The Nurse Practitioner: A Beacon of Hope in a Primary Care Crisis

Co-authored by Dr. Debra M. G. Murray.

Nov. 10-16 is Nurse Practitioner Week; the theme for this year is “Get Involved.” As board certified nurse practitioners, getting involved means sharing awareness of the importance that nurse practitioners (NPs) play in our nation’s healthcare system, especially in rural areas or sectors with significant healthcare disparities. With over 270,000 active NPs practicing today, these healthcare providers can be a beacon of hope for a growing crisis in primary care.

Shortage in Primary Care: A Growing Crisis?

Recent healthcare reform initiatives have expanded benefits to many Americans who previously lacked health insurance. Unfortunately, the increased number of patients seeking healthcare has not been met with an increased number of primary care physicians. In fact, in April 2019, the Washington Post reported that the percentage of primary care positions chosen by fourth-year medical students was the lowest on record. Where are the fourth-year medical students choosing to go? Specialty practices, such as orthopedics and cardiology, are popular choices for medical students, perhaps due in part to higher salaries in those fields.

So who will see the primary care patients, especially in rural areas? To fill this growing gap and potential crisis of approximately 58 million Americans in need of primary care services, the nurse practitioner is the professional that can be the solution to meet our nation’s healthcare needs over the next 10 years and beyond. In fact, the U.S. Bureau and Labor Statistics finds that demand for nurse practitioners is expected to increase by nearly 26% through 2028.

Demand Continues to Grow

Nurse practitioners are trained to meet all of the needs of patients, such as ordering, performing and interpreting diagnostic tests; diagnosing and treating acute and chronic conditions; prescribing medications and treatments; and managing overall patient care. In the United States, nurse practitioners see over 1 billion patients annually.

Nurse practitioners are a solution for expanding quality care services. Combining health promotion, disease prevention, health education and counseling, the NP is able to guide their patients in understanding better health and lifestyle choices. According to a 2018 American Association of Nurse Practitioners (AANP) National Nurse Practitioner Sample Survey, a patient who chooses an NP as their primary care provider has fewer emergency room visits and often shorter hospital stays. This results in lower out-of-pocket costs for the patient.

The Barriers

The first NP program began in 1965, and there still are barriers as NPs continue to expand to full practice authority nationwide. These barriers include independent practice and payor policies. Making everyone aware that these barriers still exist for NPs is part of the theme “Get Involved” of this year’s Nurse Practitioner Week.

Independent Practice

In 2010, the Institute of Medicine (IOM) issued a recommendation that focused on increasing access to care by allowing nurses to practice to the full extent of their education and training. This recommendation led to further expansion of the practice of NP’s authority as a high priority nationally. Unfortunately, there are still state-level barriers for NPs as they look to expand to full practice. These barriers must be addressed in order for the benefits of the NP role to be realized by all patients. NPs across the nation are lobbying for an expansion to full practice authority and the ability to practice independent of physician oversight. Currently, 22 states, the District of Columbia and two U.S. territories allow for independent NP practice, where NPs can use their education and training to diagnose and treat acute and chronic conditions. In 2018, Virginia became the 22nd state to authorize independent NP practice. The 28 other states require NPs to have collaborative agreements with a physician or restrict NP practice in some manner. Legislative advocacy needs to occur at the state and federal levels to allow NPs the ability to practice independently of physicians in order to meet the medical needs of underserved areas.

Reimbursement

Due to payor policies of some insurance companies, NPs may be forced to practice as employees of physicians or hospitals. The reimbursement that NPs receive for services is often less than their physician colleagues receive, even if the same service was provided to the patient. For example, a well-child visit with a pediatrician would be reimbursed by the insurance company at 100%, but the NP reimbursement would only be 80%. Another example of lower reimbursement rate that can be seen is known as ‘incident-to’ billing. This type of billing for an NP means that the billing for care delivery is under the physician’s name and not the NPs. These often more restrictive payor policies are connected to the regulation and licensure practices of the state leading to further limiting of an NPs ability to practice independently and lower rates of reimbursement either directly or indirectly for an NP.

Medicare

Several policies for Medicare-eligible patients restrict NP practice. NPs may order skilled nursing care for patients, but they may not conduct the assessments or admit patients to skilled nursing facilities. Under Medicare policy, NPs are able to serve as the attending provider and re-certify a patient’s eligibility for hospice care, but they may not provide the initial certification for hospice care. These barriers affect the patient as well.

Future of Healthcare

Even with the challenges outlined above, in the U.S., NPs have been practicing successfully for over five decades and continue to expand their ability to diagnose and treat patients. Many hospitals now use NPs for inpatient services as NPs are able to bridge the needs for the patient from the hospital to the home setting. NPs focus on health promotion through disease prevention, health education, and counseling, guiding patients to make smarter health and lifestyle choices.

Students who want to address the healthcare crisis, and who desire a healthcare career that offers an advanced-practice nursing role, should consider a graduate nursing degree with a focus as nurse practitioner. If you are considering a future as nurse practitioner, there are a variety of paths to realize this goal. Any of SNHU’s Master of Science in nursing tracks can be combined with a post-master’s NP certificate. SNHU’s Master of Science in Nursing (MSN) online degree provides you with the opportunity to acquire key competencies necessary for advanced nursing practice. The MSN electives allow you to customize your degree with specialty knowledge in the areas of continuous improvement, quality and safety of healthcare systems, patient-centered care, inter-professional collaboration, and evidence-based practice. Many of our SNHU MSN graduates have successfully pursued an NP post-master’s certification.

Charles Dickens once said, “No one is useless in this world who lightens the burdens of another.” As nurse practitioners, we treat patients as we would want our families to be treated. This purpose to help others is what makes being a nurse practitioner such a passion, but we need more of us in healthcare. There is a growing crisis, especially in the primary care setting. The nurse practitioner plays a vital role in expanding primary care capacity, improving quality care delivery, and reducing overall healthcare costs to the consumer. Learn more about the activities of 2019 National Nurse Practitioner Week and get involved by supporting a NP in your community. You might even consider a career as an NP. The different NP specialties include the areas of Family, Adult-Gerontology, Pediatric, Psychiatric/Mental Health, Women’s Health, and Neonatal. Remember, Get Involved!

Dr. Nick Carte, AGNP-C, APRN, is faculty lead in the graduate Nursing program at Southern New Hampshire University.

Dr. Debra M. G. Murray, RN, CNE, PHCNS-BC, CPNP-P, is an associate dean in the graduate nursing program at Southern New Hampshire University.