|KCNPNM White Paper|
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 Kentucky.
Copyright © 2010, 2011 by the Kentucky Coalition of Nurse Practitioners and Nurse Midwives
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 government.1-11
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 medically
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 Assistants.5
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
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."
nurse practitioners and physicians. The result of the review indicated nurse practitioners
appear to have more effective communication, counseling, and interviewing skills than
physician care, it was found that there was greater compliance with treatment, increased
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 behavioral
changes. NMs used less anesthesia and technology and patient outcomes were the
same as physicians.18
indicate that the quality of care provided by NPs is equal to that of physicians. 1-4
care provided by HIV expert physicians.4
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.
Nurse practitioners 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
the four years of basic nursing education already completed in their undergraduate
studies. Though annual tuition and fees (in addition to living expenses) are comparable
for APRNs and for medical students either at public or private institutions (approximately
$35,000/year public vs. $60,000/year private), APRN master degree students who
attend programs full time will complete them in two years compared to a completion
time of four years for medical students.21
eight years to educate a primary care physician. There are 2,749 nurse practitioners and
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
$81,397 compared to $167,970 for family and general practice physicians, $156,010 for
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
nurses resulting in 78% fewer infants deaths, 11 fewer preterm births, fewer prenatal
and infant re-hospitalizations. Health Care Savings in this group – included 750 hospital
days saved for a total savings of $2,496,145.26
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.
outpatient. These patients had fewer hospital readmissions –saving $4,845 per patient,
with improved Quality of Life.27
community hospitals participated in this study.28
on the Center for Medicaid and Medicare Services performance measures. NP
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 decreased by
1.34 days; $2,576 savings per case).30
decreased ventilator days, improved heart failure outcomes and decreased
complications such as skin lesions, urinary tract infections and pneumonia. Comparison
of nurse practitioner and physician management of high cholesterol following
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
Utilization 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.
Utilization of Nurse Practitioners at the Worksite
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 coverage.
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.
(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
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 practice
residency slots available in 2008, only 2,387 were filled.22
from NP programs nationally is growing. According to the American Academy of Nurse
Practitioners’ National NP Database (2009) approximately 8,000 new graduates were
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
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 under close
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 to care.
Collaborative Prescribing Agreements
enter into a collaborative prescribing agreement. Because of this, NPs and NMs willing
to practice in underserved areas of Kentucky are not able to establish practices.
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.
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.
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.
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 providing.
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 providers.
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for Health Issue Brief (July 2010) The
New Health Reform Law: What It Means for Kentuckians.
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