Project gives nurses primary care duties, pay
Project gives nurses primary care duties, pay
Critics say nurses lack necessary education
This month, New York’s Columbia Presbyterian Medical Center and Oxford Health Plans Inc. will launch a pilot project giving Oxford enrollees the option of designating a nurse practitioner as their primary care provider. Not only will nurse practitioners assume all the responsibilities of a primary care physician including diagnosis and referral but they’ll be paid at doctors’ rates.
Although some physicians greet the project with skepticism, it promises to provide an opportunity to assess whether nurses can handle the role of gatekeeper in a managed care setting, and whether patients are ready to accept them in that role, says Ben Safirstein, MD, vice president of medical affairs at New York City-based Oxford Health Plans. If successful, the project also could represent a milestone in the movement toward greater responsibilities and more equitable pay for nonphysician providers, he adds.
As part of the project, twenty advanced nurse practitioners from Columbia Presbyterian will be officially listed as primary care providers. They will be able to admit patients to the hospital, prescribe drugs, and refer patients to specialists or emergency care. None of this is particularly unusual for nurses at Columbia Presbyterian, says Sarah Cook, MEd, RNC, IBCLC, DPNAP, vice dean of nursing and professor of clinical nursing at the medical center. Cook says advanced nurses there have performed a number of primary care duties for years. Indeed, in the Columbia Presbyterian Physician’s Network (CPPN), nurse practitioners have had full admitting and prescriptive authority. "The real difference is that they’ll be paid appropriately for that care now," she says.
CPPN’s track record regarding the use of nurses played a big part in Oxford’s decision to test the waters in using nurses as primary care providers, says Safirstein. "We thought this would be an ideal opportunity to set up a beta site where we had the hospital, physicians, and nurses sitting at the same side of the table in some sort of collaborative research project to determine outcomes," he says.
NPs, PAs prove very effective’ in Air Force
Other factors also led Oxford to initiate the project. One was that the medical literature seemed to suggest that, in primary care settings where there is mutual and collaborative agreement with physicians, nurse practitioners can add "meaningful value" to the delivery system, says Safirstein. Another was the recognition that in rural areas, as well as high-density urban areas, there exists a paucity of primary care physicians. The U.S. Navy and Air Force have frequently used physician assistants and nurse practitioners as primary physicians in distant bases where no physician was available, says Safirstein, who served in the Air Force and found such practitioners to be "very effective."
The health plan also had received numerous requests from enrollees who wanted to see a nurse practitioner rather than a physician. It remains to be seen, however, whether large numbers of enrollees will choose a nurse practitioner as their primary provider, says Safirstein. If the project generates sufficient interest among enrollees, it likely will be expanded to include additional sites.
Katherine Chavigny, MD, director of the office of nursing affairs and related health professions at the Chicago-based American Medical Association (AMA), considers the pilot project part of an ominous trend, as managed care plans "do anything they can to reduce physician costs."
"I do not know why anyone would choose to see a nurse practitioner," she says. She explains that the education of nurse practitioners doesn’t sufficiently address primary care, which is a matter of first contact with the patient and first diagnosis. "Nothing can replace the medical degree for preparing people for that kind of responsibility," says Chavigny.
Further, the reasoning behind the project is flawed because when assessing the ability of nurse practitioners to handle primary care, the project’s designers compared the nurses’ education to that of physicians-in-training rather than to fully fledged physicians, says Chavigny.
Cook counters that in certain cases, nurse practitioners’ education and training is perhaps more appropriate than medical training in meeting the primary care needs of enrollees. She cites in particular nurses’ traditional focus on preventive care and health education, as well as their case management duties in overseeing patients with chronic conditions.
"I find some nurse practitioners extremely knowledgeable about chronic disease states, especially asthma," says Safirstein. "And having managed one of the largest inner-city asthma programs [in the country], I find nurse practitioners sometimes superior to primary care physicians."
Chavigny argues, however, that any perceived advantage nurse practitioners have in focusing on education and prevention is likely to disappear once they fall under the same constraints as primary care physicians. "They will be so busy doing diagnoses and treatment that they will not have the time to spend talking and educating patients, which has been the primary source of patient satisfaction with nurse practitioners," she says. She adds that nurses’ education efforts will be further hindered if the managed care plan limits them to 15-minute interviews, as it does with physicians.
The issue of nurses performing primary care duties is further complicated by the increasing scrutiny focused on physician gatekeepers, Safirstein admits. In light of recent reports suggesting that primary care physicians often under-diagnose complex illnesses, critics contend that giving nurses diagnostic responsibilities will only strengthen the case of some medical specialty groups who would like to circumvent primary care gatekeepers altogether.
"Clearly, there’s every evidence in the world to suggest that primary care physicians do not take care of patients with certain heart problems as well as cardiologists," says Safirstein. "What will happen to the nurse practitioner? I’m not sure. However, this is an opportunity for us to investigate that question."
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