(Place Author Note Here if Required)
Introduction
It is well accepted that nurse practitioners provide excellent health care, meeting quality standards and also a cost effective alternative to the traditional medical model. As a profession, we are capable of independent practice. The issue being that In New York State, as well as 34 other states, Nurse Practitioners is required to maintain a collaborative agreement with a physician. A collaborative agreement is a very loosely defined set of mandates, left opened to many different interpretations. Also, according the Patient Protection Affordable care Act (PPACA), Nurse Practitioners are recognized as providers but there patients must be assigned to a primary care physician in order to eligible to receive benefits. This research will bring evidence that nurse practitioners are capable of independent practice with a proven track record of quality and patient satisfaction equal to and exceeding physician quality measures. Also, outlined is the impending need for independent practice by Nurse Practitioners, due to current provider shortages and impending surge in demand for providers in 2014 driven by the Affordable Care Act (ACA), also known as Obama Care.
Population Need: Why Here, Why Now in these United States
Most of the uninsured populations are concentrated in areas labeled Health Professional Shortage Areas (HPSA). As of January 2012, the population in these areas alone, 194.4 million people lives with a shortage of 5800 Primary Care Providers; without the added burden of additional aging, America as 77 million baby boomers age. The growing demand will exacerbate the growing shortage (HRSA, 2013).
In 2014 Obama care will bring 48 million nonelderly Americans uninsured people into the health system (Kaiser 2012). And According to the American Association of Medical Colleges, the United States will be short some 45,000 primary care physicians by 2020. Five Facts about the Uninsured population:
- Most have low-or moderate incomes.
- More than three-quarters are in a working family. CHIP or Children’s Health Insurance Program Provide a key source of coverage. About one-quarter of uninsured adults go without care, compared to only 4% of those with private insurance. Medical bills leave uninsured with debt-uninsured pay more than one-third of their care out-of-pocket ( www.KFF.org/KCMU).
- The on slot will not only increase the overall numbers of people seeking quality care but also may increase medical complexity due to possible neglect of current health issues.
- We have a Nurse Practitioner seasoned workforce in the US. To date there are over 155,000 practicing nurse practitioners in the US of these 71% provide services to Medicare patients.
- Their Medicare visits excess 170,000,000 per year (www.aanp.org).
Legislation
According the PPACA,-Patient Protection Affordable care Act (2013), “Nurse Practitioners are authorized as ACO participants (Accountable care organizations) Participants agree to lower the cost of health care while meeting identified performance standards by sharing resources and care in a coordinated manner. Assignment of patients to those who are being cared for by a primary care physician, while it does not prevent nurse practitioners from joining an ACO, it does prevent their patients from being assigned to a Medicare ACO (www.aanp.org).
Unfortunately, New York State is one of the states that still require a collaborative practice agreement. This is a loosely defined set of practice guidelines that does not address any requirements for quality measures for the nurse practitioner or the physician collaborator.
Appendix A
“The collaborative agreement shall include provisions for referral and consultation, coverage for absences of either the nurse practitioner or the collaborating physician, resolution of disagreements between the nurse practitioner and the collaborating physician regarding matters of diagnosis and treatment, the review of a representative sample of patient records every three months by the collaborating physician, record keeping provisions and any other provisions jointly determined by the nurse practitioner and the physician to be appropriate”( www.op.nysed.gov).
New York has approximately 16,000 nurse practitioners (NPs) across the state. However, not all New York State Nurse Practitioners are required to have a written collaborative agreement with a physician, namely Nurse Midwives are an exempt group. Licensed midwives are not supervised; they are independent practitioners.
New York State law provides that licensed midwives shall have collaborative relationships with:
- A licensed physician who is board certified as an obstetrician-gynecologist by a national certifying body; or
- A licensed physician who practices obstetrics; or
- A hospital, that provides obstetrics through a licensed physician having obstetrical privileges at such institution, that provide for consultation, collaborative management and referral to address the health status and risks of his or her patients and that includes plans for emergency medical gynecological and/or obstetrical coverage (www.op.nysed.gov).
Currently there is legislation pending in front of the New York State Senate, and Governor Andrew Cuomo, which says: Pass the Nurse Practitioner Modernization Act (A4846-2013/S. 4611-2013) in New York State, which will eliminate the requirement for the written collaborative agreement between a nurse practitioner and physician.
Appendix B
With the Advent of the affordable Care Act, care will be provided by either a Medical Home or Accountable Care Organizations (ACO). ACO are groups of doctors hospitals and other health care providers, who come together voluntarily to give high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program (www.cms.gov).
Core features of a Medical Home- Each patient will has an ongoing relationship with a primary care physician, The physician leads a team that collectively takes responsibility for patients, whole-person orientation, providing preventive services as well as care for both chronic and acute illnesses, Care is coordinated and facilitated by information technology, Patients have enhanced access to care through systems such as open scheduling and expanded hours. Payment recognizes the added value that medical homes provide to patients—Nov 2007, Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Nurse Practitioners are already recognized as key providers in their care models.
ACO Atlantic and ACO New jersey formed in April of 2012, one of 27 and the 2nd largest in the country with 50,000 Medicare patients. This ACO has embarked on a systematic redesign of care. Cardiac Success program has achieved 4% to 6 % 30 day readmission rate by cooperating with protocol based-approaches that rely on nurse practitioners and nurses to coordinate with heart failure specialists and referring physicians. Medicare attributing actual outcomes to specific providers is at least 18 months away (Shulkin 2012).
AC0-Partners- Boston 3- year CMS demonstration project focusing on high-cost Medicare patients. The intervention relied on the assignment of nurse care managers to each identified patients and leveraged information technology systems to track and communicate real-time changes in patient status care plans. Outcomes after 3 years included a 20% reduction in hospital admissions, 4% lower mortality rates, and approximately 7% net cost savings (Miford and Ferris, 2012).
Quality and performance of nurse practitioners
Newhousee Et al., 2011, conducted a in a systematic review of 118 studies comparing APRN care vs. Physician provided care. The researchers documented a thorough review of the literature. They extirpated 118 of either randomized controlled trial (RCT) or observational studies from 1990 to 2008. Thirty-seven studies (14 RCTs and 23 observational studies) examined patient outcomes of Patient satisfaction. Glucose control, Lipid control, and Blood pressure control. Emergency department (ED) or urgent care visits when comparing NP and MD care, there is a high level of evidence to support equivalent levels for glucose and the same or improved outcomes. When comparing NP and MD groups, there is a high level of evidence to support better blood pressure. Eleven studies (three RCTs) reported the utilization outcome. There is a high level of evidence to support equivalent rates of hospitalization. Eight studies (one RCT) reported patient mortality. Outcomes from 21 studies (two RCTs and 19 observational studies) were aggregated for 13 outcomes of care managed by length of stay and cost. Four studies (two RCTs) reported cost outcomes. Three studies (one RCT) reported patient complications. The conclusion was there was no difference was found in patient outcomes and patient’s satisfaction between nurse practitioners and physician groups. Study weakness were there was a low level of heterogeneity and few quality RCT’s. NURSING ECONOMIC$/September-October 2011/Vol. 29/No. 5 Please note: I do not know where this source came from, but if you follow the format I have already implemented you just need to put the author name (last name first) then this information.
Horrocks, Anderson, & Salisbury ( 2002) preformed a systematic review meta-analysis of 11 RCT’s and 23 observational studies examining the quality of primary care nurse practitioners and physicians care at the first point of contact with a patient. Quality of care measures included communication skills, accurate diagnosis, investigations appropriately carried out, and appropriate advice given. The results of RCT’s studies demonstrated that care by the nurse practitioner had a 95% CI interval 0.07 to .47 meaning patients were more satisfied with their care anywhere from 7% to 47% of the time. Observational data studies we compared the findings qualitatively and calculated odds ratios. No significant difference was found in patient satisfaction for patients attending either provider with these studies. The research had important limitations including many different outcome measures and none of the studies was adequately powered to detect rare serious adverse outcomes. Nurse practitioners and doctors did not have similar work circumstances or similar pressures on their time. It is necessary to determine whether the differences between nurse practitioners and doctors in patient satisfaction and quality of care remain if they work under identical circumstances.
Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors Sue Horrocks, Elizabeth Anderson, Chris SalisburyBMJ 2002;324:819–23 *same as above
Two-hundred and fifty nurse run clinics in the US this NY times article mentions that popular opinion is that Nurse practitioners being nurses force more on the person while physician focus more on the disease. Also, what were mentioned were nurse practitioners, due to a salary do not have the same time pressures that physicians have thus are able to spend more time with patients (Rosenburg, 2012). The evidence presents that nurse practitioners provide the same quality of care that a physician would provide. That being said, a large RCT comparing quality under the same work circumstances would be needed to further support this theory.
Conclusion
As this paper demonstrated, to date in this country there is a great need for quality providers. With impending legislation of Obama Care in 2014 and the aging baby boomer generation the need will skyrocket. Nurse Practitioners have demonstrated that as a group they provide equal quality care to that of physicians. A large number of nurse practitioners have legislation that supports independent practice. There is lack of legislation that regulates or outlines expectations for collaborating with physicians. Given the evidence, I strongly recommend that collaborative practice agreements be abolished. And that we move towards quality measures for all practitioners instead.
(Appendix A)
Sample Collaborative Practice Agreement-New York State
This agreement sets forth the terms of the Collaborative Practice Agreement between (nurse practitioner and specialty as listed on the State issued certificate) and (name of collaborating physician and specialty if any) at (name and address of agency or entity where practice takes place). This agreement shall take effect as of (date).
Introduction
(YOUR NAME RN, NP) meets the qualifications and practice requirements as stated in Chapter 257 of the Laws of 1988 and Article 139 of the Education Law of New York State, holds a New York State license and is currently registered as a registered professional nurse in good standing, holds a certificate as a nurse practitioner pursuant to Sec. 6910 of the Education law and herein meets the requirement of maintaining a collaborative practice agreement with (NAME OF COLLABORATOR, MD/DO) a duly licensed and currently registered physician in good standing under Article 131 of the New York State Education Law.
I. Scope of Practice
The practice of a registered professional nurse as a nurse practitioner may include the diagnosis of illness and physical conditions and the performance of therapeutic and corrective measures including prescribing medications for patients whose conditions fall within the authorized scope of the practice as identified on the college certificate. This privilege includes the prescribing of all controlled substances under a DEA number. The nurse practitioner, as a registered nurse, may also diagnose and treat human responses to actual or potential health problems through such services as case finding, health counseling, health teaching, and provision of care supportive to or restorative of life and well-being. This practice will take place at (above identified agency) or in such other facility or location as designated by (name of identified agency) or by the parties of this contract. The following exceptions to the certified scope of practice have been agreed upon by the undersigned parties: (list exception(s)).
II. Practice Protocols
The protocols used in this (identify specialty as listed on State issued certificate) practice are contained in (name approved protocol text with all bibliography citations) and in (cite location of any other protocols which are germane to this particular practice).
III. Physician Consultation
The parties shall be available to each other for consultation either on site or by electronic access including but not limited to telephone, facsimile and email. Each party will cover for the other in the absence of one of them or (names of third parties) who are designated by (YOUR NAME, RN, NP and NAME OF COLLABORATOR MD/DO) as appropriate for coverage in the absence of both parties. In the event that there is an unforeseen lack of coverage, patients will be referred to the appropriate emergency room.
IV. Record Review
A representative sample of patient records shall be reviewed by the collaborating physician every three months to evaluate that (name of NP)'s practice is congruent with the above identified practice protocol documents and texts. Summarized results of this review will be signed by both parties and shall be maintained in the nurse practitioner's practice site for possible regulatory agency review. Consent forms for such review will be obtained from any patient whose primary physician is other than (name of collaborating physician).
V. Resolution of Disagreements
Disagreement between (name of nurse practitioner) and (name of collaborating physician) regarding a patient's health management that falls within the scope of practice of both parties will be resolved by a consensus agreement in accordance with current medical and nursing peer literature consultation. In case of disagreements that cannot be resolved in this manner, (name of collaborative physician's) opinion will prevail. In disagreements between the nurse practitioner and non-collaborating physicians, the collaborating physician’s opinion will prevail.
VI. Alteration of Agreement
The collaborative practice agreement shall be reviewed at least annually and may be amended in writing in a document signed by both parties and attached to the collaborative practice agreement.
VII. Agreement
Having read and understood the full contents of this document, the parties hereto agree to be bound by its terms.
Nurse Practitioner (Specialty):
Printed Name___________________________________________ RN license #________________ Certificate #_________________________ Signature______________________________________________ Date_______________________ Collaborating Physician:
Printed Name___________________________________________ MD license #________________ Board Certification__________________________________________________________________ Signature______________________________________________ Date_______________________
References
American Association of Nurse Practitioners. Medicare Legislation.(2013). Retrieved
articles/327-policy-payment-rate-changes
Centers for Medicare and Medicaid Services. Accountable Care Organizations (ACO).
(2013). Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ACO/index.html?redirect=/aco/
Henry J Kaiser Commission on medicaid and the uninsured: key facts. (2012). Retrieved
Miford, Creagh E. DO, & Ferris, Timothy G. MD, MPH Mayo Clinic Proc. August
2012.87 (8) 717-720. Retrieved from http.//dx.doi.org/10.1016/j.mayocp.2012.05.009
New York State Education Department. License Requirements: Nurse Practitioner.
(2012). Retrieved from http://www.op.nysed.gov/prof/nurse/np.htm
Rosenburg, Tina. The Family Doctor, Minus the M.D. (2012). Retrieved from
http://opinionator.blogs.nytimes.com/2012/10/24/the-family-doctor-minus-the-m-d/
Shulkin, David J. Mayo clinic Proc. Aug 2012:87(8) 721-722.
Retrieved from http//dx.doi.org/10.1016/j.mayocp.2012.05.2012
U.S. Department of Health and Human Resources. HRSA. Data Warehouse. (2013).
Retrieved from http://www.datawarehouse.hrsa.gov/hpsadetail.aspx.
