We need more nurses for better medicine

Linda Aiken & Claire Fagin

March 12, 1993|By Linda Aiken & Claire Fagin

THE United States has a shortage of primary-care physicians.

This limits the options for improving access to cost-effective health care.

Nurses are a national resource with the potential to meet this challenge.

Since the late 1960s, federal policy has promoted two strategies increase primary care. The first included federal support for establishing a new physician specialty in family practice.

It has not yet been successful. Between 1970 and 1990, the proportion of doctors in primary-care actually declined and the rate of decline is accelerating.

In contrast, the second strategy -- employing advanced-practice nurses (nurse practitioners, clinical nurse specialists and nurse midwives) -- has been enormously successful.

Two decades of research, summarized last summer in the Yale Journal on Regulation, show clearly that advanced-practice nurses provide care of comparable quality and at lower costs than do physicians.

Advanced-practice nurses can safely substitute for physicians for up to 90 percent of primary care needed by children and Nurses deliver less than 4 percent of U.S. births.

80 percent required by adults. The Yale report concluded that significant financial, legal and professional barriers prevent the effective use of nurses.

Primary care by nurses is less costly than physician care. Nurse practitioners and nurse midwives prescribe fewer drugs, use fewer tests and select lower-cost treatments and settings.

Historically, nurses have been more likely than doctors to practice in areas where there is insufficient health care. Nurse anesthetists deliver 85 percent of anesthesia services in rural areas.

About one in five nurse practitioners and midwives practice in rural areas and close to 50 percent practice in inner cities.

International comparisons suggest that at least 75 percent of all prenatal care and delivery of babies could be safely provided by nurse midwives, but nurses deliver less than 4 percent of U.S. births.

The following ideas would lead to the more productive use of nurses:

* To increase primary care for Medicaid recipients, nurse practitioners and nurse midwives should qualify for direct reimbursement at the same rate as physicians.

Bonus payments should be given to physicians and nurses practicing in underserved rural and urban areas.

* Where fee-for-service arrangements exist, qualified nurses should be eligible for direct reimbursement by Medicare. This would save costs, not increase them.

* Hospitals must be required to offer admitting privileges to nurse midwives and nurse practitioners as a condition of participation in Medicaid and Medicare. Without admitting privileges, nurses cannot practice under state, Medicare and Medicaid legal guidelines.

* The high cost and uncertain availability of malpractice insurance for nurse midwives impede the growth of nurse midwifery practice. Malpractice insurance reform and possibly tort reform are required.

America needs a collaborative system where health care professionals are used appropriately and cost effectively.

By more effectively using nurses for primary care, the goals of national health care reform -- improved access to appropriate services at affordable cost -- can be achieved.

Linda Aiken and Claire Fagin are professors of nursing at the University of Pennsylvania. Dr. Fagin is president of the National League for Nursing.

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