When Medscape News reached out for insights, we responded. Read our data-rich Q&A that shines a bright light on risks to patients when NPs practice without physician supervision.
– We understand that, at least 25 states allow nurse practitioners full practice authority without supervision by physicians. What are some potential impacts of these laws? What are some concerns related to allowing nurses to practice without physician supervision?
There are many ramifications regarding the expansion of nurse practitioner scope of practice via legislation without regard to education. Legislators support scope of practice expansion primarily because they believe it will increase access to care in rural areas and will decrease costs. Neither of these claims is accurate and both are easily disproven by looking at data from states who have had independent practice for nurse practitioners for decades. In Arizona, for instance, nurse practitioners have long had independent practice, but as of 2015, only about 9% of them were working in rural areas. Similar numbers are seen in other states as well, including Idaho, Utah, and Oregon.
A detailed, well-constructed analysis from Stanford in 2022 showed that, “compared to physicians, NPs significantly increase resource utilization but achieve worse patient outcomes.” Nurse practitioners tend to order more lab testing, more imaging, and make more unnecessary referrals than physicians do, which drives up the cost of healthcare.
A study out from a large multispecialty clinic, the Hattiesburg Clinic, revealed that “in hindsight and “with a wealth of internal data,” which includes cost data on more than 33,000 patients enrolled in Medicare, “the results are consistent and clear: By allowing APPs to function with independent panels under physician supervision, we failed to meet our goals in the primary care setting of providing patients with an equivalent value-based experience.” They found that NPs spending, when risk-adjusted for patient complexity, was about $28.5 M annually greater than that of physicians. The bulk of the higher cost came from increased test orders, specialist referrals, and more patients being sent to emergency medicine departments.
Nurse Practitioner education has changed drastically since 2010, when the ACA allocated $200 million for nurse practitioner education. This spurred a dramatic growth in for-profit nurse practitioner schools, many partially or fully online, requiring as little as 500 hours of clinical experience for graduation. Many of these schools also have near-100% acceptance rates, with the national average for acceptance to NP schools being 66%. In 2021, nearly 60% of Family Nurse Practitioners graduated from mostly or fully online programs.
While an online education with minimal clinical experience may seem acceptable for someone who has already worked as a nurse for many years before attending nurse practitioner school, the reality is that many NP schools are “direct-entry,” requiring no prior nursing experience. As of 2019, 25% of NPs graduated from programs that required no prior nursing experience.
Physician education isn’t just longer than Nurse Practitioner education, it is more rigorous and standardized. Physicians finish 4 years of medical school after an undergraduate degree, then complete at least 3 years of residency training for primary care. NPs can enter a direct entry program with no prior nursing experience and become an NP in as little as 15 months. Patients have no idea of the true education and training of the NP treating them.
Another argument we hear is that NPs are increasingly being required to earn a doctorate degree, rather than a master’s level degree. The Doctor of Nursing Practice (DNP) degree was created by Mary Mundinger at Columbia University. Her dream was to create a clinical degree for NPs, which would more closely replicate physician clinical education. This degree would also give them “title parity” with physicians. The DNP has failed in its mission to increase clinical training for NPs. Mary Mundinger herself published a paper in which she lamented the fact that only 15% of DNP programs were clinical in nature. The other 85% were focused on leadership and research. Ms. Mundinger called it a “potential crisis in Nurse Practitioner education”.
You might imagine that patient safety is impacted when physicians are removed from the care team, and that is correct. Some prominent stories include that of Betty Wattenbarger, the 9 year old who was dismissed by an urgent care NP only to die of pneumonia hours later. The photos her parents took while in the urgent care show an acutely ill child with blue lips, something anyone with medical education would not have missed. Another is the story of Alexus Ochoa, a 19 year old athlete who was seen in an Oklahoma emergency department with shortness of breath. The FNP (Family Nurse Practitioner) who saw her with no physician on-site ignored the paramedics who told her they thought Alexus had a pulmonary embolus—a blood clot in her lungs that could be fatal. The NP instead documented that she thought Alexus was withdrawing from narcotics, gave a cardiac medication that removed Alexus’ ability to compensate for her illness, and delayed getting a CT scan for at least 6 hours. Alexus died. The NP admitted in her deposition that she had never been taught about the cardiac medication she gave and didn’t understand cardiopulmonary (heart and lung) function.
– Many NP groups say NPs essentially practice medicine as physicians and should be paid on an equal pay scale. What is the PPP’s thoughts on this assertion? Why is it important to make a clear distinction about physicians’ capabilities and nurses’ capabilities?
Nurse Practitioners practice advanced nursing. Physicians practice medicine. There is no state that allows NPs to practice medicine, so no claim can reasonably be made that NPs “do the same thing” as physicians. Further, when a physician is sued for malpractice, she is held to a medical standard of care. When an NP is sued for malpractice, she is held to a nursing standard. The two are not the same. Even in states that require appropriate NP supervision by physicians, when the NP is sued for malpractice, it is the physician who is often held liable because the two are not the same.
Many professions have team members of varying qualifications whose work sometimes overlaps. Despite the overlap in duties, they are not paid the same: paralegals and attorneys, nurses and certified nursing assistants or medical assistants, bookkeepers and Certified Public Accountants or Certified Financial Planners, Physical Therapy Assistants and Physical Therapists all come to mind as examples.
– What is your take on the New York case? (If you don’t have time to read the case or make a comment about it, that’s fine and we can take this question out.)
We understand that Nurse Practitioners in New York have filed a lawsuit to demand higher wages, claiming they do “much of the same work as physicians”, but believe they are being discriminated against because most Nurse Practitioners are female. We would argue that NPs are appropriately paid less than physicians because they do not do the same job and do not have the same qualifications, completely unrelated to gender.
Physicians, regardless of gender, have seen a marked decline in wages over the past few decades. Adjusting for inflation, Medicare reimbursement to physicians has decreased 26% since 2001. There is downward pressure on all healthcare compensation for many reasons that have nothing to do with gender: overhead costs, payer mix, patient type, practice setting.
Women currently make up about 38% of physicians practicing in the United States and comprise nearly 55% of current medical students. Any gender discrimination claims made by Nurse Practitioners will be moot as women become more predominant in medicine in the coming years.
REFERENCES:
https://tafp.org/media/advocacy/scope-distribution.pdf
https://pubmed.ncbi.nlm.nih.gov/24119364/
https://kffhealthnews.org/news/article/nurse-practitioners-trend-primary-care-specialties/
https://pubmed.ncbi.nlm.nih.gov/30943837/
https://bucshon.house.gov/news/documentsingle.aspx?DocumentID=4485
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
https://www.newsnationnow.com/investigation/transparencyinhealthcare/
Al-Agba, N., & Bernard, R. (2020). Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Universal-Publishers.
Bernard, R. (2023). Imposter doctors: Patients at Risk. Universal-Publishers.
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