Whether or not the country is facing a dearth of physicians in the coming years has been a hotly debated topic that has come to the fore with the expansion of Medicaid and creation of state health exchanges. One potential solution to the problem of too many patients and not enough providers is to use mid-level healthcare providers such as nurse practitioners (NPs) to augment staffing.

Mid-level providers in the field say their numbers are growing and that working with them can help reduce costs, grow a practice, and increase patient satisfaction. Susanne Quallich, an NP in the Department of Urology at the University of Michigan in Ann Arbor, conducted a survey in 2011 looking at the roles NPs were playing in urology. NPs performed a wide range of functions in urology practices, although not all NPs were working at their highest level of practice. 

Many procedure-based functions like prostate biopsies and bladder distention were only performed by a small number of respondents.

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Economic benefits

NPs, she noted, earn about half as much as a family practitioner or internist, making them an economically viable way to increase access to care. More patients can be seen and physicians can concentrate on higher-cost services like surgery while the NP performs office-based tasks.

Christina Braun, an NP in the kidney and pancreas transplant program at the University of Pennsylvania Health System in Philadelphia, said the program went from having two NPs in the office to seven in one year. This was, in part, because of difficulty finding physicians, but also because program personnel saw the value of using NP, she said. The group receives a higher Medicare reimbursement if a patient is contacted by phone within 48 hours of a transplant and then seen within a week. This is CMS’ way of trying to avoid hospital readmissions. Physicians also receive a higher reimbursement if they see dialysis patients four times a month.

Mid-level providers in her group work in the entire spectrum of care, Braun said.  They see patients before surgery, in the hospital, and prior to transplantation.

“On the pre-transplant side, we are able to pick up more history,” she said. “We can spend more time with patients and get more information to make sure we are heading in the right direction.”

“Doctors could see patients three times a month, but if they see them four, they get extra money and it is a sufficient enough amount of money to pay a nurse practitioner’s salary and still come out ahead,” said Charla Litton, a nurse practitioner and member of the board of directors of the American Nephrology Nurses Association.

Litton works with renal patients before they go on dialysis. Her job is teaching diabetics and patients with early- to middle-stage chronic kidney disease how to avoid moving to stage 5. If their progression cannot be slowed, she teaches people how to prepare for dialysis. Mid-level providers can be used in CKD clinics, run anemia management programs, coordinate educational programs, help patients get on kidney transplant lists, achieve tighter control of mineral and bone metabolism, make sure fistulas are working properly, and gather information for residents in university research programs, Litton said.

In fact, universities with residency programs are a great place to use NPs, she said. While physicians there are training and working with residents and conducting research, NPs can pick up slack in the office. Litton said she sees many renal NP in rural settings where there is a shortage of providers.

Physician resistance

While many specialists, such as dermatologists and gynecologists, rely heavily on mid-level providers, not every specialty has been so willing to embrace them. This is in part because there is not one set scope of practice for these providers.

Eighteen states and the District of Columbia require no physician supervision for NPs, Litton said. The remaining states all require different degrees of supervision.

“A lot of people don’t understand what our scope of practice is,” she said. “One of the problems is that every state isn’t the same.”

What may be a greater impediment, however, is the power struggle between doctors and mid-level providers. Physicians typically do not like the idea of losing control, especially if they are not certain of the skill level of the person to whom they are turning over their patients’ care. This ambivalence can be seen in statements by the American Medical Association regarding nurse practitioners. In a brief, the group said that, with “appropriate education, training and licensing, these providers” do provide safe patient care. They added that patient safety is threatened when nurse practitioners perform services outside of their scope of practice.