Nurse practitioners play key role in providing health care

YAKIMA, Wash. -- After eight years of working as an advanced registered nurse practitioner at a busy medical clinic in Yakima, Greg Swart decided to hang out his own stethoscope.

It's an unusual move. Only a handful -- 7 percent -- of the roughly 3,600 nurse practitioners in the state practice autonomously, that is, outside the direct supervision of a medical doctor.

But nurse practitioners and other allied health professionals are poised to become important warriors on the front lines of primary-care medicine, where projections of a shortage have many policy experts worried about the real impact of health care reform that expands coverage to nearly everyone.

"I think there's a huge role for nurse practitioners, physician assistants and nurse midwives as we face the primary-care shortage in this county," said Anita Monoian, chief executive of Yakima Neighborhood Health Services.

Monoian, chairwoman of the National Association of Community Health Centers, has made the short-age of family doctors the focus of her term.

For Swart, 37, going into the primary-care business for himself was all about controlling his destiny and spending more time with patients.

"In today's health care environ-ment, with the focus on dollars, the patient can get lost in the shuffle," said Swart, who left Cornerstone Medical Clinic and cashed out his retirement funds a few months ago to open a family practice on West Yakima Avenue.

He is board-certified and will conduct routine health care exams for men and women, well-child checks and sports physicals. He'll remove moles and stitch up minor lacerations.

The state of Washington, along with Oregon and Alaska, was a pioneer more than 15 years ago in granting practice autonomy to nurse practitioners, who are more properly titled advanced registered nurse practitioners.

In recent years in Washington, nurse practitioners have seen their scope of practice broadened to include the writing of prescriptions for narcotic painkillers.

"It is a small profession but a growing one," said Terry West, deputy executive director of the state Nursing Care Quality Assurance Commission.

A nurse practitioner is a registered nurse who has completed specific advanced training -- a master's or doctoral degree -- in the diagnosis and management of both acute and chronic medical conditions. They specialize in everything from family practice to orthopedics.

Nurse practitioners can't exceed the scope of practice outlined in their license. For example, if a patient has chest pain, the nurse practitioner is expected to refer him or her to a specialist, experts say.

In 2015, a doctorate will be the entry-level requirement for newly educated nurse practitioners.

Today, roughly half the states allow nurse practitioners to practice on their own.

Nurse practitioners and physician assistants -- the latter cannot practice without a doctor's supervision in this state -- have come a long way.

Monoian recalled that when she started Yakima Neighborhood Health in 1979 and hired a physician assistant, the Yakima County Medical Society was skeptical.

"They wanted to know what we were up to," Monoian said. "But if you look at health care now, the vast majority of organizations have a physician assistant or nurse practitioner in their practices."

The current president of the Yakima County Medical Society, Dr. Roy Gondo, a family physician, didn't return calls requesting comment for this story. But many physicians remain opposed to letting nurse practitioners work independently.

The group with perhaps the most to lose from a larger supply of lower-paid health professionals is the American Academy of Family Physicians.

Median pay for nurse practitioners is about $83,000, while primary-care doctors make from $120,000 to $190,000 a year, according to Merritt Hawkins & Associates, a physician recruiting firm.

The American Academy of Family Physicians' position is that the interests of patients are best served when their care is provided by a physician or through an integrated practice supervised directly by a physician.

Dr. Stan Flemming, former president of Pacific Northwest University of Health Sciences and a family physician, said that while there is a role for nurse practitioners in primary care, nothing can replace the intensive clinical training of a medical doctor.

Doctors get 10 or 11 years of training compared with six to eight for nurse practitioners, depending on the specialty.

"Nurse practitioners come to the table with significantly different skill sets, levels of training and experience than physicians," Flemming said.

Still, noted Monoian, medical schools aren't generating primary-care doctors fast enough and won't for the foreseeable future. The United States will need 40 percent more primary-care physicians by 2020, according to projections by the Academy of Family Physicians.

The elderly are at particular risk from a shortage of primary-care practitioners. A recent survey for the Medicare Payment Advisory Commission found that 29 percent of Medicare beneficiaries had problems finding a primary-care physician, compared with 17 percent of younger patients who were privately insured.

Nurse practitioners and family physicians have put forth dueling studies about their effectiveness.

According to a widely cited study by the Congressional Office of Technology Assessment, nurse practitioners can deliver as much as 80 percent of the health services provided by primary-care physicians.

Swart doesn't like to emphasize one profession over the other. He leases space from longtime family physician Dr. William Robinson, and said he likes knowing there's a medical doctor across the hall.

"I'm the first to tell you I don't know everything," he said. "Primary care is just that -- we see them for basic things. Certain people are so complex, I refer them to a specialist. Knowing your limitations, that's the big thing."

* Leah Beth Ward can be reached at 509-577-7626 or lward@yakimaherald.com.

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