Where Doctors Are Scarce Nurse Practitioners Step In

The health center typically has four doctors on duty, but the clinical director, Dr. Randall Bayshore, says his staff would never meet local demand if it weren’t for the two nurse practitioners who provide the same care, to the same number of patients, as the doctors.

Buckingham County is one of roughly 5,800 U.S. communities, with about 55 million residents, that have a shortage of primary care physicians. In these places, many residents are forced to forgo regular checkups and treatment for chronic diseases such as hypertension and diabetes — harming their overall health.

A White House nurse prepares to administer the H1N1 vaccine to President Barack Obama at the White House on Sunday, Dec. 20, 2009

In 2014, when the new federal health care law extends insurance coverage to 30 million more people, the doctor shortage is likely to get worse. Anticipating this, states and the federal government are offering repayment of medical school loans and other incentives to encourage newly minted doctors to practice primary care in needy areas.

But efforts like these take years to pay off. So as an additional step, states are trying to loosen decades-old licensing restrictions, known as “scope of practice laws,”  that prevent nurse practitioners from playing the lead role in providing basic health services.

Nurse practitioners, registered nurses with advanced degrees, are capable of providing primary-care services such as diagnosing and treating illnesses, prescribing medication, ordering tests and referring patients to specialists. But only 18 states and the District of Columbia currently allow nurse practitioners to perform these services independently of a doctor.

Political tension

A 2010 Institute of Medicine report, “The Future of Nursing,” cited nearly 50 years of academic studies and patient surveys in concluding that primary care provided by nurse practitioners has been as safe and effective as care provided by doctors. But efforts to change “scope of practice” laws to give nurse practitioners more independence have run into stiff opposition.

Organized physician groups, which hold sway in most legislatures, are reluctant to cede professional turf to nurses. Arguing that nurse practitioners lack the necessary level of medical training, they insist that it is unsafe for patients to be treated by nurse practitioners without a doctor’s supervision.

Some doctors also have a financial incentive to limit nurses’ independence. Often carrying heavy medical school loan debt, they can be loath to see their revenue diverted by competing health care services, particularly those with lower fees. The Federal Trade Commission has weighed in on legislative efforts to give nurse practitioners more autonomy in several states, arguing that physician groups have no valid reason for blocking such laws other than to thwart their competition.

Virginia is a case-in-point. After several failed attempts over the last decade, the legislature finally passed a nursing “scope of practice” law in 2011 that doctors and most nurse practitioners in the state say is a step forward. According to its authors, the aim of the law is greater patient access to primary care across the state.