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Too much independence for NPs?

At one N.Y. clinic, HMOs are treating—and paying—nurses like doctors

From the January 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Robin Warshaw

Patients awaiting primary care treatment are being summoned from some waiting rooms with these words: "The nurse will see you now."

But that contact may not be for just a brief preliminary session before a physician's arrival to the examining room. Today, 26 states allow nurse practitioners (NPs) to practice independently, without physician oversight. Nationwide, NPs are serving as primary care providers for more and more patients.

In late September, that trend gained momentum when a new primary care practice in midtown New York City that relies on advanced practice nurses to provide most of the care opened its doors. While the NPs at the practice are trained differently—and for fewer years than physicians—they are being paid the same as doctors by HMOs like Oxford, United, Prudential and Multiplan.

The Columbia Advanced Practice Nurse Associates (CAPNA), a practice affiliated with Columbia Presbyterian Medical Center, charts new ground for the expansion of nurse practitioners into territory once considered the sole domain of medical doctors. While NPs have received provider reimbursement at physician rates before, those have chiefly been for Medicaid patients in underserved areas or Medicare patients in rural sites, not for privately insured patients in a community well-endowed with physicians.

The CAPNA clinic, however, is in New York's posh East Side, far from underserved rural parts of the state and a world away from the city's impoverished neighborhoods where physicians are in short supply. Because it is competing for patients with commercial insurance, the clinic has generated considerable controversy in the New York medical community and beyond.

Critics question whether practitioners with four years of nursing school and a master's degree can function as the main providers for primary care patients. While many physicians acknowledge that NPs can do an adequate job with most primary care complaints, they say they are concerned the nurses cannot handle more challenging patient conditions.

The clinic also raises bigger questions, such as how the expanding authority of NPs will affect primary care specialties like internal medicine. Will NPs usurp the primary care role of many internists or help relieve overburdened physicians? And why are the NPs at the clinic being paid the same as physicians?

There's no doubt that "mid-level practitioners" such as NPs are an important component of modern health care. According to a 1994 study conducted by researchers from the Group Health Association of America (now the American Association of Health Plans) and The Johns Hopkins University School of Hygiene and Public Health, about two-thirds of HMOs surveyed had NPs and physician assistants on staff.

And while NPs have been paid as Medicaid providers for years, typically in rural areas, provisions of the Balanced Budget Act make them eligible for direct and indirect Medicare reimbursement in urban and suburban areas. In addition, the Department of Veterans Affairs last year began allowing NPs to practice solo, without any connection to doctors. And last July, VA facility managers received an agency memo encouraging the use of NPs when vacancies arise for primary care physicians.

The CAPNA practice is taking this trend a step further: Its NPs appear to be positioning themselves in direct competition with primary care doctors for commercial patients. NPs at the clinic are not only providing primary care, but they're being listed in the all-important directories published by the HMOs, references that help steer patients to participating providers.

Advocates for NPs point out that physicians shouldn't feel threatened by the move toward more independence for NPs. According to Mary O. Mundinger, dean of the School of Nursing at Columbia University, who played a key role in developing the CAPNA practice, NPs "aren't trying to build an alternative system. We're just a valuable option in the mix."

Physicians wary

Many physicians in the state, however, are wary. For years, NPs in New York have fought for the right to practice more independently of physicians, an effort that led to legislation that describes NPs' relationship with physicians as collaborative, not supervisory.

The law also gives NPs unrestricted prescriptive authority, full diagnostic and treatment capabilities and hospital admitting privileges.

"We haven't gone beyond what New York state has prescribed," said Robert P. Jacobs, FACP, regional medical director of New York for Oxford Health Plans, one of the HMOs supporting the clinic. "NPs do not require minute-to-minute oversight. They have a collaborative practice agreement that addresses clinical protocols, that talks about the appropriate timing of referrals and when the primary care physician should jump in."

Newspaper ads for the clinic, however, describe advanced practice nurses as "a new choice in primary care" who can "diagnose illness, write prescriptions, admit you to the hospital, refer you to specialist physicians, and more." In short, critics complain, the ads give the impression that NPs at the clinic replace the primary care physician.

Some NPs at the clinic reinforce that image. "We like using the word collaboration rather than supervision," said Renee D'Aiuta, one of the four NPs in the CAPNA office. "It's a collegial relationship. I interact with the collaborating physician the same way physicians interact with each other."

The CAPNA practice schedule includes early, late and Saturday appointments, as well as follow-up care offered at the patient's home or workplace (if travel time is paid). The office stresses prevention and patient health goals, which NPs say their nursing background prepares them for perhaps better than doctors'.

Patients come to the NP practice with a variety of needs, from well visits to treatment of urinary tract infections, upper respiratory infections and shortness of breath. "Anyone who's 18 or older can choose the practice," Ms. D'Aiuta said. "As primary care providers, there's nothing that we can't see. If you have a complicated diabetic history, we don't say, 'We can't take you.' "

For a patient she treated who had shortness of breath and a history of hyperthyroidism, Ms. D'Aiuta said, "I really need to consult with an endocrinologist and possibly refer to him." After the patient's condition stabilizes, Ms. D'Aiuta added, she would return to the CAPNA office for her primary care. Referral protocols for the nurses are no different than for primary care physicians, she said.

Most physicians don't have a problem with the idea of NPs getting more involved in educational and counseling roles. Instead, they take exception to the idea of NPs independently seeing patients, doing the physical and history, and then coming up with some sort of treatment plan, all without ever talking to a physician.

"I prefer to see an internist in the background of that model to monitor what is happening. As soon as you go beyond the lines of stable patients, that's where potential or real problems can emerge," said Paul J. Davis, FACP, professor and chairman of the department of medicine at Albany Medical College. "The physician is better able to handle what is out of the algorithm."

That position is echoed by many physician organizations. A 1994 ACP position paper on the subject supports collaborative relationships between NPs and physicians, but says that it cannot support NPs practicing independently until there is solid evidence that patient care is not compromised. The AMA and the American Academy of Family Physicians similarly support the use of NPs only if practicing under physician supervision.

"Nurse practitioners fill a role in health care, but they should practice under the supervision of a physician," said Walter J. McDonald, FACP, the College's Executive Vice President. "Collaborative practice is something that we favor and encourage, but not independent practice."

Advocates assert there's room for both NPs and physicians at the clinic. "Some of the internists at the site provide primary care, but not exclusively," said Ms. Mundinger from Columbia's nursing school. "Doctors are delighted to have us there. They see us as [a resource] who can refer to them and they can refer to us."

Drawing the line

But few physicians appear to be ready to embrace NPs as fully independent colleagues. While research has shown that NPs can perform about four-fifths of the services provided by primary care physicians with comparable quality, there has not yet been such research on care given by NPs in fully autonomous settings. Without those data, many physicians remain skeptical.

"They're saying they can do 85% of what doctors do, and do it as well if not better," said Charles N. Aswad, MD, executive vice president of the Medical Society of the State of New York. But he wonders what happens to patients who fall into that other 15%.

NPs often portray such criticism as proof that doctors are merely protecting their turf. "The physicians who seem to be most anxious [about nurse practitioner incursions into their territory] are the ones who've not teamed up with NPs," said Jan Towers, PhD, director of governmental affairs for the American Academy of Nurse Practitioners.

But many physicians who have had positive experiences with NPs in limited settings still insist that they should not practice independently.

Moshe Rubin, ACP Member, a board-certified internist and gastroenterologist who "collaborates" with NPs at the CAPNA office, has worked with NPs in a geriatric unit. He acknowledged that NPs can take much of the primary care load off physicians, but he stressed the need to refer quickly when symptoms beyond the norm crop up.

"I wouldn't expect to see all the patients who pass through their office for routine cholesterol tests or physicals," he said. "But if someone shows up and has terrible abdominal pain, I expect to hear about it and possibly even see the patient."

One of physicians' biggest fears is that some patients won't get the attention they need because the symptoms will be too subtle. "If you look at a throat in the early stages of throat cancer, many times it will look like infectious mononucleosis or strep throat," explained the state medical society's Dr. Aswad. "With limited experience, it can be a very difficult distinction to make."

Many physicians say that they need good evidence that NPs can offer the same level of patient care in an independent setting as doctors. "The data that show that NPs can deal with complex medical problems with the same degree of facility as physicians are inadequate," said ACP's Dr. McDonald. "Until there are good solid data, it has to be in a supervised role."

Data and choice

Dr. Jacobs from Oxford said that the clinic, which he describes as an experiment, was opened in part to collect exactly that type of data. "While there is a fairly significant body of literature on nurse practice outcomes, we wanted a more rigorous study," he said. "The CAPNA practice is the basis for a very rigorous clinical study."

But the clinic was started to do more than collect research. Columbia had already staffed two satellite offices in the city's Washington Heights neighborhood with NPs, primarily because there weren't enough physicians practicing in that part of town. Most patients in those offices are covered by Medicaid, which reimburses for NP services.

Dr. Jacobs said that Columbia approached a number of HMOs to see if there was interest in paying NPs directly. Oxford was interested in the idea as a way to give consumers a wider choice of providers, according to Dr. Jacobs. "There is an interest on the part of a small but always present number of people to see NPs as their primary care provider," he said.

In fact, a number of consumer advocates applaud the growing use of NPs. "Studies have shown that nurse practitioners provide very high quality care," said Geri Dallek, director of health policy for Families USA. "It's important that patients have choice in medical care and feel that they have control."

According to Ms. D'Aiuta, the NP who works at CAPNA, patients choosing the group have been predominantly female and under 40. Some have had previous experience with NP care or are looking for a provider who may be more accepting of the patient's use of a chiropractor, massage therapist or herbal remedies. "It's a type of relationship they're looking for," said Ms. D'Aiuta.

Critics complain that patients may not know exactly what type of care they're receiving from the clinic and are not making a fully informed choice. Dr. Aswad from the New York medical society said that the clinic's ads didn't adequately explain just how far NPs can go in treating patients, or that the clinic is viewed by Oxford as an experiment.

"The public would get the perception that NPs were an actual substitute for a physician," Dr. Aswad said. "There was no mention of the doctors with whom they were connected, other than saying we have doctors available to consult. That's not the same thing as admitting to the public that they have to work under a collaborative agreement."

Dr. Aswad also said that the HMOs pay NPs at the clinic the same rate as physicians to support the image that patients are receiving equal care. Nationally, the mean salary for NPs is about $50,000, significantly less than the pay of most physicians.

Why would an HMO pay NPs the same as physicians? Dr. Aswad predicted that once the clinic is established—and patients are comfortable with the idea of getting their care from NPs—HMOs like Oxford will slash the clinic's reimbursement and bring it more in line with what NPs elsewhere are paid. He points to Oxford's financial troubles—the HMO's stock has been in a freefall since last spring—as evidence that the company may be looking for a way to cut the costs of providing primary care.

Dr. Jacobs, however, said that Oxford's decision to pay CAPNA NPs the same rate as physicians was made to avoid criticism from the medical community that the clinic was established only to save money. He said that criticism of the decision to pay NPs the same as physicians points to what he considers unfair criticism. "If I pay a discounted fee, they tell me I'm doing it to reduce costs," Dr. Jacobs said. "If I pay the same fee, they tell me that it's unfair."

But critics like Dr. Aswad have a hard time believing that HMOs like Oxford aren't looking at the use of NPs in primary care settings as a cost-saving measure. "We in the medical profession have to pay close attention to what is happening with these managed care companies, whose primary responsibility to their stockholders demand that they try every possible way to control costs," he said.

Robin Warshaw is a Philadelphia-based freelance writer.

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