THE NEW GENERATION OF PROVIDERS

Turf wars?
In the trenches, it's cooperation that matters

After years of circling the wagons and battling over turf, doctors and advanced-practice nurses are finding it pays to work together.

By Wayne J. Guglielmo
Senior Editor

At last December's AMA House of Delegates meeting in San Diego, some physicians spoke out as if they were defending their territory against an invading horde.

The objects of their verbal fire were advanced-practice nurses and other health providers. More and more in recent years, APNs (RNs who have received additional education to assume more specialized and auto-nomous roles in health care) have insisted that, in many areas of medicine, they can do just as good a job as doctors. Unlike PAs, who generally work in tandem with and under the supervision of a doctor, APNs have been working to establish themselves as independent practitioners.

Some doctors are resisting that effort. The San Diego delegates, for example, pushed for an AMA pledge to work toward repeal of state laws granting prescribing authority to APNs and physician assistants. In the end, cooler heads prevailed, and the house of delegates voted to hold the line against future incursions, while studying the impact of existing state prescribing laws.

The AMA's measured—but still defiant—stance is mirrored by a number of state medical societies around the country. Doctors and nurses in Pennsylvania, to name one battleground, are disputing the effects of a bill that would shift oversight of APNs from the nursing and medical boards to the nursing board exclusively. Pennsylvania doctors fear the law would permit APNs to practice independently of physicians, while the nurses insist that the bill would change nothing except the ability of APNs to sign their own scripts. Similar disputes over autonomy have erupted in Ohio and Colorado.

Is organized medicine exaggerating the threat posed by this new wave of providers? Indeed, in attempting to hold the line against such practitioners, is organized medicine out of step with its own constituents, many of whom have successfully incorporated NPs, certified nurse midwives, and PAs into their practices?

Collegiality is alive and well

Physicians actually encouraged the rise of advanced-practice nursing when Medicare and Medicaid were enacted in the mid-1960s. Most thought the demand for medical services would soon outstrip physicians' ability to deliver it. "As a medical school professor in the 1970s, I often said to myself, 'We're not going to be able to keep up with the demand,' " says health economist Jeffrey C. Bauer, who was then on the faculty of the University of Colorado Health Sciences Center and has written about the period in his book, Not What the Doctor Ordered (1998).

The solution was not only to train more doctors, but also more health professionals who could supplement what doctors did. Nurses' training, once "more apprenticeship than academic in nature," Bauer writes in his book, became increasingly rigorous, and nurses started earning MS and PhD degrees. At the same time, medics in the Vietnam war came home to jobs as PAs. Before long, Bauer says, these providers were more than ready to pitch in—usually with the blessings of their doctor colleagues.

That spirit of cooperation persists today between many practicing doctors and their nonphysician colleagues. "There are lots of physicians out there who are participating very creatively and progressively with APNs and other health professionals," says Bauer, now senior vice president of Southfield, MI-based Superior Consultant Company.

One of them is FP Jeffrey M. Bishop of West Palm Beach, FL. A PA in the Navy before entering osteopathic school, Bishop is the senior and founding member of the 12-doctor Western Community Family Practice Associates. The group employs three NPs and one PA. The NPs work out of the group's main office, while the PA is assigned to two physicians who practice in a satellite office in nearby Jupiter.

"We use our NPs and our PA the same," says Bishop. "For one thing, they triage all of our walk-in acute care. They've also developed their own patients over time—patients who'd actually rather see them than the physicians."

Bishop is neither surprised nor threatened by that. "Overall, they take more time with patients, and they're very good at patient education," he says. "After a while, the people they see start to feel very comfortable with them."

There's also an economic payoff, says Bishop. "Depending upon experience, I start our NPs at anywhere from $52,000 to $55,000 annually, plus benefits. That's one-third to one-half what I pay a physician, so it's an investment that boosts the bottom line."

Bishop acknowledges that some doctors are biased against NPs and PAs. But, he adds quickly, "a lot more feel they can't live without them." Occasionally, a specialist will call Bishop's office, asking to speak to a doctor instead of the NP who referred the patient. "That's when I get on the phone and educate this guy that the NP is the one he should be talking to," says Bishop. "I absolutely believe that an NP or PA can treat 90 percent of what a primary care doctor does."

FP Marc A. Ringel of Brush, CO—a small rural town in the northeast part of the state—feels much the same way, although for slightly different reasons. Ringel's three-doctor family practice employs an NP and two PAs. Economically, their impact on the practice is "neutral," he says, but overall "it's a better practice" because of them.

What specifically do they contribute? For one thing, Ringel says, extra hands. "There's more work here than the physicians can manage, and it's problematic for us to recruit physicians for such a rural setting."

The NP and PAs also add "depth and backup" to the practice, says Ringel. Two are women, and they assist the three male doctors in dealing with obstetrical, gynecological, and pediatric care. One of the practitioners has also developed an expertise in alternative medicine, which adds yet another dimension. And all help run the practice, providing "terrific input during committee meetings."

In Pennsylvania, doctors are keeping a grip on the reins

Such glowing reports about the value of NPs and PAs aren't uncommon, but some in organized medicine want them to remain subordinate to doctors. "Few doctors I know would recommend doing away with NPs or PAs," says former AMA president Nancy W. Dickey. "But ask them if they'd be similarly supportive when the NP or PA takes the next step and says, 'I would prefer to do what I do independently.' "

That push for autonomy is currently being played out in the Pennsylvania statehouse. During the 1999 legislative session, Rep. Patricia H. Vance, herself an RN, introduced a bill that would place all advanced-practice RNs—including NPs, nurse anesthetists, and clinical nurse specialists—under the sole licensing authority of the board of nursing. Under current law, the nursing board has statutory authority over all advanced-practice nurses except NPs, who are dually licensed under the nursing and medical boards.

The bill would also clear up a nearly 25-year-old muddle involving prescriptive authority for NPs. Provided APNs stay within their scope of practice and obey nursing board rules, the bill authorizes them to prescribe and administer anesthetics and drugs, including controlled substances in categories II through V, without a doctor's cosignature.

The state medical society, however, says the bill is vaguely worded and could do away with the current requirement that NPs collaborate with doctors on patient care. Warns the society in one of its physician handouts: "Giving APNs more autonomy without increasing their training is not good medicine for anyone."

Supporters of the bill dismiss such rhetoric as misleading—and worse. Under the new law, they say, nurses would only have prescriptive authority within their scope of practice. Beyond that, they would have to consult with a physician. As for other provisions physicians object to—the authority to perform therapeutic and invasive procedures, for example—APNs do selected procedures of this kind all the time, says Jan Towers of the Washington-based health-policy office of the American Academy of Nurse Practitioners. "After all, we're not talking about removing someone's appendix."

For Towers, all the talk by physician groups comes down to one issue: the battle over turf. "They're concerned over losing control," she says, adding that doctors who've actually worked with NPs don't share that fear. "It's the physicians who haven't worked with us—who don't have a clear sense of what we do—who seem the most concerned."

In Pennsylvania, the turf battle could very well continue during the 2000 legislative session.

Compromise keeps the peace in some states

Physicians in Colorado and Ohio are also debating APN independence—and they seem more inclined than Pennsylvania doctors to meet the nurses halfway. A new law in Colorado is expected to free nurse midwives from the direct supervision of a physician. (Colorado is one of 13 states that mandates such oversight.) Instead, they'll be required to practice in accordance with the standards of the American College of Nurse-Midwives, which require that a nurse midwife consult or refer to a physician when appropriate. More than half the states have similar laws or regulations in place.

"There shouldn't be any need for a patient under the care of a nurse midwife to see a physician just to satisfy an arbitrary state requirement," says Alyson Reed, a policy analyst with the college, headquartered in Washington, DC. "On the other hand, no midwife should practice without a system in place for the safe coordination of care with a physician and other members of the care team."

Besides giving nurse midwives more autonomy, the Colorado legislation will allow them certain practical benefits. First, it will open the way for them to gain wider hospital admitting privileges. Second, it will permit them to be reimbursed directly for their services, rather than through a supervising physician. The new law will also benefit physicians, says Reed. "Under the old law, physicians could potentially be held vicariously liable for everything nurse midwives did. That wasn't a great incentive for them to use our services."

Following the lead of the American College of Obstetricians and Gynecologists, which endorses collaborative arrangements between nurse midwives and physicians, the Colorado Medical Society in January came out in support of the bill. To lobbyist Charlie Hebeler, who negotiated with the medical society on behalf of the nurse midwives, that support isn't surprising. Says Hebeler: "We worked hard to bring the language of the bill into conformance with the way people are actually practicing now." The bill was passed by both houses of the legislature early this year. As of press time, the governor was expected to sign it.

In Ohio, the governor recently signed a bill granting APNs the authority to prescribe controlled and noncontrolled substances without a doctor's cosignature. Prescriptive authority for Ohio APNs has been limited to a number of legislatively established university pilot programs.

Introduced in early 1999, the bill was initially opposed by the Ohio State Medical Association. The association backed off, however, after bill sponsors agreed to several changes. One was that APNs be given prescribing privileges for Schedule III to V—but not Schedule II—drugs. A second was that all APNs—except those in pilot programs as of the effective date of the bill—be required to participate in a one-year externship with a physician. The association also insisted that the bill establish an "APN-to-collaborating-physician ratio," thereby making it less likely that a single physician would end up working with an unlimited number of APNs. The agreed-upon ratio is 3-1.

In deciding not to oppose the final bill, Ohio doctors were bowing to the prevailing "political reality," according to Marla Eshelman Bump, the medical group's associate director of legislation. "It was becoming increasingly difficult to argue why Ohio is so different from the overwhelming majority of other states that allow APN prescriptive authority," Bump says. "Besides, it's always better to be at the negotiating table than not."

That's a message organized medicine needs to hear—that practicing doctors are willing to use already strong working relationships with APNs and other providers to resolve their political differences. As Jan Towers of the American Academy of Nurse Practitioners says, "If everybody would just calm down a bit, we could work this out to everyone's benefit, particularly the patients'."

Wayne Guglielmo. Turf wars? In the trenches, it's cooperation that matters.

Medical Economics

2000;6:194.