Advanced practice providers impact care
Advanced practice providers impact care
Look at the changing face of family planning, and you are likely to see the advanced practice provider in large representation.
Whether it is a nurse practitioner (NP), certified nurse-midwife (CNM), or physician assistant (PA), these nonphysician clinicians play an important role in family planning, particularly when it comes to the provision of care to underserved populations, says Sharon Schnare, RN, FNP, CNM, MSN, a Seattle-based clinician and reproductive health care consultant.
"The evolution of nurse practitioners, midwives, and physician assistants has meant that contraceptive services are provided in every area of the United States — from rural, urban, to inner city," notes Schnare. "The capacity to reach the broadest group of women and provide contraceptive health services — along with cancer screening and other health care — has had a monumental impact on the health of women, men, and children in this country."
Nurse practitioners have made a tremendous impact on the quality of care in family planning programs, particularly in providing access to services, says Susan Wysocki, RNC, NP, president and CEO of the Washington, DC-based National Association of Nurse Practitioners in Women’s Health (formerly the National Association of Nurse Practitioners in Reproductive Health). "In the days before nurse practitioners, patients often had to wait en masse for an itinerant physician to come in after regular hours," she recalls. "Now family planning clinics can offer consistent access."
Nurse-midwives have maintained their commitment to serve women who are economically disadvantaged, yet women from all socioeconomic groups value the personalized, low-tech, and hands-on care provided by nurse-midwives, states Deanne Williams, CNM, MS, executive director of the American College of Nurse-Midwives in Washington, DC.
Legal changes, new opportunities affect practice
A 1998 report on the current projected work force of nonphysician clinicians (which also includes other disciplines such as chiropractors, acupuncturists, naturopaths, optometrists, nurse anesthetists, and clinical nurse specialists), shows that these three dynamics have altered the provision of all patient care services, affecting nonphysician clinicians:
• State laws and regulations have been revised, enhancing the practice parameters of such providers.
• The health care market is creating new opportunities for those providers to engage in clinical practice.
• The number of such providers being trained is growing.1
Over the last two decades, nurse practitioners have become recognized in all 50 states and have some degree of prescriptive authority, says Wysocki. Nurse-midwives have experienced a similar growth, says Williams. In 1996, the last year for which statistics are available, nurse-midwives were licensed to practice in 50 states plus the District of Columbia, had prescriptive authority in 47 states, and attended more than 7% of vaginal births in the United States, she says.
The growth of advanced practice providers has resulted in payment changes, as well. Nurse practitioners have gained a major victory in gaining direct reimbursement from Medicaid and Medicare, says Wysocki. While Medicare reimbursement for NPs is more complicated because of the system’s use of waivers, such payment is an important step for providers, she notes.
Nurse practitioners of all specialties have 216 million patient encounters per year and write more than 500,000 prescriptions per day, Wysocki estimates. Since current prescription tracking systems are outmoded, it is difficult to track the impact of such providers accurately, she notes.
Computer systems in pharmacies often do not have data fields to encompass providers outside of physicians, Wysocki explains. When a prescription is written by an advanced practice provider, the computer automatically credits the physician, who in most cases is the first name on the prescription pad. Subsequently, the physician who is in practice with the advanced practice provider is evaluated as a "high prescriber," even if that physician never sees patients. The National Association of Nurse Practitioners in Women’s Health is conducting a survey to determine the number and types of prescriptions written by nurse practitioners for women’s health, Wysocki states.
Training of nurse practitioners, nurse-midwives, and physician assistants has increased substantially in recent years, according to the 1998 report.1
The number of institutions offering master’s-level NP programs grew from fewer than 100 to more than 250 between 1992 and 1997, with the number of NP graduates increasing from 1,500 in 1992 to 6,350 in 1997. The number of CNM training programs doubled in size during that time period, and the number of CNMs graduating increased fourfold, the report shows. Physician assistant training programs also doubled, as did their number of graduates.
As for all health care professions, the chaos created by the dramatic switch to a profit-driven health care system has made professional life more difficult for nurse-midwives, says Williams. Many well-established collaborative relationships have fallen apart as reimbursement rates decreased and competition for clients increased. The demand for the midwifery model of care remains high, however, and members of the profession have shown a remarkable capacity to design new working relationships, she notes. (Advanced practice providers offer their views on changes in family planning and practice issues, p. 13.)
Reference
1. Cooper RA, Laud P, Dietrich CL. Current and project workforce of nonphysician clinicians. JAMA 1998; 280:788-794.
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