One year ago last month, Columbia Advanced Practice Nurse Associates (CAPNA) opened an office in an upscale neighborhood in midtown Manhattan. In April, 60 Minutes profiled the independent nurse practitioner group, which is led by Mary O’Neil Mundinger, DrPH, RN, dean of the Columbia University School of Nursing. In a segment titled “The Nurse Will See You Now,” the show’s host Morley Safer described the nurse practitioner as “a highly trained professional who is providing an alternative to the expensive primary care physician — some say a better alternative.” One of CAPNA’s practitioners, Edwidge Jourdain Thomas, MS, ANP, reinforced this theme by declaring, “We can do anything that a primary care physician can do.” CAPNA was also featured in a recent issue of U.S. News & World Report.¹ (For more information on CAPNA, see “A new option for primary care services?”)

CAPNA is new, and it’s currently the only practice of its kind in the country. Whether it’s a fluke or a trendsetter no one can say now. Still, its apparent success has fueled the long-standing debate about the distinction between functioning as an advanced practice nurse (i.e., a nurse practitioner, clinical nurse specialist, nurse midwife or nurse anesthetist) and acting as a physician substitute. The 60 Minutes segment generated strong criticism from the medical community, including a response from the AAFP’s then-president Neil H. Brooks, MD. Brooks took issue with the approach to primary care medicine espoused by CAPNA representatives, emphasizing the value of training family practice residents and nurse practitioners as teams. “The end result of this extensive training and teamwork is truly comprehensive health care where patients are the winners,” says Brooks.

Across the country, nurse practitioners and family physicians work together in practices where their skills complement each other. At the same time, some doctors argue that, without ready access to supervising physicians, nurse practitioners are likely to order more tests and consultations and be quicker to admit patients to the hospital, thereby driving up health care costs.

Others caution against getting caught up in the media hype. “Worrying that we can be replaced by nurse practitioners says that we don’t have a high image of what family practice is about, who we are and what we can do,” says Jonathan Harris, MD, of Endwell Family Physicians in Endwell, N.Y.

“Nonphysician providers have historically thrived in settings where physicians were unavailable — places they were unable or unwilling to go,” says Bruce Bagley, MD, of Latham Medical Group in Latham, N.Y., and a member of the AAFP Board of Directors who was recently chosen as president-elect. “It remains to be seen if independent nurse practitioners will be economically viable in areas of physician oversupply.”

What is clear, however, is that the market-driven health care system continues to look for new, more cost-effective ways to deliver services, and options like CAPNA that at least promise greater cost-effectiveness can’t be ignored.

The bottom line

While the nursing community is quick to point out that nurse practitioners have been functioning independently for many years, CAPNA is unique. “Five magic bullets have come together,” says Linda Pearson, MSN, FNP, editor-in-chief of The Nurse Practitioner and a family nurse practitioner.

• CAPNA is run exclusively by nurse practitioners.

• The nurse practitioners have hospital admitting privileges, a move Pear-son acknowledges is “cutting edge.”

• They are listed on the provider panels of managed care organizations (MCOs) and reimbursed at the same rate as physicians. Few advanced practice nurses in the country have received such recognition from commercial insurers.

• They are caring for an affluent population. Unlike the nurse practitioners in underserved areas who diagnose and treat patients when a physician is unavailable, these nurse practitioners are in direct competition with area physicians.

• The practice’s leaders are extremely media-wise. They have launched a slick media campaign complete with billboards and a state-of-the-art web site emphasizing that CAPNA’s services are “comprehensive, skilled, accessible, convenient and personalized.” According to Pearson, the practice represents “top-of-the-line sophistication.”

Nurse practitioners in full-time practice across the country number more than 50,000. The majority of these individuals are family nurse practitioners, adult nurse practitioners and pediatric nurse practitioners.

Forty-six states now require nurse practitioners to be certified. To be eligible for advanced practice certification, a registered nurse must hold a master’s or higher degree in nursing and must have been prepared to provide care to a specified population (e.g., adults, families, children, acute-care patients). The American Nurses Credentialing Center (ANCC) reports steady increases in the numbers of nurse practitioners certified each year. In 1995, for example, the ANCC certified 3,066 family nurse practitioners; last year the figure rose to 4,577.

No one is willing to speculate about the growth of independent nursing practices. Currently, less than 15 percent of all nurse practitioners operate such practices. However, the American Nurses Association (ANA) views the Columbia University School of Nursing project as “a significant breakthrough for nurses.” As pointed out in The Wall Street Journal, CAPNA could have “broad implications for HMOs, doctors and nurses nationwide, providing a closely watched test of the ability of nurses to assume an increasing share of the primary care duties now performed by doctors and of whether patients are willing to go along.”²

It may be too soon to speculate about CAPNA’s long-term viability, but changes in federal and state legislation, the influence of managed care and growing patient acceptance have definitely created more and different opportunities for nurse practitioners to work with other health care professionals and to practice autonomously.

Breaking down barriers

The laws and regulations governing nursing practice have not changed overnight. “It has been a slow but forward-moving process over the last 10 to 15 years,” says Jan Towers, PhD, NP-C, CRNP, a family nurse practitioner who is director of government affairs, practice and research at the American Academy of Nurse Practitioners (AANP). “As is often the case, we’ve worked to legitimize what nurse practitioners were already doing,” says Pearson.

Nurse practitioner lobbying activities at the state level have focused on achieving professional autonomy and securing prescriptive authority.³ Nursing organizations have also lobbied vigorously for federal and state laws supporting adequate reimbursement for nursing services. “One objective in all of this has been to make sure that there’s nothing legislatively that prevents nurse practitioners from being listed as independent providers on panels,” Pearson says.

Autonomy. To obtain the most autonomous practice possible, nurse practitioners have pushed to remove requirements for physician supervision and mandatory collaboration from nurse practice acts. To date, 25 states and the District of Columbia have removed these statutory requirements.

Prescriptive authority. With the passage of a bill in Illinois granting title recognition and prescriptive authority to advanced practice nurses, nurse practitioners in all states and the District of Columbia now have some authority to prescribe. In 17 of these states and the District of Columbia, nurse practitioners can write prescriptions (including ones for controlled substances) without any physician involvement.

Reimbursement. For many years, federal and state reimbursement policies limited the care nurse practitioners could provide by placing restrictions on the coverage of their services. Passage of the Balanced Budget Act of 1997 (BBA), however, changed all that. The BBA, which went into effect this year, liberalized Medicare coverage of nurse practitioner services. (See “Billing for NP Services: What You Need to Know,” Family Practice Management, May 1998.)

Medicare once limited coverage to services performed in rural areas and nursing facilities; now nurse practitioners may receive direct Medicare reimbursement regardless of the setting or place of service. While nursing supporters applaud Congress’ action, the AMA has been instructed by its House of Delegates to support legislation to rescind this provision.

Provider status. Most recently, the focus of nursing organizations has shifted “to convincing bean counters to include nurse practitioners on MCO panels,” says Pearson. According to Towers, “nurse practitioners are ideally suited to address prevention and health promotion, but some MCOs have imposed limits on patient services and blocked patient access to certain providers, preventing us from providing these valuable services.” Nursing organizations have launched campaigns to educate nurse practitioners about negotiating with MCOs and have coached them on how to describe their roles and the benefits of their services.

A winning combination

Although some MCOs have been reluctant to recognize nurse practitioners as primary care providers, the managed care environment has created a growing demand for nurse practitioners, especially in family practices. (See “Does Your Practice Need a Midlevel Provider?” Family Practice Management, September 1994, page 43.) Practice arrangements with nurse practitioners vary according to state laws and regulations as well as individual practice philosophies.

Considerable anecdotal evidence confirms that a nurse practitioner can help a growing practice accommodate more patients while controlling costs. “The economic reality is we can’t spend more time with patients,” says Jeffry Hatcher, DO, of Paris Family Medical Center in Paris, Ill. “Working with a nurse practitioner frees me to see the patients who need me the most.”

Hatcher has been working with Louwanna Wallace, MSN, NP, for more than five years, and he admits that he couldn’t meet the needs of the rural Illinois population he serves without her. They share the patient load, divide nursing home duties and, as a quality-control measure, review each other’s lab test results and X-rays. While Hatcher does not supervise Wallace on a case-by-case basis, he does sign off on all her charts.

Endwell Family Physicians in upstate New York has worked with nurse practitioners since 1978. “Ours is a collaborative relationship,” says Harris, one of three family physicians who started the practice in 1977. The seven family physicians and eight nurse practitioners maintain their own patient panels. Harris admits that the arrangement is considered controversial by some, but he says it’s been a huge success. (See “Family Physicians and Nurse Practitioners — A Perfect Team,” Family Practice Management, June 1998.)

“With very well-trained people, who understand what they can and can’t do, there’s tremendous synergy. Together, the physicians and nurse practitioners are much more effective than they are separately,” says Harris. Pearson agrees: “The best care people can receive is from a team approach of the physician, nurse practitioner and other team members.”

The heart of the debate

No one disputes the value of a physician-nurse practitioner team, but are nurse practitioners who hang out their own shingles pushing the boundaries too far? “It may make economic sense to bean counters to use nurse practitioners, but they don’t have the training to function as independent practitioners,” says Hatcher. “They’re very good at handling single-system disorders, but when you get into multisystem disorders, you need a physician.”

Early nurse practitioner training involved nondegree, certificate programs of one year or less. Today the nursing community strongly supports master’s degree preparation for entry-level practice. Although the level of education is higher, the focus has remained the same: Nurse practitioner programs emphasize primary care, preventive medicine and patient education.

“Family physicians offer a different service to patients,” says Bagley. “With four years of medical school and three years of residency training, their depth of understanding of complex medical problems cannot be equaled by lesser-trained professionals.” It’s in the patient’s best interest, according to Bagley, for family physicians and nurse practitioners to work together.

Also at issue is whether nurse practitioners require physician supervision. Nursing contends that the focus should be on collaboration (a collegial arrangement) rather than supervision (a subservient relationship). “We must learn to function as a true interdisciplinary team,” says Towers.

Medicine has a different viewpoint. “We feel that there should be a supervisory relationship and a sense of team effort,” says Bagley. The AAFP takes the position that the “interests of patients are best served when their care is provided by a physician or through an integrated practice supervised directly by a physician.”

In the final analysis, it’s unlikely that the two camps will resolve their differences. So who will have the final say about the role of nurse practitioners? It may be health care consumers.

High marks from patients

“Government agencies have studied nurse practitioners in a variety of settings for many years,” says Sue Whittaker, MSN, RN, associate director of state government relations for the ANA. “Study after study has shown that nurses provide excellent primary care.”⁴

A 1993 Gallup poll found that 86 percent of consumers were willing to see a nurse practitioner for primary care. Patients tend to rate nurse practitioners highest in the areas of communication skills and health promotion. According to the AANP, more people are choosing nurse practitioners because “they provide individualized care, focusing not only on health problems, but also on the effects health problems have on people and their families; they explain the details of health problems, medications and other topics to help people fully understand how to take care of themselves; and they ask about people’s worries and concerns about their health and their health care.”

Are the lines blurring?

Interestingly, it would appear that what attracts patients to nurse practitioners is closely linked to the characteristics that set family physicians apart from other medical specialties. (See “Does this sound familiar?”)

In its philosophical statement on the scope of family practice, the AAFP has this to say: “While knowledge and skill may be shared with other specialties, the family practice process is unique. At the center of this process is the patient-physician relationship. It is the extent to which this relationship is valued, developed, nurtured and maintained that distinguishes family practice from all other specialties. ... The family physician’s care utilizes knowledge of the patient in the context of the family and the community. This care emphasizes disease prevention and health promotion. The family physician refers the patient when indicated to other sources of care while preserving continuity of care.”⁵

Today the strongest selling points for nurse practitioners are their training in and focus on health promotion and their willingness to spend the time needed to get to know patients and to understand their needs and concerns. These are the strengths CAPNA is promoting, and the strategy appears to be working. The group continues to report steady growth in its midtown practice. Only time will tell whether nurse practitioners will be as successful in carving out a role in primary care as family physicians have been. If they do succeed, however, the fact that they are using essentially the same arguments that family physicians have used for years will endow their success with an irony that family physicians may find hard to appreciate.

What do you think?

In a statement on the scope of practice for nurse practitioners, the AANP acknowledges that “the role of the nurse practitioner continues to evolve in response to changing societal and health care needs.” Is there a role for independent nurse practitioners? Could independent nursing practices, over time, pose a threat to family practices? Do the roles of family physician and nurse practitioner overlap? Has family practice moved so far from its roots that independent nurse practice might take its place? As more nurse practitioners assume responsibility for wellness care and patient education, what impact will this have on the unique relationship between family physicians and their patients?

We would like to hear from you. Fax your comments to Family Practice Management at 816-333-0303 or e-mail us at fpmedit@aafp.org. We’ll publish selected comments in an upcoming issue.