Consider It Done

The VA health system recently sought senate legislation to empower nurse practitioners within the Veterans Affairs Department to practice independently, regardless of state-based limitations on their practice. This would allow all advanced-practice nurses (APNs) such as midwives, clinical nurse specialists, nurse anesthetists and nurse practitioners to practice without a supervising physician.

Currently, 21 states, the District of Columbia, and the Indian Health Service allow APNs to practice independently. One of the primary motivators for this initiative was the critical deficit of access to care for veterans.

Since this announcement, there has been a marshalling of forces on both side of this conversation. Physician groups, most notably the AMA, have denounced this plan as one that risks the lives and well-being of patients, stating that APNs lack the education and training to provide medical care and that there is no factual basis to establish that APNs practicing independently would deliver quality of service equal to or better than physicians.

Similarly, APN professional organizations such as the AANP and AACN have responded vigorously with their own rebuttals, stating that there are over 40 years of studies looking at outcomes, costs and patient satisfaction that prove that APNs provide safe and appropriate care and, in some cases, superior care.

As an APN who is very involved in an organization with a majority of physician members, I want to respond to this controversy. But what camp am I in, exactly? As a person who has practiced for 27 years in many arenas, I am humbled every day by all the things I still don’t know.

But I realize that independent practice doesn’t mean going solo, without consultation or collaboration. It just takes away the myriad barriers to our practice as APNs.

For example, I work in Illinois, a “restricted practice” state where I have a collaborative practice agreement and prescriptive authority. Recently, a patient of mine who lives in Indiana was discharged with home care services. Despite my being his only provider during hospitalization, I was not allowed to sign his home-care orders because in Indiana, that can only be done by a physician.

So, a physician who did not know the patient or the case had to sign the form. Did this improve the safety or efficacy of the care I delivered? No – it just delayed the patient’s care. Many states have limitations on APN practice that create barriers to patients’ access to care, an issue for so many in rural or underserved areas.

Does that fact that our training is different indicate that we provide inferior care? Are we less committed? No. Every provider has limitations to their training and practice. If you are a primary care physician, and you reach the limit of what you know or are comfortable treating, you refer to a specialist.

Does the specialist then go on message boards and state that primary care physicians are threatening the lives of patients, or lack sufficient training? No. It’s the same with APNs. Many conditions, many patients, many populations, many times can be managed by APNs. Sometimes a physician needs to provide medical evaluation or collaboration and support, but one professional is not superior to the other.

Independent practice of APNs is already happening. Look at critical access hospitals, Native American reservations, schools… Who is the first contact in your consult services? Who is collaborating with your ortho team and effectively co-managing those relationships and patients? Many times, it’s an NP or PA. NPs have been delivering care without hindrance to their practice in 21 states.

Healthcare is a rapidly evolving landscape right now due to a myriad of factors, including payment models, the Affordable Care Act, the dearth of physicians in rural or urban areas, the aging population and the increase in complexity of inpatients. Tell me: should we hold fast to the idea that the only way to deliver care is a way that has been in place for a hundred years? Or, should we really step back and look at redesigning the way we train all providers and deliver medical care? We cannot be innovative if we cling to the way things have always been done. And innovation is required. When you start with the supposition that the only way for all patients with all medical conditions to receive safe, effective and adequate care is through physicians that prevents any novel perspective or intervention.

In multiple studies, measures such as quality of care, prescribing practices, patient compliance, improvement in conditions and resolution of acute problems have been shown to be equivalent between physicians and nurse practitioners. In some arenas such as communications with patients and preventive care, NP ratings exceeded those of physicians.

The Health Care Cost Institute evaluated the impact of independent scope of practice for NPs and determined that it was associated with a 1-4% increase in health care costs in two of three patient cohorts. But provider prices for primary care services fell by 1-4% following the implementation of independent scope of practice for NPs. So in all, no there was no evidence of a negative impact in independent practice for NPs.

Healthcare is a rapidly evolving landscape requiring innovation, but we cannot be innovative if we cling to the way things have always been done. I firmly support the VA legislation to allow APNs to practice independently regardless of state regulation.

Tracy Cardin

Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.

In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.

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