, you know exactly what they have based on their title.

  • 10:13:04

    BLACKWELDERUnfortunately, with the different state regulations, APRNs, you can't have that same consistency. Seventy-five percent will have a masters. We are not sure how many hours, whether it's 3,800 to 6,600, how much clinical training is involved just from the title alone. What I'm pleased with is the APRN has a consensus model trying to standardize the process from RN to APRN. This was finished in 2008, and they're hoping for movement to 2015.

  • 10:13:35

    BLACKWELDERBut the problem is this ongoing educational push and the approach to coordinating licensure accreditation certification is still just a model. It's not in place yet. And that creates silos of care. It creates uncertainty of what the training and education experience might be from state to state and sometimes practice to practice.

  • 10:13:56

    REHMWhat do you think about that, Ken Miller, that there are different standards of training right now?

  • 10:14:04

    MILLERI don't think the standards are different. There are national standards for all nurse practitioner programs. And those...

  • 10:14:10

    REHMThat are consistent across the country.

  • 10:14:12

    MILLERAcross the United States. And actually the Collegiate Commission on Nursing Education is one of the entities that accredit schools that have nurse practitioner programs, and they have a set of standards that are followed. There are also standards that have come out from the National Organization of Nurse Practitioner faculty. So there are all types of standards nationally that are used by various schools and various entities.

  • 10:14:41

    MILLERThe other thing I would like to correct is that there are approximately 93 percent of all nurses have graduate degrees, not the 75 percent. But I think, more importantly, one of the things that we have to look at is the fact that this really isn't about education and talking about number of hours. It's really about outcomes.

  • 10:15:03

    MILLERAnd you can go all the way back to 1970s when the first research studies were done on nurse practitioners. And most of these studies were done by physicians back then. From the 1970s to current, what you will see is the outcomes produced by nurse practitioners are equivalent to, and in many cases, better than the outcomes that family practice physicians have.

  • 10:15:28

    REHMMary Agnes, do we have statistics on that?

  • 10:15:32

    CAREYWell, the October issue of Health Affairs, which is a very well-respected journal, did a review of 26 studies and found that the clinical outcomes were similar, whether you got a care from a nurse practitioner or for a physician. And, in fact, according to this analysis of these studies, patients had a higher level of satisfaction with their nurse practitioners. They felt they talked to them more, spent more time with them and understood them better. So, of course, that's always in the eye of the beholder.

  • 10:15:57

    REHMSure, sure. What about that, Dr. Blackwelder?

  • 10:16:01

    BLACKWELDERWell, that Health Affairs study in October by Mundinger, the methods process is one certain and there were a lot of variability in that. And some of the data that goes back many years, some of it was done in the United Kingdom, which is a different system. Some of the papers were actually from practices that had collaboration with a physician. So there was another review of all the data that suggested it's difficult to make that generalization that the outcomes are the same.

  • 10:16:30

    BLACKWELDERObviously, outcomes data is critical, and this is what we all need to be looking for. What we are showing is -- there was a recent Health Affairs article in January that demonstrated that team-based care, which includes physicians, nurse practitioners, nurses, Pas and many other providers, are starting to show better outcomes across the board with better use of technology, team-based care with much less cost. And that improved outcome seems better than with individual groups, so that's the latest data from Health Affairs and a very impressive and exciting information.

  • 10:17:04

    REHMMary Agnes.

  • 10:17:05

    CAREYHere's another complication separate from analyzing the studies. It seems to be the issue of access is paramount here. If you're in a low, you know, a rural area, for example, where there isn't -- there are shortages of access to doctors, if you're in a low-income area, perhaps there aren't enough doctors, can nurse practitioners step in and fill the void?

  • 10:17:25

    CAREYAnd team-based care is certainly discussed in the health care law and there's a great emphasis on it. But the question here is can people get access to medical care, and can nurse practitioners allow more access in areas where you just don't have enough physicians?

  • 10:17:41

    REHMBut aren't we actually facing a primary care physician shortage?

  • 10:17:48

    CAREYAccording to the American Association of Medical Colleges, which trains our doctors, it says that we're going to have an estimated 90,000 physician shortage by 2020 that will grow to 130,000 by 2025. They also talk about something like 250,000 physicians are expected to retire over the next decade. So we already have stress on the system, and now we have millions of people coming in with a new health care law.

  • 10:18:09

    REHMKen.

  • 10:18:10

    MILLERYeah, I agree with that. And I think the other thing that -- derived from that data is the fact that there is going to be a shortage, about 40- to 45,000 family practice docs to do primary care. I think the other thing you have to look at is that the schools are ramping up. And we're turning out 2.5 times as many family nurse practitioners as the docs are turning out family practice docs.

  • 10:18:33

    REHMInteresting. Ken Miller, he is a nurse practitioner, associate dean at the Catholic University of America School of Nursing. We'll take a short break here. I see there are many of you who'd like to join the conversation. We'll get right to you.

  • 10:20:05

    REHMAnd welcome back. We're talking about the well-loved nurse practitioners. There are many state legislators now considering expanding, legalizing the role of those nurse practitioners to operate independently without being under the supervision of a practicing MD. Here with me in the studio, Mary Agnes Carey. She is senior correspondent for Kaiser Health News. And Ken Miller, he is nurse practitioner and associate dean at The Catholic University of America School of Nursing.

  • 10:20:52

    REHMAnd on the line with us, he is Dr. Reid Blackwelder. He is a family physician and president-elect of the American Academy of Family Physicians. Mary Agnes, had there been any studies which reflect on the safety of a patient under the care of a nurse practitioner as opposed to being under the care of an MD?

  • 10:21:26

    CAREYMy memory of a 2010 analysis by the Institute of Medicine, which is a really well-known advisory panel of physicians and other experts, had said that there was no -- that nurse practitioners were just as safe as physicians. And perhaps there's been studies since then, but that was one landmark report where the authors of the report came out and said nurse practitioners should be able to practice to the full scope of their practice and that we need more nurses, nurse practitioners and so on out there delivering care to help meet the need for medical care.

  • 10:21:58

    REHMKen Miller, as a nurse practitioner, what would be a situation where you would think it would be important to call in a physician?

  • 10:22:13

    MILLERI think any time you go outside your scope of practice or you find a complex patient that you cannot treat in your clinic, you would contact a specialist or refer them to somebody else. And I think that same phenomenon holds true for the family practice docs. There's not a single profession out there that works independently -- none.

  • 10:22:34

    MILLERWe all rely on one another. We rely on the respiratory people. We rely on the psychologist. We rely on social work. We rely on specialist docs. And when we have a problem that we can't solve, we will refer that person out to the appropriate specialist, whether it'd be an MP or a physician.

  • 10:22:52

    REHMDr. Blackwelder, what is your thinking on the forecast of a shortage in primary care physicians and how might that include an expanded role for nurse practitioners?

  • 10:23:12

    BLACKWELDERThere's definitely a crisis in primary care in this country. But primary care is another one of those words that can be defined in different ways. So I appreciate the reference to primary care physicians. But even that term is different because general internal medicine is not a common specialty. And internal medicine, a lot of folks have specialized, same in pediatrics, while family physicians tend to stay in primary care. So the access issue is certainly important to primary care physicians and physician-led teams.

  • 10:23:44

    BLACKWELDERAlso, health care coverage for all is a key component for improving outcomes, we know that. As we look at the shortage criteria, even when we were looking at teams, there's one other shortage that's critical that we don't hear much about, which is of another key member of the team, and that's the nurse, not the nurse practitioner. There's predicted to be an RN shortage of 260,000 by the year 2025. And these are critical members for us to be able to take care of our patients, regardless who else is part of that team. One other comment on the referrals, I completely agree, safety.

  • 10:24:20

    BLACKWELDERWe run into safety trouble when people practice beyond their education training and experience, regardless of what your title is, your license, insurance, so on. One of the important things, though, is that in a primary care team, not all members of the team are interchangeable. We have different roles. You can't just take one and replace with another and say we're giving the same quality care. Family physicians are uniquely qualified, given our position, our education, our training.

  • 10:24:46

    BLACKWELDERWhen a patient is beyond the scope of another member of the team, my preference would be that the first specialist to call -- and I don't think people mean this when they say specialist -- would be a family physician because we are able to take those undifferentiated problems and decide which of the various specialists might need to see that patient. I just had a patient in my office who had a very complicated heart disease, had bad reflux disease, has had amputations, is sedentary.

  • 10:25:16

    BLACKWELDERAnd I was able to talk to him on the phone, bring him into my office, spend some time to decide, did I need his cardiologist, a GI doc or anyone else, was able to do the EKG in the office to arrange the outpatient test, called folks to make sure we're all in the same page, and in one visit and one outpatient test, I've got him taken care of and managed because part of the challenge of referring for specialty care is increase in cost and not necessarily even finding the right specialist at that time. That's the role family physicians can do better than anybody.

  • 10:25:48

    REHMAnd how different is that from what you would do, Ken?

  • 10:25:52

    MILLERI don't think it's different at all. I think family nurse practitioners, as we've repeatedly said, is that they can actually function just like family practice docs. And when we run into an issue related to something with cardiac, we can read cardiograms. We can read EKGs. We can make the appropriate referral.

  • 10:26:14

    MILLERIf I have somebody that comes into my clinic and they have a broken ankle, I'm immediately going to refer that person either to the nearest emergency room or to an orthopod to deal with that issue. And I don't think that any one profession is omniscient and has the ability to oversee every other profession.

  • 10:26:35

    REHMMary Agnes, what about Dr. Blackwelder's point that there is in fact a shortage of RNs?

  • 10:26:45

    CAREYWell, that's certainly part of the ongoing, you know, shortage of medical professionals and the pressure coming in from all these people coming into the system. But one other element of this is that there are some feeling that nurse practitioners could, if you will, take care of some of the easier cases, leaving the complex cases, just as the doctor described, to them.

  • 10:27:06

    CAREYSo if you've got -- you really need a very experienced physician taking care of someone who has an ear infection or a common cold or has got a chronic condition they're monitoring, couldn't nurse practitioners lighten the load, if you will, take care of those and leave those complex cases for the doctors.

  • 10:27:22

    REHMNow, here is a tweet about the practice as a whole. It says, "Many physicians resist nurse practitioners based on the manner in which revenue is allocated in group practices." Mary Agnes.

  • 10:27:44

    CAREYI might kick this to Ken, but that is my understanding as well.

  • 10:27:45

    REHMAll right. Ken.

  • 10:27:46

    MILLERYeah. I think that's true. Nurse practitioners typically get 85 percent of what a family practice doc would get. However, in certain circumstances, if they bill under the family practice docs number, they can get a hundred percent if the family practice doc is on site. So I think there are ways to compensate for that.

  • 10:28:05

    MILLERBut I think the other things that you need to look at is when nurse practitioners started looking at patients. If you look at the data, one of the things that that shows is that nurse practitioners have fewer admissions and readmissions to emergency rooms, and they have shorter hospital stays than when seen by family practice physicians.

  • 10:28:24

    REHMAnd joining us now is Sandra Nettina. She is a nurse practitioner at Columbia Medical Practice in Columbia, Md. She is past president of the Nurse Practitioner Association of Maryland. Good morning to you.

  • 10:28:44

    MS. SANDRA NETTINAGood morning, Diane. Hello, everyone.

  • 10:28:45

    REHMGlad to have you with us.

  • 10:28:46

    MILLERGood morning.

  • 10:28:46

    CAREYHello.

  • 10:28:47

    BLACKWELDERHello.

  • 10:28:47

    REHMSandra, you're in a large group practice that includes MDs, so tell us the difference between what you do for patients and what the doctors do.

  • 10:29:01

    NETTINAI think, you know, on a large level, we do similar things. You know, we all need autonomous practice. I think there's a fear that nurse practitioners are going to run out, and everybody is going to open their own independent office. And I don't just see that -- I don't see that happening. I see, you know, all kinds of health care providers practicing with some autonomy and taking accountability for the type of care they give.

  • 10:29:27

    NETTINAI see patients that are largely -- my panel of patients that usually see me, but they have the option of seeing other types of providers in the office, including the physicians, and vice-versa. Now, it's a -- it's great to have a large group practice. Patients have options, you know, to come in at various times. We can see patients on Saturdays and evenings too. But that can't -- you know, that's not possible in all areas...

  • 10:29:56

    REHMSure.

  • 10:29:56

    NETTINA...for all patients. So there needs to be the options of nurse practitioners being able to sort of set up shop if they need to in a certain area.

  • 10:30:04

    REHMAnd you live in Maryland, a state that does allow nurse practitioners to set up their own practices. From your perspective, what are the pros and cons of doing that?

  • 10:30:18

    NETTINAWell, there's a lot of pros. I do, as a volunteer, have my own practice with a cold weather shelter. Here in Howard County we have grass-roots crisis center, and we run a cold weather shelter. And I go weekly to provide health care to people that don't have insurance and don't have money to pay. So, you know, I'm able to do that for them. My backup is the emergency room, but I keep a lot of people out of the emergency room and, you know, keep them as healthy as possible.

  • 10:30:49

    REHMSo in your current situation, you're on salary now. Is that correct?

  • 10:30:56

    NETTINAYes.

  • 10:30:57

    REHMSo how do the doctors sort of dole out who gets what?

  • 10:31:06

    NETTINAI make a salary, and what I bring in goes to the general practice. And then the owners of the practice, you know, make more than the people that are the employees. We bring in the money for the practice. We bring in that money, too, to invest in, you know, the very expensive IT that needs to go in. You know, electronic medical records are very expensive now.

  • 10:31:32

    REHMSure.

  • 10:31:33

    NETTINAIt's expensive for anybody to set up their own practice.

  • 10:31:36

    REHMBut would you, at some point in your career, like to do just that?

  • 10:31:43

    NETTINAI think I would. One of the things I do here in the practice is I make house calls, and I'm the only person in the practice that does that. And I just did it out of necessity. There were patients that couldn't make it into the office anymore. So now I go see them, you know, once a month, once every three months, however often need be, and take care of their needs that way. And I think there needs to be more of that, and I would love to have my own practice just doing that.

  • 10:32:09

    REHMBut what would be the difficulties for you in setting up that practice?

  • 10:32:16

    NETTINAThere are still certain insurances that don't credential and reimburse nurse practitioners. Now, we're good with Medicare, although they do reimburse at a lower rate, you know, than the physicians get paid. But like United Healthcare in Maryland and Cigna, some of the other insurances, don't credential and reimburse us directly. So we really need to be working with a physician to take those patients and get insurance reimbursement.

  • 10:32:43

    REHMSandra Nettina, she is a nurse practitioner with the Columbia Medical Practice in Columbia, Md. And you're listening to "The Diane Rehm Show." And, Sandra, can you stay on with us?

  • 10:33:00

    NETTINAYes, I can.

  • 10:33:00

    REHMOK. We'll open the phones now, 800-433-8850. Let's go to Ashton, Md. Good morning, Jamie.

  • 10:33:13

    JAMIEGood morning, Diane, and thank you for taking my call.

  • 10:33:16

    REHMCertainly.

  • 10:33:18

    JAMIEThis question is for Dr. Ken Miller. I'm a nurse, and Dr. Miller and I are former colleagues. So it's wonderful to hear your voice. But I wanted to ask -- my question is, through Catholic University, what changes in curricula have you made in recent years in order for nurse practitioners to practice in these types of acute care centers so that, you know, they have the tools that they need?

  • 10:33:53

    REHMSure. Ken Miller.

  • 10:33:55

    MILLERBasically, we have not gone to establish an acute care nurse practitioner track at the university. However, we just instituted an adult geriatric nurse practitioner program, and that program just started in January, and we were funded through HRSA to get that program up and running. Acute care may be something that we look at down the road. However, there are several other universities in the immediate area that do offer that, including the University of Maryland.

  • 10:34:23

    REHMI see. And, Sandra, would you be interested in that acute care training?

  • 10:34:31

    NETTINANo, I don't think so. I worked at that as an RN in the ICUs a number of years ago, and I saw this as, you know, taking those skills and bringing them out to the community. And I'm really interested in taking care of people where they are in the community.

  • 10:34:48

    REHMSure. And to you, Dr. Blackwelder, Sandra talked about the fact that she does house calls for those who need that kind of care. That's something that has really faded rather acutely from a medical care practice. What do you say to that as part of perhaps what nurse practitioners feel they'd like to do?

  • 10:35:21

    BLACKWELDERIt's a really important aspect of providing comprehensive care across time, which is what primary care is about, all family medicine residencies do, nursing home care and home visits as part of their training, as well as acute care chronic care prevention. So we don't have to have separate tracks. Our training provides a lot of that as a baseline foundation in all of the training that we do. And being able to be at home with a patient is huge, and creating that relationship with patients, whether it's at home or in the office, is huge. But I needed to make another comment.

  • 10:35:52

    REHMSure.

  • 10:35:52

    BLACKWELDERI certainly do appreciate that everybody on this phone call -- everybody we represent is dedicated to taking care of patients.

  • 10:35:59

    REHMOf course.

  • 10:35:59

    BLACKWELDERWe all have success stories. We all know our limits, and that's really the goal. But I really have to take exception to Ken's comment that the nurse practitioner is just like family practice physicians. Family physicians are uniquely trained. You can't substitute one member of the team for the other, given their standardized education or training in our process. However, the comments made on how we provide team-based care, how we transform our practice so that perhaps we don't jump in and do things I love -- I love well child care.

  • 10:36:34

    BLACKWELDERBut a lot of people can perform some of the tasks and services of primary care as part of my team, and we need to be able to make sure that I'm doing everything to the fullest extent of my practice. And it does mean I probably transition some of that. But we need to tap into all components. I neglected to mention that our home visits often have a PharmD going with us because medications are one of the biggest areas of risk for patients.

  • 10:36:59

    BLACKWELDERSo we're working on making sure our family medicine residents and our medical students are able to go into patients' homes to see the effect of what happens when patients are seen in an urgent care center, then hospitalized somewhere else, then see a specialist and don't have the coordinated care. That's ultimately our job, and the team is the best way to do that.

  • 10:37:18

    REHMAll right. And you used the term PharmD, which...

  • 10:37:22

    BLACKWELDERYeah.

  • 10:37:22

    REHM...I want to come back to 'cause I have no idea what that is. We're going to take just a short break here. When we come back, more of your questions, comments. Stay with us.

  • 10:40:04

    REHMAnd just before the break, I think you, Dr. Blackwelder, used the phrase PharmD which, I gather, is a pharmacist with a doctorate, and that is someone -- part of your team that you might take along. I want to clear up one particular difference -- and, Ken, maybe you can do this -- what's the difference between a physician assistant and a nurse practitioner?

  • 10:40:39

    MILLERMuch of what nurse practitioners do and physician assistants do is identical. The difference is that we have our own license and we are not under the direct supervision of a physician. PAs generally have some responsibility to a physician. Nurse practitioners do not necessarily have that same.

  • 10:41:04

    REHMNow, here's something from Jodie in Wainscott, N.Y., who says, "I've gone to my doctor and have been seen by the nurse practitioner for service. I think I should pay less for this because of less education and training. However, I am billed as though I have seen a doctor." Mary Agnes.

  • 10:41:32

    CAREYWell, this is -- my guess is I don't know the contract that that medical practice has with that insurer, but it -- my assumption is since it's a physician-supervised care, they're paying at a physician rate of reimbursement versus -- we were talking earlier how Medicare pays nurse practitioners about 85 percent of what they pay physicians.

  • 10:41:48

    CAREYSo again, you know, what you are authorized to do in a state, what your license allows you to do affects how you're categorized, how you can bill you insurers and how you can get paid. And this is why nurse practitioners are pushing all over the country to get more autonomy because they want to have that direct root instead of having to work under a physician's supervision.

  • 10:42:08

    REHMSuppose a nurse practitioner is sued. What happens?

  • 10:42:14

    CAREYWell, if you got medical malpractice insurance, it probably depends on the criteria of your policy.

  • 10:42:18

    REHMAnd you have to have that in order to operate independently, I would think.

  • 10:42:25

    CAREYI would think the same.

  • 10:42:26

    MILLERAbsolutely. To be safe, you really should carry on medical malpractice insurance.

  • 10:42:29

    REHMBut are you saying...

  • 10:42:31

    NETTINAWe all have it.

  • 10:42:31

    REHMOh, that's what I thought, Sandra. OK. Let's take a caller in Jacksonville, Fla. Donda, (sp?) you're on the air.

  • 10:42:41

    DONDAHi. I'm a huge fan, by the way.

  • 10:42:42

    REHMThank you.

  • 10:42:44

    DONDAI just want to say that I have a unique perspective. I've had a great deal of exposure. I've had 17 collapsed lungs, two lung surgeries, breast cancer and ovarian cancer. So I've had an opportunity to be serviced by the physicians, surgeon and nurse practitioners. And across the board, I have to say that the best listeners that I have been exposed to have been my nurse practitioners, my physician's assistant. They have taken the time to listen, and therefore, in numerous occasions, have literally saved my life.

  • 10:43:13

    DONDAWhile at the hands of a physician who was in and out of the room so quickly, he or she made an error that would have cost me my life. So the bottom line for me is really this: it boils down to -- we could obviously create an organizational chart that the nurse practitioners could follow. This could be a collaborative effort. We could put this in place, take some of the burden off of the physicians.

  • 10:43:39

    DONDAIt's my belief that the physicians that I've been exposed to, the majority of them do not want to give up their power. So the discussion that we're having is not so much about the safety of the patient nor if a system could be created that would accommodate serving the patient better, but really the doctors don't want to give up the power that comes with the white coat.

  • 10:44:02

    REHMMary Agnes, do you want to comment?

  • 10:44:04

    CAREYWell, her assessment that doctors don't want to relinquish their power is a criticism of this. But, of course, as our physician is talking about, they also feel that for the patient -- for the safety of the patient, you need to have a physician involved and that physicians have more training to recognize more critical cases. But I know that Ken differs with that.

  • 10:44:22

    CAREYBut one thing about that's interesting to me and, you know, I work for Kaiser Health News, we've written about this subject and people write in. And one of the comments was ostensibly from the physicians, how the author described himself or herself, and their argument was if a nurse practitioner set up their own practice and had to meet the same caseload demands as a physician, they may not be able to spend as much time to get as much data.

  • 10:44:47

    CAREYWhere, you know, doctors are having -- they have a much larger caseload because they've got to meet certain income requirements and insurance only reimburse them a certain amount. And I don't know if Ken wants to jump in on this, if you have your own practice as a nurse practitioner, are you subject to those same time constraints?

  • 10:45:01

    REHMYeah. Sure. I want to hear from both Ken and Sandra.

  • 10:45:06

    MILLERI don't think you have the same time constraints. I think most of nurse practitioners see patients in 15- to 20-minute blocks. So you can see three or four patients an hour. Physicians, on the other hand, if they have to keep up, if their salary is going to be dependent upon it, then what they do is they see more and more patients. And I can think of examples when I was in New Mexico where the family practice docs at the university were actually seeing patients probably every 10 minutes or so because they had to pull in a percentage of their salary.

  • 10:45:39

    MILLERI think the problem that you run into with doing that -- and I do know another physician in New Mexico who sees patients every two to three minutes, and I'm just waiting for the date when he gets sued. He has five nurse practitioners waiting for -- working for him. But I think, you know, going in and seeing somebody in two to three minutes and then coming out and diagnosing and treating is -- I find that interesting.

  • 10:46:07

    REHMSandra, give us an idea of how long you spend with each patient. Then I want to hear from Dr. Blackwelder.

  • 10:46:18

    NETTINAWell, fortunately in my office, we're allowed 20-minute appointments, which is adequate for, you know, a one-problem visit or following up on a couple of chronic conditions where patients are stable. But oftentimes, people have additional problems, and they want to take care of everything in one visit. And whether it be the nurse practitioners or the physicians, we're spending, you know, 40, 45 minutes with our patients.

  • 10:46:45

    REHMInteresting. Dr. Blackwelder, how do you respond?

  • 10:46:49

    BLACKWELDERWell, certainly, every patient deserves to be listened to, and I'm really sorry for our caller that she wasn't getting that care across the board. It shouldn't matter what you do. In fact, at East Tennessee State, we recognize how important this is across the board, that in our health sciences center we have the largest inter-professional communications course in the country where we bring together nursing students, pharmacy students, psych students and medical students to work with simulated patients and trained facilitators to help teach these critical communication skills.

  • 10:47:21

    BLACKWELDERBasically, I agree that patients get as much time as they need, hopefully. I know there are pressures. And our country needs to be shifting from paying for volume to paying for value. And this is true of everyone. And I would say physicians really are wanting to take care of their patients. And if you're going to talk about power, I think it's collaborating power. It's not relinquishing it or gaining it. We all have to get off of that and realize that we each have a role, that we need to work together to maximize what we can do.

  • 10:47:49

    REHMAll right. Mary Agnes.

  • 10:47:52

    CAREYWell, here's the thought that just is predominant in my mind. You've already got shortages around the country of -- for primary care physicians. We've talked about people that are retiring. We're talking about physicians that are retiring. You've got millions of people coming in as part of Affordable Care Act. And I think the question here is the system is going to be changing. Our delivery system for health care will be changing.

  • 10:48:16

    CAREYDoctor is correct where -- the health care law talks a lot about shifting the incentives instead of the amount of services you provide is being paid for the quality of service you provide. But the larger questions that are going to be answered from now into the next decade is, how do we deliver medical care? If you do a team-based approach, does that mean the doctor has to be on site?

  • 10:48:36

    CAREYHow many times does a nurse practitioner, for example, have to consult with that physician? How does it effect the compensation that the nurse practitioner receives? There are certain collaborative arrangements in place, in states. There is pressure to change them. But, I mean, these are pressures that are just not going to go away.

  • 10:48:52

    REHMAnd how is the Affordable Care Act going to address some of those issues?

  • 10:48:58

    CAREYThat's very interesting. There were a lot provisions in the health care law to increase residency slots of primary care, to increase the training of advanced practice nurses. The problem they're running into is some of these things are funded and some are not. For example, the health care law created a National Health Care Workforce Commission. Fifteen members, all experts, supposed to look at where are the workforce shortages, right, wasn't funded. They haven't met.

  • 10:49:23

    CAREYBut then on the other side in 2010, $15 million was given out to support 10 nurse managed clinics for three years so -- unless it was mandatory funding as part of the health care law, which was passed in 2010. If this money that is allocated in law, designated but not appropriated -- and right now, we have a lot of fights in Congress over funding between the parties -- you may have some of these programs best intentions in the world. But if they're not funded, they're not going to be implemented.

  • 10:49:51

    REHMAre you having a great many applications from women and men at Catholic University School of Nursing who want to become nurse practitioners?

  • 10:50:07

    MILLERYes. I think what's beginning to happen around the country, not just at Catholic but around the country, is that we're seeing an upswing in terms of the number of nurses who want to come on to become nurse practitioners. We're gearing up because we know there is going to be a horrendous shortage in 2014 if these 30 to 40 million people come on. So if you look at the schools around the country, many of them are ramping up. They're doubling the size of their programs.

  • 10:50:34

    REHMSandra, are you going to have to go back to school to enhance your education if you decide to go out on your own?

  • 10:50:47

    NETTINAI don't think so. I think I would take courses as needed on any particular procedures I needed to do and that type of thing. But I've had such a general great nursing background. And then 20 years of experience as a nurse practitioner with all types of patient, I can really apply those in the home and in the community very easily.

  • 10:51:09

    REHMSome insurance plans do require a doctor to be on site. Isn't that correct?

  • 10:51:18

    CAREYI think that's correct. I might kick that to Ken.

  • 10:51:19

    MILLERYeah, that is correct. Yes.

  • 10:51:21

    REHMSo -- go ahead, Sandra.

  • 10:51:23

    NETTINAYeah. No. CareFirst is our BlueCross BlueShield product here in Maryland. And they don't require a doctor to be on site, nor does Medicare.

  • 10:51:36

    REHMAnd...

  • 10:51:37

    NETTINAOr visits in the office or in the home.

  • 10:51:39

    REHMYeah. Now, Dr. Blackwelder, with a number of states considering expanding of the allowance of nurses to open their own practices, how do you think that could affect the practice of medicine?

  • 10:52:03

    BLACKWELDERWell, as was stated several times, there are already different arrangements in place in different states of different levels of care, 18 areas with independent practice and 33 with varying other arrangements. And even in the states with the independent practice, we're still faced with the same problems that are really the biggest issue.

  • 10:52:24

    BLACKWELDERSome of the other issues are important, and they're important in some states and to some folks. But what's important is that in our country, our outcomes are not good and our cost is continuing to go up and that the current systems, wherever they are, whatever state they're in, are not working. And this points toward the need for medicine has to change.

  • 10:52:46

    BLACKWELDERWe truly have to be shifting, all of us, in every state regardless of what state regulations exists to becoming better at collaborative care, at team-based care. Every member of the team is critical, must find the best way to practice to our full scope of training, education. But we have to make this work to really create a true change in our process.

  • 10:53:09

    REHMAnd you're listening to "The Diane Rehm Show." But going back to what you said earlier, Mary Agnes, there does not seem to be any study, which would indicate a difference in outcomes between someone who's been cared for by a nurse practitioner or an MD. Is that correct?

  • 10:53:36

    CAREYThat seems to be the preponderance of the evidence that there is not a difference. But as Dr. Blackwelder noted, he's talking about -- and I've read this from several physicians -- they feel that they still -- with their amount of training, they can recognize complications that someone with less medical training may not. I know that there are people who will disagree with that. But again, the evidence -- majority of studies seem to suggest there aren't -- there isn't really a difference in outcomes.

  • 10:54:00

    REHMAll right. I want to take one last caller -- Let's see -- in Dallas, Texas. Frank, you're on the air.

  • 10:54:10

    FRANKYes, ma'am. Thanks to you for having me. I wanted to find out, since the nurse program is building up near the year 2023, near 90 millions of baby boomers are coming into (word?).

  • 10:54:28

    REHMYes.

  • 10:54:30

    FRANKHow -- are we going to socialize the medicine? Is this what we're tying to do by getting the nurse? There are over -- I'm a fully trained physician. I'm an oral surgeon. And I have 25 years of practice.

  • 10:54:42

    REHMAnd you're saying you're internationally trained, and yet you are having difficulty with licensing. Is that correct?

  • 10:54:52

    FRANKThat's correct, ma'am.

  • 10:54:54

    REHMSo what happens here? Couldn't those who are trained abroad, Mary Agnes, get licensed here more easily to perhaps fill that gap of shortages we're going to experience?

  • 10:55:09

    CAREYI think that that would be probably up to state medical associations to take that step. But the caller is right. We've got about 50 million Medicare beneficiaries right now that's going to go to 80 million in 2030 that, plus all these folks coming from the health care law, put tremendous pressure on the system for people to be able to get primary and specialty care.

  • 10:55:28

    REHMSo is that going to mean that we're going to see more nurse practitioners, Ken?

  • 10:55:35

    MILLERI think we are going to see more nurse practitioners for the future. And I think nurse practitioners are going to -- even though they wanted to work autonomously, they also know that no provider, no health care provider works independently. We all depend on one another. And I think that's -- the big issue is that it has to be on a peer level.

  • 10:55:56

    REHMAnd you believe that many of these nurse practitioners will at least begin, as Sandra has, operating within a practice and then perhaps eventually establishing an independent operation?

  • 10:56:16

    MILLERAbsolutely. And when I look at these states in the Southwest, that's exactly what happened. Many of them started in working in practices and they went out and established their own clinic. And there were -- when I left there several years ago, there were 20 nurse-owned and managed clinics that were seeing approximately 5,000 patient visits a year.

  • 10:56:36

    REHMAnd that could be where you're headed, Sandra?

  • 10:56:39

    NETTINAI don't know yet. But I think -- I love nursing because there is so many opportunities and I've really grown in this profession. And I just -- I love primary care now and being able to really take care of the patients at an advanced level.

  • 10:56:53

    REHMI'm so glad, and I hope you all continue. Sandra Nettina, nurse practitioner at Columbia Medical Practice in Columbia, Md., Ken Miller, he's a nurse practitioner, associate dean of The Catholic University of America School of Nursing, Mary Agnes Carey, senior correspondent for Kaiser Health News and Dr. Reid Blackwelder, family physician, president-elect of the American Academy of Family Physicians. Thank you all so much.

  • 10:57:33

    MILLERThank you. I just want to...

  • 10:57:33

    CAREYThank you.

  • 10:57:33

    NETTINAThank you.

  • 10:57:34

    BLACKWELDERThank you very much, Diane.

  • 10:57:35

    REHMAnd thanks for listening, all. I'm Diane Rehm.

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