Increased autonomy for nurse practitioners as a solution to the physician shortage.
Abstract: In this paper, the author addresses decreased access to health care in underserved areas and the shortage of primary care physicians and how nurse practitioners (NPs) can fill this void. In order to make up for the lack of primary care doctors, NPs need to be politically involved in fighting for their autonomy; specifically, they must work toward removal of the statutory requirement that NPs practice in collaboration with a physician. NP associations need to increase membership, encourage members' political involvement, and move legislative agendas to bring about change. Although this paper focuses mainly on New York, it does highlight NP legislative agendas and how they were used to fight for autonomy in other states.
Article Type: Report
Subject: Medical personnel (Supply and demand)
Labor supply (Surveys)
Author: Pericak, Arlene
Pub Date: 03/22/2011
Publication: Name: Journal of the New York State Nurses Association Publisher: New York State Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 New York State Nurses Association ISSN: 0028-7644
Issue: Date: Spring-Winter, 2011 Source Volume: 42 Source Issue: 1-2
Topic: Event Code: 600 Market information - general Canadian Subject Form: Labour force
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Legal: Statute: Affordable Care Act
Accession Number: 278760662
Full Text: Throughout the United States, the shortage of primary care physicians, particularly in rural and low income areas, stands as a barrier to the goal of delivering adequate health care to all Americans. According to the physician workforce study survey conducted by the Healthcare Association of New York State (HANYS) in 2008, New York State has a severe and worsening shortage of physicians, which is affecting access to care.

Thomas Nicotera, MHHA, JD, director of membership and public affairs at the Nurse Practitioner Association New York State (NPANYS), reports that almost every county in New York is listed as being underserved (T. Nicotera, personal communication, July 6, 2009). This shortage of physicians is secondary to changing societal and healthcare needs. Primary care in our healthcare system is in crisis because there are far more people in need of primary care than there are primary care providers. The initiation of the Affordable Care Act, signed into law in March 2010, has compounded this issue. This act promises to provide insurance to 32 million Americans (Fairman, Rowe, Hassmiller, & Shalala, 2011).

Cooper (2004) notes that "physician shortages are emerging" and posits that, "by 2020 or 2025, the deficit could be as great as 200,000 physicians or 20% of the workforce needed" (p. 705). This undersupply of providers is due largely to the static growth of physicians every year, along with low numbers of physicians selecting primary care as a specialty (Hooker, 2006; Sheldon et al., 2008, Lakhan & Laird, 2009).

While it is certainly possible to devote greater resources to recruiting applicants for medical school who would commit to primary care, as Weiner (2002) argues, educating more physicians might not be a cost-effective use of our tax dollars. The cost and time to educate a nurse practitioner (NP) is significantly less than that required to educate a physician. One goal advocated by the HANYS survey is to increase usage of mid-level providers, which includes NPs (2008).

Healthy People 2020

Healthy People 2020 is a multiyear public agenda that has established a roster of national health objectives. These determinants align with the achievement of long and healthy lives for all people across the life span (U.S. Department of Health and Human Services, 2011). Determinants of health as outlined by Healthy People 2020 include "policymaking, social factors, health services, individual behaviors, and biology and genetics." NPs are educated to address individuals in light of the social, economic, and environmental factors that influence their health--in close keeping with the recommendations of Healthy People 2020.

NPs filling the void

According to the Center for Health Workforce Studies (2004):

Brock (2008) notes that NPs are filling a huge void as they provide primary care in the North Country area of New York's St. Lawrence county. This medically underserved area has a lack of primary care doctors and specialists. A report published in the American Academy of Family Physicians commented on the primary care physician shortage and noted that healthcare access is the most challenging problem facing our healthcare system, especially in underserved and low-income areas (Arvantes, 2008). In this same article, the author commented that increased healthcare access needs to be addressed not only by more physicians, but also with the help of NPs and physician assistants. In fact, NPs are more likely than physicians to provide care to those who are underprivileged and live in rural, underserved areas (Hooker, 2006). This is evident in New York where 14% of the M D workforce practices in Health Professional Shortage Areas as compared to 26% of the state NP workforce (Increasing access, 2007). Grumbach, Hart, Mertz, Coffman, and Palazzi (2003) emphasize that "limited research suggests that family physicians, nurse practitioners, and physician assistants are especially likely to practice in rural communities and might be more likely to care for low-income patients" (Introduction, para. 3). Furthermore, no study has extensively compared the geographic spread of clinicians in different primary care disciplines (Grumbach et al., 2003).

"Forty million Americans have no health insurance of any kind," according to Woods (2006, p. 150). Nurses need to find ways to help with President's Obama's initiated Affordable Care Act, which promises to bring equality to a healthcare delivery system that includes uninsured Americans.

Join state associations

NPs need to advocate for their autonomy and must strive to educate and convince legislators to remove barriers to their practice. There are no studies to support that, with newfound autonomy, NPs will magically appear in underserved rural and inner city areas. Clearly, however, under statutory collaboration, NPs are often restricted from practice in these areas because they lack a physician with which to collaborate. NP and nursing associations need to increase membership, encourage members' political involvement, and move legislative agendas to bring about this and other needed change. The first priorities are to understand the legislative requirements in each state that affect an NP's scope of practice and how the scope of practice in turn affects the delivery of health care.

New York is one of the 24 states that require physician involvement for diagnosing and treating patients with required written documentation (Pearson, 2009). According to the director of Membership and Public Affairs at the N PANYS, "There are less than 20% or 2,600 nurse practitioner members in New York's nurse practitioner association, and the State Education Department certifies about 14,000 NPs" (T. Nicotera, personal communication, July 6, 2009). In other words, less than 20% of the 14,000 NPs in New York State are members of the NPANYS, the official state organization for NPs (Pericak, 2009).

According to Nicotera:

We need more members and, in addition, more political involvement from the members would help to move the legislative agenda. We are still overcoming these barriers, but barriers can be overcome with continuous attention to the legislative agenda. Political involvement from nurse practitioners includes financial support around organized lobbying activity, legislative visits, [and] letter or e-mail writing, both will make a difference to move legislative agendas. Nurse practitioners should meet key legislators in their home offices because the power of being a constituent is very effective. The NPANYS supports its legislative agenda in part through the organization's Political Action Committee. In addition, the NPANYS has established the Legacy Fund, which supports public relations activities (T. Nicotera, July 6, 2009, personal communication).

NPs, with support from their state organizations, need to continue to educate legislators about the importance of NPs in the healthcare arena. Clarin (2007) suggests that physicians lack knowledge of NPs' scope of practice and have had little or no formal education about collaboration with NPs.

Educate legislators, promote activism

According to Philips, Harper, Wakefield, Green, and Fryer (2002), turf battles interfere with MDs' and NPs' healthcare goals. Even though NPs and MDs practice well together, it is at the policy level where doors are closed to healthcare access. Education is an important step when it comes to moving legislative agendas. Legislators and community members need to be educated on both the economic and societal value of care provided by NPs. In New York, educating members of the state legislature and other key stakeholders about the NP role needs to continue. To facilitate passage of crucial legislation, NPs need to lobby their legislators, and educate physicians, lawmakers, and consumers about the removal of statutory collaboration and the need to obtain third-party reimbursement to allow access to care for patients.

Political activism can move legislative agendas for NPs and can be in the form of providing education about the role of the NP to legislators and members of the community, as well as to members of the medical society. NPs have power in numbers and related to their knowledge of the healthcare system in America. The healthcare system would collapse without nurses, and a crisis in health care would result due to absent NPs. NPs can be powerful by using their voices to make significant changes in the healthcare environment. Beginning steps for every NP are to understand the relevant state legislative agenda and how it affects the NP scope of practice.

NPs are in a unique position to work with their state associations to expand their scope of practice. By opening up their scope of practice, they will have more autonomy, which will translate into improved access to care for patients. In other words, NPs need to fight for their autonomy, no matter how long it takes. NPs in the District of Columbia and the state of New Hampshire were consistent in their fight for autonomy, and they were able to remove statutory collaboration and can now practice autonomously. New York State NPs should model their fight on what these NPs did and what their predecessors did in the NPANYS to gain their legal title and scope in 1988. Another example of patience and perseverance in New York was the death certificate bill signed into city law by Governor Cuomo on July 20, 2011, allowing NPs to sign death certificates in the same manner and with the same responsibilities as physicians. In addition, NPs should examine how nurse midwives in the state of New York lobbied with the help of their patients to remove statutory collaboration in 2010.

Examples to follow

According to Karen V Scipio-Skinner, RN, MSN, executive director of the District of Columbia Board of Nursing, "NPs in Washington, DC, were able to be free of a mandated collaborative practice because they had key legislators working with them. The NPs were united with other advanced practice registered nurses (certified midwives, clinical nurse specialists, and certified registered nurse anesthetists), which made them politically powerful, and they all worked toward the same goal" (K. Scipio-Skinner, personal communication, June 17, 2009).

According to Lisah Carpenter, BSN, JD, executive director of the New Hampshire Nurse Practitioner Association, "New Hampshire NPs were persistent in their legislative struggles. This proved successful because they are free of mandated statutory collaboration" (L. Carpenter, personal communication, June 13, 2009). NPs in New Hampshire can enjoy their own private practices independent of physician oversight. According to Sampson (2006), it was the long and hard fight and the alliance with professional and community networks that made a difference in New Hampshire.

According to Lynda Woolbert, MSN, RN, PNP, executive director of the Texas-based Coalition for Nurses in Advanced Practice:

Woolbert concludes, "NPs need to work together and must realize it may take a long time to get legislation passed, but persistence is the key and involvement makes a big difference" (L. Woolbert, personal communication, July 1, 2009).

New York NPs should be encouraged by the efforts of Texas NPs. That state has stricter regulations than New York, and, in spite of this, changes are being made. Focusing on social advocacy, staying united, and becoming active in professional organizations are all ways that NPs can use their power to influence legislative agendas.

Fight for autonomy

NPs need to shift their focus from individualism to social advocacy and solidarity. If nurses in general, including NPs, could widen their lens to include the social, economic, and political barriers to health care, they would be in a better position to influence public policy (Kos-Munson, 1993). Nurses are influential when they come together to form a group committed to an issue. Peters (2002) stresses the importance of nursing leaders becoming active in issue networks. More nurses need to join their state associations or coalitions, with the main objective of advocating for their profession. In order for a nurse to reach full potential, legislative action is needed. Nurses and NPs need to be more involved in policy making, which influences the delivery of care. Philips and colleagues (2002) agree that NPs in particlular need to be consistent in their fight for autonomy.

Conclusion

Our healthcare system is in need of change, and a start would be for NPs to become politically involved. NPs in New York can be successful in passing the removal of statutory collaboration if they are persistent, connect with key legislators, join their state NP or nursing associations, and work together toward common goals. The current and future needs of our population must be met by a healthcare system that is affordable and sustainable, and one that can provide access to high quality services to all Americans, including the 48 million who are uninsured. NPs can literally be the change that they want to see in the existing American healthcare system.

* Related CE activity on page 24.

REFERENCES

Affordable Care Act, H.R. 3962 (2010).

Arvantes, J. (2008). Primary care health professionals in short supply at CHCs. American Academy of Family Physicians News Now. Retrieved from http://www.aafp.org/online/en/home/publications/news/ news-now/professional-issues/20080820-chc-report.html

Brock, C. (2008, May 11). More NPs coming to north country. Watertown Daily Times. Retrieved from www.watertowndailytimes.com/article/2008051 1/NEWS03/370841 193

Center for Health Workforce Studies. (2004). Final report: Nurse practitioners in New York State a profile of the profession in 2000. Retrieved from http://bhpr.hrsa.gov/ healthworkforce/reports/npny2000.pdf

Clarin, O. (2007). Strategies to overcome barriers to effective nurse practitioner and physician collaboration. journal for Nurse Practitioners, 3(8), 538-548.

Cooper, R. (2004). Weighing the evidence for expanding physician supply. Medicine and Public Issues, 141(9), 705-714.

Fairman, J. S., Rowe, M. D., Hassmiller, D., & Shalala, D. E. (201 1). Broadening the scope of nursing practice. New England journal of Medicine, 364, 193-196.

Grumbach, K., Hart, L. G., Mertz, E., Coffman, J., & Palazzi, L. (2003). Who is caring for the underserved? A comparison of primary care physicians and non-physician clinicians in California and Washington. Annals of Family Medicine, 1 (2), 97-104.

Healthcare Association of New York State. (2008). Access to care in crisis: Physicians in short supply. Rensselaer, NY: Author.

Hooker, R. S. (2006). Physician assistants and nurse practitioners: The United States experience. Medical journal of Australia, 185(1), 4-7.

Increasing access to health insurance coverage and moving toward universal healthcare coverage: Testimony before the New York State Departments of Health and Insurance, (2007) (testimony of Seth Gordon and Joy Elwell).

Kos-Munson, B. (1993). Who gets health care: An arena for nursing action. New York, NY: Springer.

Lakhan, S. E., & Laird, C. (2009). Addressing the primary care physician shortage in an evolving medical workforce. International Archives of Medicine, 2(1), 14.

Pearson, L. J. (2009). Pearson report. The American journal of Nurse Practitioners, 13(2), 8-82.

Pericak, A. (2009, summer). Increasing our membership is vital to legislative agendas [Editorial]. The Communique, p. 11.

Peters, R. M. (2002). Nurse administrators' role in health policy: Teaching the elephant to dance. Nurse Administration Quarterly, 26(4), 1-8.

Philips, R. L., Harper, D. C., Wakefield, M., Green, L. A., & Fryer, G. E. (2002). Can nurse practitioners and physicians beat parochialism into plowshares? Health Affairs, 21(5), 133-142.

Sampson, D. A. (2006). Determinants and determination: Negotiating nurse practitioner prescribing legislation in New Hampshire, 1973-1985 (Doctoral dissertation). Retrieved from http://repository.upenn.edu/ dissertations/AAI3225536

Sheldon, G. F., Ricketts, T. C., Charles, A., King, J., Fraher, E. P., & Meyer, A. (2008). The global health workforce shortage: Role of surgeons and other providers. Advances in Surgery, 42, 63-85.

U.S. Department of Health and Human Services. (201 1). Healthy People 2020. Retrieved from www.healthypeople.gov

Weiner, J. (2002). A shortage of physicians or a surplus of assumptions? Health Affairs, 21(1), 160-162.

Woods, D. J. (2006). Forty million uninsured, the ethics of public policy. Public Integrity, 8(2), 149-164

Arlene Pericak, FNP-BC, DA

Arlene Pericak is an assistant professor and graduate director of Nursing at the Sage Colleges in Troy, NY.
The largest number of NPs (32%) work
   in suburban areas, but almost as many
   (31%) practice in an inner-city area, while
   another 15% practice in a rural area or
   small town. Sixty-seven percent of rural
   NPs provide primary care (p. 3).


The Texas APRNs are challenged with a very strong medical society,
   the strongest in the nation. APRNs in Texas do not have removal of
   statutory collaboration; in addition, they have stricter
   regulations than New York. Furthermore, APRNs in Texas practice
   with supervision that is complex and greatly restricts the scope of
   practice. For example, NPs cannot make medical diagnoses or treat
   medically. It was clear, though, that once NPs educated the
   legislators, agendas were easier to get passed. For example, in the
   last 4-5 years, the APRNs have been very active in rural east Texas
   educating their legislators about the role of the NP. Because of
   their persistence and involvement, they were able to procure
   legislative support for prescriptive authority under nursing.
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