The Need for Increased Nurse Managed Clinics

Introduction

There is a shortage of primary care physicians in the United States.  The Patient Protection and Affordable Care Act (PPAC) is expected to increase access to primary care services for 32 million Americans.  The current shortage of physicians who care for adults is projected to reach up to 44,000 by 2025.  This problem can be alleviated by allowing advanced practice registered nurses (APRNs) to practice primary care with greater autonomy.  Advanced Practice Registered Nurses have been shown to be able to deliver the same outcomes as a physician with lower costs.  Using APRNs as a source of primary care is a resource that needs to be used if affordable healthcare is to be provided to the growing population in the United States.

 

Literature Review

The largest group of health care providers in the United States are nurses with close to around 2.9 million registered nurses (RNs) (Naylor & Kurtzman, 2012).  Of the RN population, around eight percent are APRNs.  According to Stokowski (2010), “each year, 8,000 new NPs graduate, and 7,000 of these new graduates are prepared as primary care NPs.”  The U.S. Department of Health and Human Services (HRSA) has begun supporting the creation of nurse managed clinics (“HRSA Electronic,” ND). States which have implemented these recommendations and taken advantage of this system have seen positive economic and health benefits according to Naylor and Kurtzman (2010). The literature is abounding with examples of the need for greater access to health care and the enormous gap that exists between need and availability.  Physicians are no longer able to meet the ever increasing demand of primary care patients simply based on the sheer volume of patients in need.  Illinois alone is facing nearly 1000 medically underserved areas including several communities in almost every county in the state (“Medically underserved areas,” 1995). It is clear from the literature that we can no longer limit patients access to healthcare by limiting the scope of practice and billing privileges of primary care APRNs who are qualified and experienced in providing care to families and individuals in a primary setting. Nurse managed clinics with increased autonomy and billing rights  headed by these APRNs is the solution to the widening health care disparity gap.  Coddington and Sands (2008) found that “nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations”.  This finding illustrates the need for more nurse managed clinics which are able to reach the highly underserved populations unable to obtain insurance and thus appropriate health care. Their findings show that not only are nurse managed clinics able to meet the growing concern of a shortage of primary care providers but that they are also able to provide cost effective care to bridge the gap for uninsured individuals unable to seek health care otherwise. In 2010 the Institute of Medicine declared that “current laws in some states were hampering the ability of advanced practice nurses to contribute to innovative health care delivery solutions” (Frellick, 2011). These findings indicate the need for innovative solutions in health care provision.  Limiting the ability of advanced practice providers will only increase the health disparities currently affecting the country. It becomes vital that cost effective and productive solutions to the increasing number of patients, decreasing number of primary care physicians, and increasing costs of health care be examined in order to appropriately treat patients.

Policy Analysis

For a policy recommendation to be implemented, it must go through a rigorous process.  In order for the policy to be effective, this process must follow certain steps.  In Milstead’s Health Policy and Politics, this process is laid out into four stages: agenda setting, legislation and regulation, implementation, and evaluation (Milstead, 2008).

Agenda setting requires getting the attention of government that there is a need for a new policy or for a change in an existing policy.  Currently in the State of Illinois there is no official policy requiring an insurance company to reimburse APRNs acting as primary care the same was as a physician.  The Illinois Society for Advanced Practice Nursing is an example of an organization that uses advocacy to bring forth the issue to the attention to the State.

The second phase in the policy process, legislation and regulation, is the government response to a public problem and often starts in the legislative branch; the response takes its form in laws, rules and regulations, and programs (Milstead, 2008).  Since 2006, Illinois’ Medicaid Department, the Department of Health and Family Services, began reimbursing APRNs at 100% of the physician rate (Illinois Society for Advanced Practice Nursing, n.d.).  The current Illinois Nurse Practice Act states that, “If an advanced practice nurse engages in clinical practice outside of a hospital or ambulatory surgical treatment center in which he or she is authorized to practice, the advanced practice nurse must have a written collaborative agreement” (Illinois Nurse Practice Act, 2007).  The collaborative agreement must be with a physician.  Having a collaborative agreement can place limitations on an APNs ability to act as a patient’s primary care provider, thereby having adverse effects on the patient’s well being and overall health status.  This also limits the amount of time physicians and nurses are able to spend with patients.

The implementation phase is when legislation takes effect and is put into place.  Once a policy has been put into place, the evaluation process should be implemented. Milstead (2008) notes that, “evaluation must be started early and continued throughout a program” (p. 25).

Recommendations

Nurse managed clinics are the solution to the shortage of healthcare providers, the number of underserved populations, and redirect primary care services to disease prevention and health education in addition to treatment, if the appropriate policies are put into place. In order to facilitate the establishment of nurse managed clinics in primary health care, preliminary actions need to be taken.  A revision to the scope of practice guidelines in the Illinois Nurse Practice Act will allow APRNs more autonomy in practice.  APRNs need to be able to practice without the legal ‘supervision’ of a physician and qualify for healthcare provider reimbursement from federal and private insurance companies.  Currently, APRNs need to file for reimbursement under a physician and are only given a percentage of what physicians would receive.  Insurance companies will need to develop a policy that will incorporate APRN’s into reimbursement policies at the same rate as a primary care physician.  As a result, APRN’s will be able to practice in an appropriately funded primary care setting.  Research has indicated the use of APRN’s improve the cost and patient satisfaction in primary healthcare.  Modifying the scope of practice guidelines and ensuring adequate reimbursement will bring the United States closer to an overall effective healthcare system.

Conclusions

The United States Department of Health and Human Services (HRSA) has identified 942 medically underserved communities (MUA) within Illinois (“Medically underserved areas,” 1995).  Communities are designated as an MUA based on the number of primary care physicians per 1,000 people, infant mortality, and the number of the population over the age of 65 among other things. Illinois is not the only state threatened by MUA, aging populations, and limited access to health care.  Nationally, 15% of the U.S. population is underinsured. Fully autonomous nurse managed clinics can provide a cost effective solution for improving access to health care for underinsured individuals and create a solution for treating those individuals living in MUA. By more fully incorporating APRNs into general practice through greater autonomy and billing privledges will ease the strain currently effecting practicing physicians by diverting some of their patient load and lessening the need for them to oversee and sign off on all care provided by APRNs.   Allowing greater autonomy and billing privileges will ease the health care burden, save money, and allow access to health care for underserved populations. According to Naylor and Kurtzman (2010), a study in Massachusetts, after the implementation of universal coverage legislation, revealed “cumulative statewide savings of $4.2-$8.4 billion for the period of 2010-2020” by substituting physician visits with nurse practitioner visits in primary care.  Providing APRNs with  advanced education and clinical experience prepares them to assume the role of primary provider and creates a positive solution to health care disparities currently affecting our nation and community.

 

References

Illinois Society for Advanced Practice Nursing.  (n.d.)  Reimbursement issues.  Retrieved from http://www.isapn.org/?page=ReimbursementIssues

Medically underserved areas & populations (mua/ps). (1995, June). Retrieved from http://bhpr.hrsa.gov/shortage/muaps/

hrsa electronic handbooks for applicants/grantee. (ND). Retrieved from https://grants.hrsa.gov/webExternal/FundingOppDetails.asp?FundingCycleId=610C1741-CBE5-4EB2-9695-70FB02891AC4&ViewMode=EU&GoBack=&PrintMode=&OnlineAvailabilityFlag=&pageNumber=&version=&NC=&Popup

Milstead, J.  (2008).  Health policy and politics: A nurse’s guide (3rd ed.).  Sundbury, MA: Jones and Bartlett

Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-899.

Stokowski, L.  (2010).  The nurse practitioner will see you now.  Retrieved from http://www.medscape.com/viewarticle/723986_print

 

Coddington, J., & Sands, L. (2008). Cost of health care and quality outcomes of patients at nurse-managed clinics. Nursing Economic$, 26(2), 75-83.

 

Frellick, M. (2011). The nurse practitioner will see you now: Advanced practice providers fill the physician gap . H&HN: Hospitals & Health Networks,, 85(7), 44-49.