EDITORIAL
Pd?nury Care: In Rural America and Your Own Bmkyard
N
ursing’s role in primary health care is changing, and as we look forward, there are many uncertainties. Emily Friedman (1990), writing in the Journal of the American Medical Association, notes that one of the touchiest questions is the degree to which nurses wish to, and will be allowed to, function independently. The move toward independent nursing practice has been steady, if slower than many nurses have hoped. Two issues, cost containment and access to primary care, now are fueling the trend toward autonomous practice for nurses. Interestingly, some of the most innovative models are coming from rural areas. The numbers of nurse practitioners, certified nurse-midwives, and certified registered nurse anesthetists have risen over the past 20 years. For example, there now are more than 20,000 nurse practitioners, and 16%of them practice in rural areas. About 22% of the 4,260 nurse-midwives and 18%of the 22,500 nurse anesthetists also practice in rural areas (Lutz, 1991). These independent practitioners, known as advanced practice nurses within the profession and midlevel practitioners outside of nursing, are part of the solution to rural America’s chronic problem in attracting physicians. Nurse practitioners provide primary care, preventive care, patient education, and management of minor illnesses. Nurse-midwives provide prenatal, labor, delivery, and postpartum care, as well as gynecologic care and family planning. Rural hospitals are relying more on primary care and outpatient services for revenue, and mid-level practitioners are viewed as the most economic providers of such care (Lutz, 1991). Rural areas, underserved by physicians, are the testing grounds for new models that allow nurses to function independently. Two keys make the models
July/August 1992
work: legal authority to write prescriptions and direct reimbursement for services. As it stands now, nurse practitioners can, to some extent, prescribe drugs in 36 states. The story on direct reimbursement is more complex. Since the 1977 rural health clinics legislation was enacted, mid-level practitioners have been able to practice independently from physicians and receive reimbursement through clinics for Medicaid and Medicare services. In 1990, Congress approved direct reimbursement for nurse practitioners working in rural areas; the federal government now mandates Medicaid reimbursement for certified nurse-midwives, as well as for pediatric and family nurse practitioners (Lutz, 1991). As nurses take over providing primary care for some rural populations, both nurses and physicians in other areas are asking questions. Why is a nurse with advanced education qualified to deliver primary care to rural populations but not to affluent, urban populations? When third-party payers reimburse clinics for services at a fixed rate, what fiscal sense does it make to have a physician provide primary care that a nurse practitioner can provide? Who is the most appropriate provider of primary care in terms of outcomes and cost? Because nursing’s interest in primary care overlaps traditional physician practice, conflict is inevitable. The new models of care delivery being forged in rural areas will redefine the working relationships between nurses and physicians, as well as the financial arrangements. Rural models offer us hope of resolving the issues collaboratively because there are not enough resources to go around in rural health care to make turf battles worthwhile (Friedman, 1990). As nursing’s autonomy grows, the public will need to know more about nursing care and choosing health-care providers. Nurses can help people to understand the choice between a nurse practitioner and a physician for safe, affordable primary care, or between a nurse-midwife and an obstetrician. One of the best means of educating, of course, is by example in your own backyard. Your choice of a personal, primary care provider reflects your values and speaks louder than your words. Karen B. Haller, RN, PhD Editor
References Friedman, E. (1990). Nursing: Breaking the bonds?Journal of the American Medical Association, 264, 3117-3122. Lutz, S. (1991, May 13). Practitioners are filling in for scarce physicians. Modern Healthcare, 24-25, 28-30.
J O G N N
28
Pd?nury Care: In Rural America and Your Own Bmkyard
N
ursing’s role in primary health care is changing, and as we look forward, there are many uncertainties. Emily Friedman (1990), writing in the Journal of the American Medical Association, notes that one of the touchiest questions is the degree to which nurses wish to, and will be allowed to, function independently. The move toward independent nursing practice has been steady, if slower than many nurses have hoped. Two issues, cost containment and access to primary care, now are fueling the trend toward autonomous practice for nurses. Interestingly, some of the most innovative models are coming from rural areas. The numbers of nurse practitioners, certified nurse-midwives, and certified registered nurse anesthetists have risen over the past 20 years. For example, there now are more than 20,000 nurse practitioners, and 16%of them practice in rural areas. About 22% of the 4,260 nurse-midwives and 18%of the 22,500 nurse anesthetists also practice in rural areas (Lutz, 1991). These independent practitioners, known as advanced practice nurses within the profession and midlevel practitioners outside of nursing, are part of the solution to rural America’s chronic problem in attracting physicians. Nurse practitioners provide primary care, preventive care, patient education, and management of minor illnesses. Nurse-midwives provide prenatal, labor, delivery, and postpartum care, as well as gynecologic care and family planning. Rural hospitals are relying more on primary care and outpatient services for revenue, and mid-level practitioners are viewed as the most economic providers of such care (Lutz, 1991). Rural areas, underserved by physicians, are the testing grounds for new models that allow nurses to function independently. Two keys make the models
July/August 1992
work: legal authority to write prescriptions and direct reimbursement for services. As it stands now, nurse practitioners can, to some extent, prescribe drugs in 36 states. The story on direct reimbursement is more complex. Since the 1977 rural health clinics legislation was enacted, mid-level practitioners have been able to practice independently from physicians and receive reimbursement through clinics for Medicaid and Medicare services. In 1990, Congress approved direct reimbursement for nurse practitioners working in rural areas; the federal government now mandates Medicaid reimbursement for certified nurse-midwives, as well as for pediatric and family nurse practitioners (Lutz, 1991). As nurses take over providing primary care for some rural populations, both nurses and physicians in other areas are asking questions. Why is a nurse with advanced education qualified to deliver primary care to rural populations but not to affluent, urban populations? When third-party payers reimburse clinics for services at a fixed rate, what fiscal sense does it make to have a physician provide primary care that a nurse practitioner can provide? Who is the most appropriate provider of primary care in terms of outcomes and cost? Because nursing’s interest in primary care overlaps traditional physician practice, conflict is inevitable. The new models of care delivery being forged in rural areas will redefine the working relationships between nurses and physicians, as well as the financial arrangements. Rural models offer us hope of resolving the issues collaboratively because there are not enough resources to go around in rural health care to make turf battles worthwhile (Friedman, 1990). As nursing’s autonomy grows, the public will need to know more about nursing care and choosing health-care providers. Nurses can help people to understand the choice between a nurse practitioner and a physician for safe, affordable primary care, or between a nurse-midwife and an obstetrician. One of the best means of educating, of course, is by example in your own backyard. Your choice of a personal, primary care provider reflects your values and speaks louder than your words. Karen B. Haller, RN, PhD Editor
References Friedman, E. (1990). Nursing: Breaking the bonds?Journal of the American Medical Association, 264, 3117-3122. Lutz, S. (1991, May 13). Practitioners are filling in for scarce physicians. Modern Healthcare, 24-25, 28-30.
J O G N N
28
