Gazing into the Future of Advanced Practice Nursing

As policymakers and health care providers in the United States wrestle with dramatic changes to the health care system, a projected shortage of providers, particularly in primary care, is a major concern. Numerous experts have suggested that advanced practice nurses should play a significant role in addressing this concern, but others question whether that is appropriate.

Against this backdrop, Science of Caring gathered three of the nation’s thought leaders in nursing to discuss the future of the advanced practice role. Dean David Vlahov of the UCSF School of Nursing moderated the discussion with Susan Hassmiller, senior adviser for nursing at the Robert Wood Johnson Foundation, and Dean Catherine Gilliss of Duke University School of Nursing. Bios of each appear at the end of the discussion.

The Numbers

David Vlahov: Does the US need more advanced practice nurses?

Susan Hassmiller: Absolutely. The baby boomer generation is aging, chronicity is increasing and so is the complexity of care. We need more nurse practitioners, more physician assistants and more primary care providers in general.

Catherine Gilliss: There are a number of dynamic forces at play. Recent reports confirm that there are not enough physicians selecting careers in primary care. For those who incur a lot of educational debt, primary care is a costly specialty. Some reports say physicians leave almost $3 million in earnings “on the table” if they choose primary care versus a specialty. Meanwhile, 35 years of scientific reports indicate that nurse practitioners are at least comparable and in many cases superior to physicians in the provision of primary care. The data also tends to show NPs have patients who are more satisfied after their clinical exchanges.

So we’ve got changing workforce dynamics, fewer physicians, more interest from nurses to become nurse practitioners – and then we throw the Affordable Care Act on top of that. The need for practitioners will increase dramatically. In North Carolina alone, Medicaid currently covers more than 1.5 million people. If the state is willing to expand its Medicaid coverage, as they have the opportunity to do under the ACA, that would add another 650,000 patients, all of whom will need primary care. Nurse practitioners – and to some extent physician assistants – are the provider group most likely to fill that need.

Yet even if we can train enough NPs, state by state there is an inconsistency to how NPs practice and earn a living based on scope of practice and reimbursement policies; this can limit how effectively NPs can meet patients’ needs.

SH: The fact that physicians aren’t choosing to go into primary care for a variety of reasons leaves vast areas of the country uncovered. That’s an important reason why we need more providers and more who are able to practice to the full extent of their education and training. As the IOM report [The Future of Nursing] pointed out – and then the National Governors Association report and now an American Hospital Association report – state laws must change to allow NPs to practice fully so that populations in rural and underserved areas can be cared for and people everywhere can have choices in their providers.

CG: To Sue’s point: HRSA [the Heath Resources and Services Administration] is responsible for improving access to health care services for people who are uninsured, isolated or medically vulnerable. Right now, by their estimate, there are more than 15,000 additional primary care practitioners required to meet the target of one practitioner for every 2,000 residents. There are over 55 million residents who live in the geographic areas that are light on primary care providers.

SH: We also know that largely because of faculty shortages, more than 13,000 qualified applicants to nursing master’s programs, many of whom were headed to nurse practitioner programs, were turned away last year.

DV: A 2012 Rand Corporation report projected that the supply of nurse practitioners [defined as those who self-identify their title as “NP”] will grow approximately 130 percent between 2008 and 2025, and a report by the Association of American Medical Colleges’ Center for Workforce Studies found that by 2020, we expect a primary care physician shortage of about 45,000. Right now, nearly two-thirds of NPs are in ambulatory or primary care, and they make up about 20 percent of the primary care workforce – so that’s expected to increase dramatically.

Reducing Costs

DV: I’d like to raise another issue in health care that speaks to why we need more nurse practitioners: containing costs. If we look at the data from Massachusetts, Rand predicted that using nurse practitioners and physician assistants in Romneycare could save the state between $4.2 billion and $8.4 billion over a decade – again, that’s with a workforce equivalent to and in some areas better than physicians. And then if you look at time of training, cost of education…in the ACA section on workforce training, they set aside $168 million to train 500 new primary care physicians by 2015, $32 million for supporting the development of more than 600 new physician assistants and $30 million to train 600 nurse practitioners. That’s an interesting illustration of the comparative costs of education.

SH: There are two other reports that speak to this. One is from Florida, which is one of only two states [Alabama is the other] that does not allow nurse practitioners to prescribe controlled substances such as cough syrup with codeine or commonly prescribed ADHD medications or narcotic pain medicines for hospice patients. Yet the state’s Office of Program Policy Analysis and Government Accountability reported that if they broadened the scope of practice for NPs – I like to say, allow NPs to do what they learned in school – annual Medicaid savings could be $7 million to $44 million. And in Texas, Ray Perryman, a noted economist, said the same thing: if nurse practitioners are allowed to practice to the top of their training, they could increase the state’s economic output by $8 billion. There are a lot of these cost analyses. Decisions about allowing NPs to practice to the top of their education and training should be based on evidence about what is best for the cost, quality and access for patients. Unfortunately, turf issues get in the way and decisions are not based on evidence.

DV: You know there was a paper in Family Medicine in 2010 looking at why medical students don’t go into primary care – and the reasons were complex, but debt and projected income were not the only issues.… Prestige and using their education to the highest extent were also factors. In Academic Medicine in 2010, there was a study that found that there were multiple factors to consider when encouraging medical school graduates to choose primary care. And it’s anticipated that by 2025, most primary care will be delivered by nurse practitioners and physician assistants.

SH: We do know that some medical students are making the decision not to go into primary care with the realization that more NPs and PAs are stepping into that role.

CG: Which would mean that what we’re really up against is time. The solution is partly generational.

SH: Yes, but even if the problem of numbers solves itself over time, we still have the issue raised in the Future of Nursing report: we have a checkerboard of inconsistent laws that limit the people who will be providing primary care from providing it the best they can and as efficiently and effectively as they can on behalf of patients.

Government’s Role

DV: Can the Graduate Nurse Education (GNE) Demonstration help at least address the numbers needed? [The GNE is a $200 million project authorized by the ACA. It funds APRN preceptors at five sites across the country that partner hospitals and schools of nursing. One of the demonstrations is sited at Duke.] I was talking with people at the University of Pennsylvania. They had very ambitious goals and plans in terms of tying together nursing schools and health care settings into a coalition that then would have a residency match [for the GNE Demonstration].

SH: They had the advantage of working with Linda Aiken – who has brought tremendous leadership to GNE and has been the architect for convening the five demonstration sites for periodic dialogue. These are very complex projects.

CG: Complex for a number of reasons, including the challenge of accelerating training when we ultimately depend on physicians and the systems of care they control to participate in the clinical training of nurse practitioners, nurse-midwives, nurse anesthetists and to some extent clinical nurse specialists. Advanced practice nurses often compete with medical students and residents for access to training opportunities.

DV: A question I have: Is there going to be a phase II or more demonstration sites?

CG: I’m part of a coalition of East Coast private school deans who try to educate Congress and the administration on upcoming matters related to our field. We visited CMS in advance of the first demonstration to offer guidance, and we hope to have a dialogue in advance of subsequent projects. At this time, I’ve had no indication they will do a second round, but the first one is still quite young. These demonstrations are four-year projects and we’re just six months into year one.

SH: It may be that CMS is waiting to see what they can learn from the demonstrations.

DV: These projects could build the case for turning this into a permanent program that goes across the country, like direct graduate medical education. The problem is that right now, graduate medical education funding is at risk, and so how that works with graduate nursing education, it’s too early to predict. But at least this provides evidence, which is absolutely key for making the case for expanding these types of programs.

CG: It may be that step one is opening people’s eyes to the potential when nurse practitioners and physicians practice together. This may not have been the government’s agenda, but the GNE Demonstrations open the door to thinking about practicing and educating in new ways.

Interprofessional Education

DV: You know, this makes me think of the San Francisco VA, where – and I think it’s going on nationwide at the VA – the role of the nurse practitioner has been elevated so that nurse practitioners and primary care physicians are virtually equivalent in their scope of practice, each with their own panels. There’s a Center of Excellence in Primary Care Education – and the faculty from the medical school and nursing school work with the residents and nurse practitioner students to cultivate teams that include other professionals. They have what they call “huddles” to discuss how they’re providing comprehensive care and ensuring care continuity within a VA population.

That’s a model program, so the American Association of Colleges of Nursing and the VA are working together – I’ve been added to the committee – because there’s a lot of enthusiasm for expanding this program. It’s interesting what you can accomplish at the federal level; if you go back to 1948 and the integration of the military – that set an example for how to move forward. And when you put a number of these programs together – Graduate Nursing Education, what’s going on in the VA – we’re looking at testing ideas for expanding the training and improving the quality of advanced practice nurses.

SH: Clearly in my mind, that’s the ideal. Nurse practitioners in the military and at the VA can practice to the top of their education and training and across state lines, so they’re not hindered by unstandardized state laws. One of the things I’m onto at this moment with some research colleagues is understanding the millions at least, maybe billions – we’re not yet sure of the price tag, but enormous amounts – spent battling back and forth over the last few decades. Many medical societies are working to hinder the broadening of scope of practice in the states, and state nursing associations are going broke lobbying to pass these laws. It’s tough on everyone.

CG: Doctors and nurses just can’t continue to fight against each other. We will need some third parties to help break up some of the stalemates. Physicians have to persuade other physicians that using all members of the health care team is important for improving the health of the public. And the public has to come forward and say this is what they want.

SH: Regular people at the ground level need to be more outspoken. I believe as there are more nurse practitioners and physician assistants taking care of the public – and the public gets used to these kinds of providers – it will become a nonissue. As the demand increases and there is more acceptance, then you’ll begin to see state legislatures soften a bit. Right now they are extremely beholden to medical societies. It’s amazing how many states have petitioned the Federal Trade Commission – a recommendation of the [IOM] report – on restraint of trade in their state. This is public information on the FTC’s website, and the FTC says that there is not the access to the care that the public needs. It’s one of the reason we [the RWJF] recently funded a Coordinating Center for Interprofessional Education and Collaborative Practice at the University of Minnesota – to try to bring people together to understand and do research on the benefits of team practice and interprofessional collaboration. That’s what’s going to benefit patients now and in the future.

DV: I think all parties are moving toward that conclusion. One question I have: Can the federal government come in and actually have some kind of national legislation that would supersede the states?

CG: That’s an issue we’ve actually spoken with HHS [US Department of Health and Human Services] about in the last couple of years. There does not appear to be a mechanism for regulation across the states, but there is a possibility of CMS imposing “conditions of participation.”

SH: That’s right. In the last two days, CMS [Centers for Medicare and Medicaide Services] proposed new rules related to conditions of participation – and that is the mechanism. If you want federal funding, you have to abide by these rules. I believe this is how [HHS] Secretary Sebelius is getting at reducing the burden of access to care for the people in this country, but it’s tricky. If you look at rules that just came out, there are loopholes. MedPAC [the Medicare Payment Advisory Commission] will review the recommendations in the Future of Nursing report that have to do with scope of practice at their April 4 and 5 meeting and, ultimately, will make recommendations back to CMS.

A Changing Role

DV: Do you believe the APRN role is likely to expand in the coming years? If so, how?

CG: To the extent possible within this checkerboard of practice laws, I believe the expansion has already begun. There are some forces that make the use of NPs appealing. First, there’s cost, because reimbursement is generally at a lower level than physicians. In an era where reimbursement is shrinking, that will be a plus for NPs. The other issue is the 80-hour rule limiting the duty hours for residents, which could shrink even more. Hospitalist nurses in large medical centers are beginning to cover some of the responsibilities that residents might have taken on when they were available for longer duty hours.

DV: That’s a really strong point. Another opportunity for the role to expand is in health promotion and wellness, especially when I think about Accountable Care Organizations [ACOs] looking at integration across populations. Because the way it works in terms of financing, managing the health of a population matters. We’re not just looking at individual health and risk factors, but also at communities, even how they’re designed. The role may expand to bring together public health, urban planning and health systems – and I think that’s a fantastic direction we can go.

CG: To your point, David: At Duke we developed what we call a population care coordinator program. We did it on a contract basis at the request of an insurance company. They supported cohorts of registered nurses working in primary care practices to complete the certificate program so they would be prepared to engage in prevention oversight, the management of complex patients and in evaluating the patient panels for trends and unmet needs. They’re now implementing the role, and we’re beginning to do some evaluation of the impact. In the meantime, we’re recruiting other corporate clients for this program, which is executive style, mostly online, some face-to-face, some practicum. It’s a chance to go workgroup by workgroup and make a big impact using this educational model; it’s something we’re pretty excited about. The program allows nurses to stay at home and complete the work in 12 weeks.

DV: In San Francisco, the city is taking on a project of the World Health Organization – the WHO Global Network of Age-Friendly Cities and Communities – that centers on the question, How do you design a city and city services in a way that people are able to be as healthy as they can be as they age? Our School of Nursing here has joined a broad coalition, across multiple municipal agencies and community-based organizations, in this effort. These are all great examples of how the scope can and will change.

Leadership

CG: Nurses ought to be leading in the development of new models of care. New reimbursement approaches could encourage expansion of nursing activities into areas like transitional care, so much needed by patients as they move into and out of periods of acute illness. The GNE Demonstration is encouraging us to prepare people to manage across the continuum of care, regardless of their specialty…preventive services as well as chronic and acute care services.

DV: One of the other roles is nurse leadership and nursing administration in new organizational structures. If you have an ACO, that’s a different structure and has different kinds of needs, not all of which are perceived yet. Nursing education needs to step up to the plate to prepare people for the new realities.

CG: And while some places are doing it well now, many are not doing it well at all. We haven’t done a good job of helping nurses understand they can shape their own reality, but that doesn’t mean you do it independent of everybody else. Nurses need to be coached on how to “make the case,” how to present the evidence. I’m on the advisory board of a new Johnson & Johnson-sponsored leadership program, targeted for nurses to gain better business sense; they’re really going to focus on advanced practice nurses, particularly nurse practitioners. As we all look to retire out of the profession, we can expect a serious drain of leadership experience. We need to be intentional in developing leaders for our field.

SH: I agree. You can’t do it in a vacuum. It has to be done in partnership with employers. Academic settings need to understand what employers and society need. I would also put in a plug for mentoring. Leadership is a very big part of our Campaign for Action. Diversity is critical as well: if we don’t get more up-and-coming, diverse leaders into nursing, we’ll never get the numbers and leaders we need to care for the populations that need to be cared for.

CG: Here’s a shout-out to RWJ. Over the course of 30 years, the foundation has been investing in nurses and helping to build critical masses of people who could lead in key areas. Many of those programs continue, and even those that were brief made a tremendous impact on the field. As a primary care fellow, back in the late 1970s, that experience changed the course of my career. The RWJF Scholars program was critically important for so many people. And the current programs are very, very focused on helping people understand what to do and how to do it if you’re going to lead.

SH: Right. We have our Executive Nurse Fellows program. We now have our Nurse Faculty Scholars program and our New Careers in Nursing scholarship program. I think in just the last 10 years, we’ve invested about $350 million on nursing-only programs. Not to mention other programs that might involve nurses. That’s why we did the IOM report – and now the Campaign.

DV: It’s amazing the investment and also to see the return on investment. The foundation has been such a major supporter of moving forward the profession.

Catherine Gilliss, PhD, RN, FAAN, is the dean of Duke’s School of Nursing, as well as the Helene Fuld Health Trust Professor of Nursing and vice chancellor for nursing affairs. Gilliss’ career has been devoted to graduate nursing education, with a scientific focus on the family and chronic illness. At Duke, she has presided over the approval and initiation of the PhD degree program in nursing and the Doctor of Nursing Practice degree program, the construction of a new 59,000-square-foot building and the development of the School of Nursing’s 2005-2010 strategic plan. She has been recognized by the International Society for Family Nursing with its Lifetime Achievement in Research Award, received the Yale School of Nursing Medal and holds a doctorate from UCSF School of Nursing and honorary degrees from Yale and the University of Portland. She is a member of Sigma Theta Tau and the American Academy of Nursing, a former president of the American Academy of Nursing and the 2013 recipient of the Jane Norbeck Distinguished Service Award from UCSF School of Nursing.

Susan Hassmiller, PhD, RN, FAAN, is the Robert Wood Johnson Foundation senior adviser for nursing. In this role, she shapes and leads the foundation’s strategies to address nurse and nurse faculty shortages and ensures that RWJF’s commitments in nursing have a broad and lasting national impact. In partnership with AARP, Hassmiller directs the foundation’s Future of Nursing: Campaign for Action. This 49-state effort strives to implement the recommendations of the Institute of Medicine’s report The Future of Nursing: Leading Change, Advancing Health, for which Hassmiller served as the study director. She is the 2008 John P. McGovern Award recipient from the American Association of Colleges of Nursing, the 2009 recipient of the Florida Association of Community Colleges Lifetime Achievement Award, the 2009 recipient of the Community Service Award from George Washington University and the 2009 recipient of the Florence Nightingale Medal, the highest international honor given to a nurse by the International Committee of the Red Cross.

David Vlahov, PhD, RN, FAAN, is dean and professor at the University of California, San Francisco School of Nursing. He brings experience in interprofessional and interdisciplinary education and research, having served on the faculty as professor of epidemiology at Johns Hopkins and Columbia universities, with adjuncts in medical schools at Cornell, Mount Sinai and New York University and in the College of Nursing at New York University. He has also served as co-director of the Robert Wood Johnson Foundation Health & Society Scholars program. His expertise in epidemiology, infectious diseases, substance abuse and mental health has earned him the NIH MERIT Award. He initiated the International Society for Urban Health (www.isuh.org), serving as its first president; is a visiting professor at the Medical School in Belo Horizonte, Brazil, helping to develop their programs in urban health; and is an expert consultant to the WHO Centre for Health Development in Kobe, Japan. He also is the editor-in-chief of the Journal of Urban Health, has edited three books on urban health and has published over 610 scholarly papers.