Faced with a chronic shortage of family doctors, whom will Americans call in the next few years if they develop an ulcer, get an infection or come down with the flu? If Janet Selway gets her way, they'll have the choice of calling their family nurse.
In her Cockeysville office, Ms. Selway sees patients with strains and sprains, conducts physical exams, orders lab work and X-rays, diagnoses common health problems, writes prescriptions -- most of the routine things that a general practice physician might do in the course of a hectic day.
But she isn't a doctor. Ms. Selway, president of the Nurse Practitioners' Association of Maryland, is a nurse practitioner employed by a physician. Like many of her colleagues in the nursing field, she says specially trained nurses are ready to shoulder more of the burden of providing the nation's primary health care. Nationwide, nursing groups contend that physicians are increasingly too expensive and specialized to treat everyday illnesses.
Meanwhile, some doctors, through the American Medical Association, are trying to block any expansion of the role of nurses. Nurse practitioners and other so-called advanced practice nurses, they say, don't have the training or expertise needed to diagnose and treat illnesses without the close supervision of a physician.
Q: What is a nurse practitioner?
A: Nurse practitioners are registered nurses who are qualified to provide primary care. Ninety percent in Maryland have master's degrees.
They can diagnose and treat common minor health problems; treat a child with a middle ear infection; provide well-baby care and family-planning services; and conduct pap smears, gynecological checkups and complete physicals. They can take care of episodic illnesses and manage chronic illnesses such as diabetes or hypertension, when stable, and they can prescribe medication.
Q: There's a shortage of primary care doctors. Can nurse practitioners fill the gap?
A: Absolutely. Statistics show that you couldn't create enough family practice doctors to fill the need for at least 50 years.
Nurse practitioners can provide 60 percent to 80 percent of the usual, common services provided in a family practice by a physician.
Medicine has failed to meet the primary care needs of this country adequately. We can do it in a more cost-effective way, and we can do it well.
L Q: What are some of the restrictions on nurse practitioners?
Typically, the nurse practitioner is a salaried employee. We can own our own practices in Maryland and practice without a physician on site as long as we have a written agreement with a physician and a means of communicating with that physician when necessary. But if the physician decides he or she no longer wants to be on that written agreement, essentially the nurse practitioner is out of business.
There are also lots of barriers to insurance reimbursement for nurse practitioners. There is a Maryland law requiring insurers to pay for services by nurse practitioners. But some insurers fall under the law, and some self-insurance plans don't. Medicare also has limits. Medicare will only directly reimburse nurse practitioners who work in designated rural areas or nursing homes, and only at 85 percent of the rate they pay physicians. Nurse practitioners who work outside those areas must work for a physician to get reimbursed for treating Medicare patients. But some physicians don't take Medicare patients.
Look at how the elderly population is growing. Obviously, there's going to be a large proportion of the population that need the services that nurse practitioners can provide. But if you can't get Medicare reimbursement, you can't serve elderly patients.
Also, when we have to bill in the physician's name, we're invisible; we're not recognized.
Q: What could the federal and state governments do to make it easier for nurse practitioners to provide care?
A: Eliminate some of the reimbursement barriers, the insurance barriers and not have our practice depend on the goodwill of physicians.
Q: The American Medical Association opposes giving nurses more independence, saying nurses don't know the limits of their own knowledge and that their work should be supervised by a doctor.
Q: First of all, physicians are under a misconception. Legally, they do not supervise nurse practitioners; we collaborate.
A: As we come to the forefront with health care reform, physician groups are becoming threatened and turf battles are going to arise. Research so far has shown that nurse practitioners provide quality of care, within their scope of practice, equal to that of physicians.
As for services that depend on communication and teaching, nurse practitioners provide those better than physicians.
A: Because we can better provide the services that depend on communication and teaching. We can help people better cope with their lives and cope with the impact diseases have on their daily lives.
Q: When do you refer cases to a doctor?