In the wake of the Department of Veterans Affairs (VA) proposal to allow full practice authority for all VA advanced practice nurses (APRN), the turf battle over who is best suited to provide healthcare has been fired up again. Although this is not a new battle, the tides have been changing in favor of more authority for ARPNs, which causes the question of quality care to be raised once again.
Medical experts estimate a shortage of at least 20,000 primary care physicians by 2020. The shortage is attributed to the decline in physicians entering primary care, growing population needs and the addition of more insured as a result of the Affordable Care Act.
Considering this is not new information, solutions continue to be sought, especially in geographic areas that have high primary care shortages. Routinely, the solutions continue to include the use of APRNs. However, multiple medical groups continue to contest this obvious viable solution.
Currently, the prevailing solution from the American Medical Association and the Association of American Medical Colleges (AAMC) is to increase graduate medical education. Despite fewer students entering medical school in exchange for careers with less debt load at graduation, the AAMC continues to ask Congress for approximately $10 million to fund this solution — which would equate to about 3,000 more new physicians per year.
Therefore, the solution that continues to abound is the increased use of APRNs. With more than 222,000 nurse practitioners licensed in the United States, the work force is already present and able to care for the millions of Americans who are lacking good primary care. As of 2013-2014, approximately 46 percent of nurse practitioners were already serving in a primary care setting and continue to have low malpractice rates, indicating good outcomes and care.
According to the Kaiser Family Foundation, substantial research literature continues to support the quality of care provided by APRNs to be comparable to that provided by their physician counterparts. Recently, the Annals of Internal Medicine reported that "advanced practice clinicians (APC) and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions."
The research comparing outcomes of patient care provided by APRNs versus physicians continues to be challenging, at best. Currently, it is nearly impossible to retrospectively study the care provided due to current billing practices.
If an APRN bills under her own National Provider Identifier, she may only be reimbursed at 85 percent of the physician rate, depending on location. However, if the APRN bills "incident to" the physician she is working with, the practice is reimbursed at 100 percent. Ultimately, this makes it difficult to know exactly who provided the care and, subsequently, to study long-term outcomes.
This brings up another interesting point. If the quality of care provided by APRNs is in question, why do physicians continue to employ them and reap the fiscal benefits? It is curious that the quality of care is never called into question when APRNs work for the physicians, only when they may attempt to steal a piece of their pie.
But is it really stealing when there are so many patients that still need primary care? According to the Kaiser Family Foundation, 56 million Americans were living in geographical areas that have primary care shortages.
It is obvious that more research will be needed to convince most physician groups that effective quality care can be provided by adequately trained and educated APRNs. However, now is the time for action and solutions, not for more turf battles.
