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Counting on Nurses to Fill New Jersey's Primary Care Gap

Letting advanced practice nurses do what they're certified to do can help ease the coming shortage of primary care physicians.

While NJ Spotlight is on winter hiatus, we've asked some of the state's thought leaders to share their opinions and expertise with our community. We'll be back, rested and ready, next week.

While everyone is preparing to count down the dropping ball in Times Square to welcome in 2012, many of us in healthcare are counting down to the implementation of the Affordable Care Act in 2014. We're also wondering if we will have enough primary care providers to serve the 600,000 uninsured New Jersey residents who will gain access to healthcare.

With an estimated shortage of 1,600 primary care physicians by 2014, the concerns are growing. Nurses believe there will be enough primary care providers, if the over 3,000 advanced practice registered nurses (APRNs) in New Jersey are allowed to practice to the full extent of their education and licensure.

Fifty years ago seeing your primary care provider meant a trip to your doctor's office. Today, primary care providers can be physicians or advanced practice nurses -- who may be referred to as nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives. APRNs are registered nurses with at least a master's degree in nursing. Many programs are now developing doctoral programs, which require candidates to sit for a certification examination with the national APRN association and take the required continuing education courses to be licensed in their states. In New Jersey the Nurse Practice Act mandates a joint protocol governing prescription drugs and drug-administering devices signed by the APRN and the APRN's designated collaborating physician.

Approximately 70 percent to 80 percent of APRNs are engaged in primary patient care. According to the 2009-2010 AANP National NP Sample Survey in 2009, there were approximately 135,000 NPs practicing in the U.S.; the most common specialty areas for practicing NPs were family practice (42 percent), adult practice (21 percent), pediatrics (9 percent), women's health (10 percent), and acute care (7 percent). These APRNs may run clinics in the inner city, manage a solo private practice, work on a multidisciplinary team in a facility, or work within a school setting -- to name a few possibilities.

The Kaiser Family Foundation March 2011 publication, Improving Access to Adult Primary Care in Medicaid: Exploring the Potential Role of Nurse Practitioners and Physician Assistants, noted that sixty-five million people live in areas designated by the federal government as having a shortage of primary care providers.

The publication goes on to note:

"NPs are also, by far, the fastest-growing segment of the primary care professional workforce; between the mid-1990's and the mid-2000's, their numbers (per capita) grew an average of more than 9 percent annually, compared with about 4 percent for PAs and just 1 percent for primary care physicians. Primary care NPs work in diverse clinical settings, including physician practices, health centers, managed care organizations, retail or convenient care clinics, and school-based health centers. They are a key source of primary care in community health centers and in 250 nurse-managed health clinics across the country, which serve about 20 million patients a year. According to one account, about 10,000 NPs run their own practices."

So what are the obstacles to fully engaging these APRNs to fill the primary care gap?

  • Some are legislative and regulatory. The APRN can order all of the medications treatments his/her handicapped patient may need but can't write an order for a handicapped parking sticker.

  • Some institutions will only utilize an APRN if he/she works under a physician, restricting that APRN's ability to see patients independently.

  • Some insurance companies will not credential an APRN unless it is under a physician or if the APRN's collaborating physician is also credentialed. Patients who want to see the APRN will be forced to pay out of pocket or pay a higher copay for an out-of-network provider.

While the New Jersey State Nurses Association (NJSNA) is working to change these antiquated laws and policies, it is important to know how APRNs will help fill the primary care gap:

  • The U.S. Department of Health and Human Services set aside $50 million in grants for the cost of operation of Nurse Managed Health Centers that provide comprehensive primary care or wellness services without regard to income or insurance status of patients. The clinics will be completely run and managed by nurse practitioners. There are agencies in New Jersey who have applied for those funds.

  • Nurse practitioner training is the fastest and least expensive way to produce caregivers urgently needed in shortage areas. For the cost of training one doctor, nursing schools can produce at least three and as many as 12 nurse practitioners. New Jersey is fortunate to have a number of excellent APRN programs.

  • Horizons Innovation is working with the NJSNA on a trial to embed psychiatric APRNs into a primary care setting. By integrating psychiatric care into the primary care setting, patients have greater access to psychiatric services. Further, the coordination of the physical and psychiatric care may lead to fewer medical as well as psychiatric issues being overlooked.

  • The NJSNA supported the ACO pilot legislation, which became law this year. A key feature we liked was the use of nurse-managed clinics in underserved areas. Kathy Jackson, an APRN, ran a clinic in inner city Camden, supervising a team of nurses, social workers, health educators, and others to reach out into the community to bring healthcare to people who had no previous primary healthcare provider.

Before the ball drops on New Year 2014 and the Affordable Care Act creates an opportunity for millions of people who have not had healthcare coverage, we in New Jersey better be ready. Yes, we need more primary care physicians, but there is nothing we can do to fill the 1,600-physician gap by 2014. We can, however, remove obstacles to APRN practice and we can create programs to encourage APRNs to stay in New Jersey and practice in primary care. These things we can and must do by 2014. Happy New Year!

Patricia A. Barnett, RN, JD, is chief executive officer of the New Jersey State Nurses Association & Institute for Nursing

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