Nurse Practitioners and Nurse Midwives Provide Quality, Cost Effective Care but Barriers to their Practice Decrease Patient Access to Care
A White Paper by the Kentucky
Coalition of Nurse Practitioners and Nurse Midwives
The purpose of KCNPNM is
to establish an association to assist Advanced Practice Registered Nurses (APRNs) in
the delivery of accessible and affordable health care to the people of
Copyright © 2010, 2011 by
the Kentucky Coalition of Nurse Practitioners and Nurse Midwives
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Nurse practitioners (NPs) and nurse midwives (NMs) are committed
to providing quality health
care that is accessible. However, unnecessary
practice barriers exist that prevent them from
practicing within the full scope of their
practice and education; thus reducing patient access to
care. Extensive research has been conducted
over almost half a century documenting that NPs and NMs provide excellent care
in a safe and cost efficient manner. The studies were performed based on
rigorous research standards and the results have been frequently replicated and
indicate the care provided by NPs and NMs is equivalent to, and in some studies
exceeds, physician care.1-4 In fact, no research to date has produced negative results about
the care provided by NPs and NMs.
To provide an idea of the scope of the
research that validates the excellence of care provided
by nurse practitioners and nurse midwives,
this paper includes a wide range of sources. In
addition to sources in the nursing
literature, research indicating positive outcomes is found in
the medical literature and from the United States
Kentucky ranks higher than the
nation as a whole in cardiovascular disease, diabetes, cancer,
and infant mortality. 12, 13 Kentucky has 81 counties and regions that are
underserved.14 It is imperative that
access to health care be increased so that the health of
Kentuckians is improved. Nurse practitioners
and nurse midwives have proven that they can
provide quality services in a cost efficient
manner. After almost half a century of scrutiny, the research bears this out.
Efforts must now focus on removing barriers to practice that prevent these
health care providers from improving access to care.
Nurse practitioners and nurse midwives are advanced practice
registered nurses (APRNs) who provide primary and specialty health services.
They practice in ambulatory, acute and long term care settings. They also serve
as researchers and consultants. Nurse practitioners and nurse midwives diagnose
and treat acute and chronic health problems and they are experts on disease
prevention and health promotion. Nurse practitioners and nurse midwives
prescribe medications, treatments, and therapeutic devices and they order and
interpret diagnostic tests. Kentucky NPs and NMs are recognized as primary care
providers by Medicaid and they may have hospital privileges.
Kentucky nurse practitioners and
nurse midwives are licensed independent providers. They autonomously provide
health care services to patients and refer patients for specialty care when necessary.
In Kentucky, NPs and NMs are not required to have physician supervision in
order to practice. Currently, they are required to collaborate with a physician
only in order to prescribe medications. The requirement for collaboration
applies solely to the prescribing of medication.
Nurse practitioners have been providing
primary care in the U.S. and Kentucky for over 40 years and nurse midwives have
been providing care in Kentucky for over 80 years. In Kentucky,
APRNs have been authorized to prescribe non
scheduled drugs for 15 years and scheduled drugs (controlled substances) since
the 2006 General Assembly granted that authority. They have demonstrated that
they are safe prescribers. Countless studies have shown beyond a doubt that
these health care practitioners provide quality care, improve health outcomes
and have high consumer ratings.
In June 2009, there were 2,323 nurse
practitioners and nurse midwives licensed in Kentucky.16 As of January 9, 2011,
the number of NPs and NMs had increased to 2,749.17 Nurse practitioners
practice in 114 out of 120 Kentucky counties.17 Of Kentucky’s counties, 77rural counties are designated as Health
Provider Shortage Areas (HPSA). 14 There are also four
(4) HPSAs located within urban areas. Nurse
practitioners are practicing in 75 of the 81
Quality of Care
Data from the Medicare Payment Advisory Commission (MEDPAC), which
advises Congress on
issues affecting Medicare, from an analysis
of 2006 Medicare claims for 100% of Medicare
beneficiaries, determined that Nurse
Practitioners provided a greater percentage of primary care
services than any other practitioner or
provider type including; Family Physicians, Internal
Medicine, Pediatric Medicine and Physician
It is well documented throughout the
literature in randomized clinical trials and meta-analyses
that there are no major differences in
patient outcomes when treated by an NP or a physician.
Furthermore, several studies indicate higher
patient satisfaction with NP care over physician
groups frequently call into question the education of nurse practitioners. They insist on comparing NP training
with that of a physician and completely discount the four (4) years of nursing
education NPs receive prior to entering graduate school. The Institute of
Medicine, in its newly released report, The Future of Nursing: Leading
Change, Advancing Health (2011), has reviewed a large body of
researchindicating that despite years of additional physician training,
there is no measurable difference in the quality of basic primary care services
provided by a NP as compared with those provided by a physician.15
The American College
of Physicians understands the role NPs play in health care reform. In a statement
to Medscape Medical News, 2009, Michael S. Barr, MD, MBA,
FACP, ACP vice president of practice advocacy and improvement, stated, "The College recognizes the important role that NPs
play in meeting the current and growing demand for primary care, especially in underserved
areas. As trained healthcare professionals, physicians and NPs share a commitment
to providing high-quality care."
studies show that patients have a high or very high level of satisfaction
Congressional Office of Technology Assessment (OTA) reviewed studies
nurse practitioners and physicians. The result of the review indicated
appear to have more effective communication, counseling, and
interviewing skills than
- In a
meta-analysis review of 38 NP studies and 15 NM studies comparing NP, NM,
physician care, it was found that there was greater compliance with
satisfaction, and higher resolution of pathological conditions in
treatment provided by
NPs than physicians. Patients of NPs were more compliant than
physicians' patients in
taking medications, keeping appointments, and following recommended
changes. NMs used less anesthesia and technology and patient outcomes
same as physicians.18
measurement of diagnosis, treatment, and patient outcomes, several studies
indicate that the quality of care provided by NPs is equal to that of
quality of care provided by nurse practitioners in an HIV clinic was
equivalent to the
care provided by HIV expert physicians.4
tend to provide a more relaxed atmosphere where patients feel more
ask questions that they regard as too trivial for physicians.4
According to a Citizens Advocacy Center
Report, economic theory holds that increasing the supply of a service,
decreases the cost of the service. Therefore, increasing the supply of primary
care providers will decrease the cost of primary care. 18 Keeping in mind
that Kentucky NPs and NMs have always practiced autonomously, deleting the
requirement for a collaborative agreement for prescriptive authority will save
the cost of compensating a physician for signing the agreement and increase the
number of available primary care providers.
and nurse midwives are not advocating a two-tiered system where they are paid
less for the same work or where care provided by nurse practitioners is seen as
second class. As already noted and supported by research, care provided by NPs
and NMs is equivalent to that provided by physicians. Cost savings would be
realized by expanded primary care services and a healthier population.
A Rand Report
published in August of 2009 projected that more widespread use of nurse
practitioners with expanded scopes of practice could result in $4.2 to $8.4
billion in savings for the Commonwealth of Massachusetts.19
cost of educating APRNs is much less than physicians. APRNs are building
the four years of basic nursing education already completed in
studies. Though annual tuition and fees (in addition to living
expenses) are comparable
for APRNs and for medical students either at public or private
$35,000/year public vs. $60,000/year private), APRN master degree
attend programs full time will complete them in two years compared
to a completion
time of four years for medical students.21
is a sharp decline in medical students entering the field of primary care.21 It takes
eight years to educate a primary care physician. There are 2,749 nurse
nurse midwives in Kentucky now, who are highly qualified to participate
in the planning
and implementation of healthcare reform programs.17
Cost Effectiveness—Salary Comparison
Comparison: In 2008, Median salaries of nurse practitioners in Kentucky were
$81,397 compared to $167,970 for family and general practice physicians,
pediatricians and $144,020 for psychiatrists.23, 24
Cost Effectiveness—Treatment Comparison
§ In 1981 and 1986, the Office
of Technology Assessment analyzed NP and NM practice
and found that these APRNs provided medical care that was equivalent to or
physician care at a lower total cost than physicians.10, 25
-half of 173 high-risk prenatal patients received home care from advanced
nurses resulting in 78% fewer infants deaths, 11 fewer preterm births,
and infant re-hospitalizations. Health Care Savings in this group –
included 750 hospital
days saved for a total savings of
care provided to women with high risk pregnancies by nurse midwives
resulted in fewer hospital days and savings over the infants’ first year
Nurse Practitioners and Nurse Midwives
emphasize disease prevention and health maintenance
in the care that they provide. They are
educated to consider all patients in the cultural context
of family and community. Because of their
focus on individualized patient education and their
excellent communication skills, patients are
more likely to understand the information they
receive related to self-care and medication
management. The recipients of APRN services are
less likely to require costly emergency room
treatment and in-patient hospital care.28-34 Given
the dramatic rise in the number of Americans
with chronic diseases like diabetes, heart failure,
hypertension and COPD, these conditions are
best addressed with the structured anticipatory guidance APRNs are so skilled at
providing. Increasing the number of
APRNs employed both in primary care and in diseased-focused specialty care can
be expected to result in major cost-savings for Kentucky and for the United States as a whole.
coordinated the care of high-risk patients with heart failure, both
outpatient. These patients had fewer hospital readmissions –saving
$4,845 per patient,
with improved Quality of Life.27
care resulted in 38% savings in Medicare Costs. Six Philadelphia academic and
community hospitals participated in this study.28
heart failure patients managed by NPs had lower costs with lowered length
of stays (LOS) and had excellent outcomes, lower mortality, and met
provided quality care for Community Acquired Pneumonia (CAP) and COPD
on the Center for Medicaid and Medicare Services performance measures.
intervention model for patients with CAP and COPD resulted in 90%
compliance with all
CMS measures and significant reductions in LOS and cost savings (LOS
1.34 days; $2,576 savings per case).30
savings occurred without an increase in pneumonia readmissions.31
of nurse-managed in-patient care demonstrated decreased patient stays,
decreased ventilator days, improved heart failure outcomes and
complications such as skin lesions, urinary tract infections and
of nurse practitioner and physician management of high cholesterol
revascularization, indicated that patients in the nurse practitioner
group were more likely
to meet their cholesterol goals and to comply with prescribed drug
regimens, resulting in
of Nurse Practitioners as Attending Providers for a State Workers’
Results: NPs were more likely than physicians
to be located in rural areas and counties with
high unemployment. Injury type and severity
were similar across both provider types.
likelihood of any time lost from work was lower for NP claims.
duration of lost work time and medical costs did not differ by provider
NPs as attending providers may be a cost-effective approach to address
of Nurse Practitioners at the Worksite
- Analysis of a work-site,
nurse practitioner based practice of over 4,000 employees and
their dependents determined that when compared to claims from earlier
years, the nurse
practitioner care resulted in
significant savings of $.8 to $1.5 million with a benefit to cost
ratio of up to 15:1.35
Access to Care
According to an issue brief released by
the Kentucky Voices for Health (July 2010), an estimated 261,000 Kentuckians who are now
uninsured will eventually have coverage through Medicaid, and 221,000 Kentucky
families will receive tax credits to help purchase insurance. 36
What will be the impact of these
dramatically-increased numbers of Kentuckians who will be seeking health care
services – especially primary care services?
Today, many people in urban communities experience long waiting times
for appointments with a primary care physician. When calling to be seen for an
acute problem, it is not uncommon to be told that no appointments are available
for three (3) to four (4) weeks. Many people who are not able to obtain
appointments for minor acute illnesses will seek care in the emergency room.
Those who live in rural health care shortage areas may go without care until
their illness become serious – and much more costly. The lack of access to
primary care services will worsen as more Kentuckians obtain health care
Artificial and outdated limitations on scope
of practice for nurse practitioners and nurse midwives prevent these health
care professionals from providing care within the full scope of their
education. " Further, physicians, dentists and some other health professionals
believe they must unite in opposition to any attempt ‘to encroach on their
turf’ and lobby state legislators to stop any changes to the status quo.” 21 Countless research studies
over almost half a century have documented the excellent outcomes and high
patient satisfaction with care provided by NPs and NMs. The continued blocking
of legislation to allow nurse practitioners and nurse midwives to provide care
within their full scope of practice will only serve to worsen access to care
and drive health care costs higher.
practitioners practice in 114 out of 120 Kentucky counties.16
- Of Kentucky’s rural
counties, 77 are designated Health Provider Shortage Areas
(HPSA). There are four (4) HPSA regions located in urban areas.14 Nurse practitioners
are practicing in 75 of the 81
Health Professional Shortage Areas.14, 17
- As of
January 9, 2011 there were 2,749 nurse practitioners and nurse midwives
licensed in Kentucky.17
to Kentucky Board of Nursing data, between 1998 and 2009 there was a 180%
increase in the number of nurse practitioners and a 4% increase in nurse
midwives in Kentucky.16
National Resident Matching Program shows that family practice physician
positions have declined since 2004. In 2004 the total number of
positions offered was
2,864 and in 2008 the number had declined to 2,636. Of the 2,636 family
residency slots available in 2008, only 2,387 were filled.22
contrast to the declining number of family practice residents, the number
from NP programs nationally is growing. According to the American Academy of Nurse
Practitioners’ National NP Database (2009) approximately 8,000 new
prepared in 2008.35
This type of growth in the profession can help to meet the need for
increased primary care services anticipated by the passage of the
Patient Protection and
Affordable Care Act.
Kentucky APRNs were granted authority to prescribe non scheduled
(legend) drugs in 1996.
Since that time, the number of APRNs in the
state has significantly risen and access to care for
the citizens of the Commonwealth has
increased.16 Kentucky APRNs have been
scrutiny since they began prescribing and
that scrutiny increased in 2006 when they were
granted authority to prescribe scheduled
drugs (controlled substances). Federal law requires
that all licensure boards report disciplinary
actions to the National Provider Data Bank (NPD). No Kentucky APRN cases of
narcotic convictions or violations of drug statutes have been reported to the
NPD. The Kentucky Board of Medical Licensure has reported 15 physician cases.
Kentucky All Schedule Prescriptions
Electronic Reporting (KASPER) collects data about the
controlled substance prescribing for all
health care prescribers. In order to prescribe controlled
substances, health care providers must
register with the federal Drug Enforcement Agency
(DEA). According to KASPER, in the first six
months of 2009, APRNs accounted for 5% of the
total DEA registrations in Kentucky. However, only 3% of the
prescriptions for controlled
substances were written by APRNs. Today,
KASPER data shows that the number of APRNs with DEA registration has grown to
9.9%; yet, APRNs only prescribe 3.7% of all scheduled drugs. Since 2007, KASPER
data has shown APRNs to be responsible and judicious prescribers of scheduled
drugs. While the prescribing patterns for controlled substances by APRNs are
similar to non-ARNP prescribers, the numbers of prescriptions written by each
APRN are substantially fewer than non-ARNP prescribers.
In a study comparing the prescribing
practices of psychiatrists and psychiatric NPs in a
community mental health center, demographics
for 5507patients were examined. While
psychiatrists and NPs prescribed similar
total numbers of medications, psychiatrists prescribed
more types of antidepressants and more than
twice the number of benzodiazepines (a type of
controlled substance) than NPs. The NPs
prescribed more SSRI antidepressants and spent
more time with clients during visits. 36
Barriers to Access to Care
While Kentucky statutes authorize APRNs to practice autonomously
and without supervision,
the law does require APRNs to obtain a
Collaborative Agreement for Prescriptive Authority with
a physician to prescribe medications. What
this means is that nurse practitioners and
nurse midwives may examine patients, order
and interpret tests, and diagnose and treat
patients independently, but they cannot
prescribe medications without a collaborative
prescribing agreement (KRS Chapter 314.011
and KRS Chapter 314.042). The requirement for
a collaborative agreement for prescriptive
authority has proven to be a barrier that has inhibited the ability of nurse
practitioners and nurse midwives to meet the increased demand for health care
services. Multiple reasons exist that prevent NPs and NMs from improving access
Collaborative Prescribing Agreements
- Limit Access to Care: NPs and NMs are having difficulty locating
physicians willing to
enter into a collaborative prescribing
agreement. Because of this, NPs and NMs willing
to practice in underserved areas of Kentucky are not able to
- Limit Small Business/Practice Ownership: NPs and NMs who want to establish
practice must pay a physician to sign a
collaborative prescribing agreement. In some
cases, the physicians are charging a high fee
for this service, making it very difficult to
open the practice.
- Liability Concerns: Although it has not been supported by the evidence,
physicians believe they will be held liable
for the NP’s or NM’s practice if they sign a
collaborative prescribing agreement.
Therefore, they will not sign an agreement.
- Legal Concerns/Access to Care: Health care providers cannot
patients. Because of the collaborative
prescribing requirement, Kentucky Nurse
Practitioners and Nurse Midwives are placed
in a precarious position if a physician
decides to end the collaborative prescribing
agreement. The NP and NM can no
longer prescribe medications for their
patients and those patients are left without needed
medications. This places further limitations
on patient access to care as well as
removing the ability of the NP or NM to
practice their profession and to provide their own livelihood.
- Reimbursement for Services: Kentucky NPs and NMs are considered
Independent Providers (LIPs) by the Kentucky Board of
Nursing, the Joint Commission
on Accreditation of Health Care Organizations
(JACHO), and all the APRN certification
organizations. However, requirements for a
collaborative prescribing agreement are
misunderstood by some insurance companies,
preventing NPs and NMs from receiving
reimbursement for the services they are
The evidence indicates that nurse
practitioners and nurse midwives provide quality care, improve access to care,
improve health outcomes and reduce health care costs. However, patients in
Kentucky are prevented from receiving the full benefits of health care provided
by NPs and NMs. Current Kentucky regulations and statutes not only limit access
to care and increase cost (to patients, Medicaid and insurance companies),
these restrictions impede true health care reform for Kentuckians. In order to
improve access, decrease costs, and improve the health of Kentuckians, practice
barriers which prevent NPs and NMs from providing care within their full scope
of practice and education must be removed. Therefore, the Kentucky Coalition of
Nurse Practitioners and Nurse Midwives supports legislation and regulatory
change to eliminate obstacles to nurse practitioner and nurse midwifery
practice. Such changes would be good public policy and would increase access
for Kentuckians to well-trained, cost-effective and highly skilled health care
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