Courtney H. Lyder, ND

The debate surrounding healthcare reform has produced many offshoots, not the least of which is the question as to who will provide the care promised to the estimated 32 million people who will become eligible for healthcare coverage under the Affordable Care Act (ACA) as of 2014. Because these individuals were previously uninsured, predictions on the anticipated groundswell in demand for long-delayed primary care are staggering. Couple that with an aging population and it is not an overstatement to say that our nation is at a tipping point if this need is not addressed.

With a projected shortfall of 45,000 primary-care physicians (PCPs) by 2020, it is clear that doctors alone are not the answer. Clearly, alternative solutions must be found. And more and more, the one logical remedy is nurse practitioners.

While primary-care physicians have historically been at the frontline of evaluating and managing patients, 17 states have now enacted legislation acknowledging that nurse practitioners are qualified to handle many primary-care duties without physician oversight. According to the State Nurse Practice Acts and Administrative Rules 2012 published on the American Association of Nurse Practitioners website: "’Full Practice state licensure laws provide for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments including prescribe medications under the exclusive licensure authority of the of the state board of nursing."

In its 2010 report, "The Future of Nursing"

 an expert panel convened by the Institute
of Medicine noted that studies reveal that outcomes for patients of nurse practitioners are comparable to those of PCPs. The report, issued in part as response to the passage of the ACA, advocates nurses practice without restrictions to the "full extent of their education and training."

Nurse practitioners are prepared to take on this challenge and are uniquely equipped to deliver a broad range of services, including primary, acute, and specialty care. That’s because nurse practitioners are registered nurses who not only have advanced academic credentials (either a master’s degree or a doctoral degree), but on average have already worked 10 or more years as a registered nurse. This gives them practical, bedside experience to complement what they’ve learned in the classroom. These nurse practitioners are conducting routine medical examinations, ordering lab tests, and prescribing medications. They routinely monitor chronic conditions such as diabetes or congestive heart failure and treat minor illnesses such as colds and the flu. And just as important, along with their fellow nursing professionals, they comfort and counsel patients in both inpatient and outpatient settings.

Nurses have always been integral members of the healthcare team in medical offices and the inpatient setting. They work collaboratively in managing patient health, consulting with physician specialists, as well as pharmacists, lab and respiratory technicians, therapists and more. Care coordination is - and always has been - the central role of nurses. Often, they serve as patient advocates as well, ensuring that not only are patients fully informed about their care, but families are too. It is no surprise then that patients routinely report high satisfaction with the care they receive from nurse practitioners.

With the anticipated proliferation of accountable care organizations triggered by the ACA, there is an increasing emphasis on Patient-Centered Medical Homes as American healthcare moves away from episodic care and toward a population health management model. In this new environment, primary care will become more important than ever for maintaining and enhancing patient health.

Nurse practitioners are well prepared to not only treat patients, but to oversee prevention and disease management initiatives that are at the very cornerstone of healthcare reform. As physician shortages become more severe, nurse practitioners are a logical front line in managing overall population health. Facing this reality, and the environmental forces upon us, it is time to embrace the role and contribution of qualified nurse practitioners. The need for primary care has never been greater and the solution to this challenge has never been clearer.

, ND, ScD (hon), FAAN, is dean of the UCLA School of Nursing, a professor of nursing in the department of medicine and public health, as well as executive director of the UCLA Patient Safety Institute. He is an international expert in gerontology with the focus of his clinical work on chronic care issues affecting older adults. E-mail him 

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With a projected shortfall of primary-care physicians, it's time for alternate solutions to patient care. Nurse practitioners are one logical remedy.

Primary Care Can't Thrive Without Nurse Practitioners

Among the many challenges facing America’s healthcare system is how our nation will overcome the growing shortage of primary-care physicians. All indications point to the current shortage being exacerbated even further in the coming years due to the confluence of four unavoidable truths:

• The full implementation of the Affordable Care Act will mean the addition of as many as 35 million more Americans with health insurance into the healthcare system. All of these people will need providers whom they can turn to and trust.

• America is aging. By 2030, one in every five Americans will be elderly with the number of people over the age of 65 reaching 72 million. Older adults have special needs and complicated challenges - both physically and emotionally - and are the highest utilizers of healthcare services.

• Increasingly, people are looking for alternative, more convenient locations (other than the physician’s office) to seek care - particularly for treatment for minor conditions. These could include retail sites in shopping malls (with weekend and evening hours), urgent care centers, or even workplace clinics. Who will staff these sites?

• Today there are approximately 778,000 practicing physicians in the United States with just under half of them in primary care. Even before health reform, the Association of American Medical Colleges estimated that an additional 45,000 primary care physicians would be needed by 2020 to keep up with demand. But where will those new primary-care physicians come from? Data shows that an increasing number of medical school students are opting for specialties instead of primary care, believing that choosing that path is likely to lead to more prestige, higher income and a less-demanding lifestyle.

Fortunately, this is one challenge for which there is a clear and sensible solution: nurse practitioners.

Nurse practitioners bring a wonderful balance of education and experience to the patient. Beyond the additional classroom training that they much take to achieve this designation, the average nurse practitioner has worked more than a decade as a registered nurse in a clinical setting. The core philosophy of the field is holistic, individualized care that focuses on patients' conditions as well as the effects of illness on the lives of the patients and their families. Nurse practitioners make prevention, wellness, and patient education priorities.

As such, primary-care physicians everywhere would be wise to look at nurse practitioners as a natural complement to their practice and a logical partner in caring for their patients. For by prudently partnering with nursing practitioners, physicians can focus on areas where their skills, education and experience can be best put to use.

Nurse practitioners already deliver healthcare including prescribing or renewing prescriptions for most drugs; ordering blood tests; performing routine physical examinations; monitoring chronic conditions; counseling patients about prevention; and treating colds, sore throats and the flu.

In recent years many states have expanded the scope of duties that nurse practitioners are allowed to perform. For example, Montana allows nurse practitioners to work without any physician supervision. By contrast, Texas requires a physician’s direct (on-site) supervision at least 20 percent of the time. Twenty-eight states are debating further loosening restrictions that prevent nurse practitioners from performing more tasks independently. And it’s time that they did, for studies have shown no difference in outcomes when patients are treated by a nurse practitioner or a physician.

Nurse practitioners are part of the largest segment of healthcare’s workforce. Presently, there are more than three million nursing professionals in the United States and as many as 19 million worldwide. These nurses are expanding their roles, redefining their profession and making contributions to the healthcare system in many critically important areas including research, quality of care, and patient rights. At the same time, they have maintained their all-important role as trusted advocate and calming voice for the patient.

It is time for primary-care physicians to take a fresh look at nurse practitioners as a sensible way to provide quality care and meet the enormous patient demands the current system is simply not prepared to handle. By physicians and nurses partnering together - and looking for new ways to leverage the best that each profession has to offer - we may find that the impending crisis facing our nation is in fact no crisis at all.

, ND, ScD (hon), FAAN is dean of the UCLA School of Nursing, a professor of nursing in the department of medicine and public health, as well as executive director of the UCLA Patient Safety Institute. He is an international expert in gerontology with the focus of his clinical work on chronic care issues affecting older adults. E-mail him 

The challenge of meeting patient demand for primary-care services in the coming years is simple: nurse practitioners.

Author | Courtney H. Lyder, ND

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