A nurse may soon be your doctor. With a looming shortage of primary care doctors, 28 states are considering expanding the authority of nurse practitioners. These nurses with advanced degrees want the right to practice without a doctor's watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called "Doctor."
For years, nurse practitioners have been playing a bigger role in the nation's health care, especially in regions with few doctors. With 32 million more Americans gaining health insurance within a few years, the health care overhaul is putting more money into nurse-managed clinics.
Those newly insured patients will be looking for doctors and may find nurses instead.
The medical establishment is fighting to protect turf. In some statehouses, doctors have shown up in white coats to testify against nurse practitioner bills. The American Medical Association, which supported the national health care overhaul, says a doctor shortage is no reason to put nurses in charge and endanger patients.
Nurse practitioners argue there's no danger. They say they're highly trained and as skilled as doctors at diagnosing illness during office visits. They know when to refer the sickest patients to doctor specialists. Plus, they spend more time with patients and charge less.
"We're constantly having to prove ourselves," said Chicago nurse practitioner Amanda Cockrell, 32, who tells patients she's just like a doctor "except for the pay."
On top of four years in nursing school, Cockrell spent another three years in a nurse practitioner program, much of it working with patients. Doctors generally spend four years in undergraduate school, four years in medical school, and an additional three in primary care residency training.
Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85 percent of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60.
The health care overhaul law gave nurse midwives, a type of advanced practice nurse, a Medicare raise to 100 percent of what obstetrician-gynecologists make — and that may be just the beginning.
States regulate nurse practitioners, and laws vary on what they are permitted to do. In Florida and Alabama, for instance, nurse practitioners are barred from prescribing controlled substances.
What's the evidence on the quality of care given by nurse practitioners?
The best U.S. study comparing nurse practitioners and doctors randomly assigned more than 1,300 patients to either a nurse practitioner or a doctor. After six months, overall health, diabetes tests, asthma tests, and use of medical services like specialists were essentially the same in the two groups.
"The argument that patients' health is put in jeopardy by nurse practitioners? There's no evidence to support that," said Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health.
Other studies have shown that nurse practitioners are better at listening to patients, Needleman said. And they make good decisions about when to refer patients to doctors for more specialized care.
The nonpartisan Macy Foundation, a New York-based charity that focuses on the education of health professionals, recently called for nurse practitioners to be among the leaders of primary care teams. The foundation also urged the removal of state and federal barriers preventing nurse practitioners from providing primary care.
The American Medical Association is fighting proposals in about 28 states that are considering steps to expand what nurse practitioners can do.
"A shortage of one type of professional is not a reason to change the standards of medical care," said AMA president-elect Dr. Cecil Wilson. "We need to train more physicians."
The new U.S. health care law expands the role of nurses with:
• $50 million to nurse-managed health clinics that offer primary care to low-income patients.
• $50 million annually from 2012-15 for hospitals to train nurses with advanced degrees to care for Medicare patients.
• 10 percent bonuses from Medicare from 2011-16 to primary care providers, including nurse practitioners, who work in areas where doctors are scarce.
• A boost in the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor's.
The American Nurses Association hopes the 100 percent Medicare parity for nurse midwives will be extended to other nurses with advanced degrees.
"We know we need to get to 100 percent for everybody. This is a crack in the door," said Michelle Artz of ANA. "We're hopeful this sets the tone."
In Chicago, only a few patients balk at seeing a nurse practitioner instead of a doctor, Cockrell said. She gladly sends those patients to her doctor partners.
She believes patients get real advantages by letting her manage their care. Nurse practitioners' uphill battle for respect makes them precise, accurate, and careful, she said. She schedules 40 minutes for a physical exam; the doctors in her office book 30 minutes for the same appointment.
Joseline Nunez, 26, is a patient of Cockrell's and happy with her care.
"I feel that we get more time with the nurse practitioner," Nunez said. "The doctor always seems to be rushing off somewhere."
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