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ADVANCED PRACTICE NURSES

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ADVANCED PRACTICE NURSES

BY
Elizabeth Tupper

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Interdisciplinary Program in Health and Humanities

1992

ABSTRACT
ADVANCED PRACTICE NURSES
BY
Elizabeth Tupper

This paper will examine how the use of advanced
practice nurses, specifically nurse practitioners and
clinical nurse specialists, could change the provision of
primary care within our current health care system. Primary
care is a keystone of this system, and the profession of
nursing has a long and intimate relationship with both the
intellectual concept and the shaping of a definition of
primary care. Historically, there are three events that have
contributed to the relative positions of nurses and
physicians in the hierarchical ladder of power and authority
in the delivery of health care. These three events all
illuminate an aspect of contingency, that the system that has
evolved was due to many forces, forces which were not
rational or coordinated or planned. It is time to rethink
the division of authority that currently exists within our
health care system and look at ways that nurses can be used
more effectively. There is ample evidence of ways in which
nurses have responded even more effectively than physicians
to the most crucial problems facing our health care system--
cost containment, access, and care to underserved areas.
Therefore, advanced practice nurses should be given the due

authority and compensation for serving as providers of

primary care because they have a firm track record as being

qualified to provide the care and they are a necessary

component in our response to the problems we currently face

in the delivery of primary care.

Copyright by
ELI ZABETH ANNE TUPPER

1992

"What's emerging from the pattern of my own life is the
belief that the crisis is being caused by the inadequacy of
existing forms of thought to cope with the situation. It
can't be solved by rational means because the rationality
itself is the source of the problem...So I guess that what
I'm trying to say is that the solution to the problem isn't
that you abandon the rationality, but that you expand the
nature of rationality so that it's capable of coming up with
a solution."

Robert M. Pirsig

Zen and the Art 9; Motorcycle Maintenance

 

 

Daniel Callahan has made the observation that
Americans, as a society and as a culture, have become
enamored of medical progress and medical technology. I would
like to add physicians to the list. America perceives
physicians as being the only option in terms of the provision
of health care. This is due in large part to the authority
and power that the profession has developed over the last
century. I will propose an alternative. I propose a
redefinition of the "front line" in the provision of health
care services--that is, the providers of primary care. I
propose that we look to nurse practitioners and clinical
nurse specialists, two groups of advanced practice nursing,
for the provision of much of our primary care.1 There are
several models by which this could be accomplished, just as
there are several models under which we obtain our health
care from physicians. Most importantly, this proposal calls
for the recognition, not only by society, but also by the
legislatures, insurance companies, and physicians, of these
advanced practice nurses as independent and autonomous

agents.

he...

I will make several substantiated claims within the
confines of this proposal. First, that primary care is at
least one of the most crucial aspects of health care, if not
the most crucial aspect. Second, that primary care needs are
very inadequately met in our society, especially for poor,
urban populations and rural populations. Third, that
physicians have not been adequately responsive to meeting
these needs. Fourth, that nurses traditionally have been in
the forefront of providing primary care and, in fact, have
developed important specializations focused around primary
care. Finally, that nurses are increasingly used in crisis
situations to provide care and have certainly demonstrated
that they are capable of providing such care in an effective,

efficient, and quality manner.

I. PRIMARY CARE AND NURSING

The following discussion is based upon an assumption of
the moral importance of primary care, an assumption that is
important enough to bring out explicitly for the reader.
This is an area that occasions much debate in and of itself.
The debate revolves around issues of primary care as it
relates to other, more intensive types of care, in terms of
cost, health, and equality of opportunity. This debate also
includes those arguments regarding social justice, funding
priorities, and assignation of a price to specific lives and
to populations of particular patients. I take as one very
important assumption the position that investment in primary
care and that increased access to primary care result in both

2

an increase in overall health and number of lives saved, and
a decrease in the use of higher levels of care. This is a
result of the fact that individuals, by virtue of this
access, are enabled to attend to problems relating to health
and disease when they may be relatively simple and easy to
treat as opposed to waiting for the problems to progress to
such an extent that their health is not only at greater risk,
but hospitalization and other more intensive and expensive

2-6 The

interventions and therapies are required.
explorations of these arguments, however, is beyond the
scope or the intention of this paper. I take then, as one
foundation, the position of primacy of primary care. That
is, that primary care is one of the keystones of our health
care system, and possibly the most critical and important
component.

There are a multitude of definitions of primary care.2-

9 However, within these definitions, one can find several
characteristics in common that are considered essential.
Primary care refers to what is often described as "first
contact" care--that is, it is the individual's first contact
with the health care system. It is from this point of
contact that the individual is helped to access either other
types of care or higher levels of care. This position within
our health care system has garnered the label of the "gate
keeping" position; often times, it is only through these

primary care providers that an individual can access the rest

of the health care system. This "gate keeper" ensures

appropriate use of health care resources, that referrals to
other health care providers are made appropriately, and
discourages overuse or misuse of the health care system.

In addition, almost all definitions of primary care
contain the three C's: comprehensive, continuous, and
coordinated. The primary health care provider must be able
to function across all areas of specialty, must be able to
function across time, and also serves to coordinate the
health care "team" that is attending to the health needs of
the individual. Some definitions also include two more
important characteristics of primary care. First, that the
provider treats the entire individual and not just the
disease entity--that is, evinces a holistic approach to the
patient. Second, that to adequately perform any of the
aforementioned functions, primary care must be reasonably
accessible.

Primary care is most often delivered at sites outside
of what we consider to be the hub of the health care system.
Delivery sites include, but are not limited to, the private
office, public clinics, private clinics, health departments,
health maintenance organizations, and the individual's home.
These are often referred to as "ambulatory" care delivery
sites, and some authors use the terms ambulatory care and
primary care interchangeably.

The American Nurses Association definition is as
follows:

"Primary health care is a way of delivering
health care. It is the care that the patient receives
at the first point of contact with the health care

4

system that leads to a decision of what must be done to
help resolve the presenting health problem. It is also
continuous and comprehensive care, including all the
services necessary for health promotion, prevention of
disease and disability, health maintenance, and in some
cases rehabilitation. Primary health care includes
identification, management, and/or referral of health
problems, as well as promotion of health-maintaining

behavior and prevention of illness. It is also
holistic care, which takes into account the needs and
strengths of the whole person. Since primary health

care involves the delivery of health care from entry

into the system and is also continuous and

comprehensive, it necessitates collaboration among many
health profeSSionals."

Both the federal government and the profession of
medicine have tried to attend to this issue of access to
primary care, most especially for the poor, for those who are
geographically isolated, for urban populations, and for those
with no health insurance. The federal government expressed
its concern via its interest in and promotion of such
programs as health maintenance organizations, the National
Health Corps, and Rural Health Clinics. The medical
profession expressed its concern and interest by establishing
a new "specialty" in 1969, that of Family Practice. It was
hoped that the increased prestige and economic incentives
would lure more incoming physicians from other specialties
into the specialty of family practice. But the fact of the
matter is that our nation is experiencing a shortage of
primary care providers even as the number of practicing
physicians rises in relation to the population. A recent
news items by Gannet News Service noted that, "The American
College of Physicians estimates there will be almost 5,000
fewer internists than the nation will require in 1995 and a
shortage of 26,800 by 2020."11

5

The connection between nursing and the provision of
primary care is a strong one. Diane C. McGivern, R.N.,
Ph.D., F.A.A.N., wrote:

"In its broadest sense, primary care is defined
as the scope of nursing practice...The components of
the nurse as generalist who is oriented to the
psychosocial needs of clients and families, provides
comprehensive care, and works collaboratively with
clients were and are elements consistently defined a5
part of primary care as well as traditional nursing."
She continues:

"Nursing's recurrent themes and concerns are
characterized by the unique perspective that focuses on
the wholeness of the client, his or her quality of
life, and general well-being beyond illness needs. In
fact, and with irony, it must be noted that this very
breadth of background is what makes nursing so clearly
suited to the primary health provider role. It is a
breadth3not possessed by any other health care delivery
group.

The concepts of nurses as providers of primary care is
certainly not a recent development. Traditionally, nurses
functioned within the community as health care providers of
first contact--for example, public health nurses. Within the
profession of nursing itself, as early as 1943, one of the
great leaders, Frances Reiter, began to address the idea of
the "nurse-clinician". Her concept included the following
three aspects: "1) clinical competence in the depth of
understanding, range of function, and depth of services; 2)
clinical expertise for coordination and responsibility for
continuity of care: and 3) professional maturity in

14 The 1950's

collaboration with the medical profession."
heralded the first program specifically for advanced practice

nurses at Rutgers University in psychiatric nursing. It was

during the physician shortage of the 1960's that the use of
advanced practice nurses began to swell. The federal
government began to take a special interest in using these
providers as alternatives in areas that were inadequately
served by physicians. The federal government also began to
express its interest in these alternative providers by
funding graduate education.

I have selected for concentration two areas of advanced
practice nursing as they relate to primary care. These are
the nurse practitioner and the clinical nurse specialist.

The American Nurses Association defines a nurse
practitioner as:

"...a registered nurse prepared through a formal,
organized educational program that meets the guidelines
established by the profession. This education prepares
the nurse practitioner to provide a full range of
primary health services. Practitioners engage in
independent decision making about health care needs and
provide health care to individuals, families, and
groups across the life span."

A clinical nurse specialist is defined by the same
organization as:

"...a registered nurse who, through study and
supervised practice at the graduate level (master's or
doctorate) has become expert in a defined area of
knowledge and practice in nursing. Specialty practice
is part of the discipline of nursing that is more
focused than generalized practice; it is the diagnosis
and treatment of human responses to actual and
potentiallgealth problems within a specialized area of
nursing."

These two practice specialties, their similarities and
differences, have been the source of much ambiguity not only
outside the profession of nursing, but within it as well. It

is a point, therefore, that deserves some attention.

Educational levels between these two areas of nursing of
advanced practice are quite comparable. One survey noted
that, "The nurse practitioner programs reportedly place more
emphasis on pharmacology, primary care, physical assessment,

7 The

health promotion, nutrition, and history taking."1
other difference noted in the survey was that of both
clinical training and graduates' employment settings: Nurse
practitioners were more focused on primary care settings
while certified nurse specialists focused on secondary or
tertiary settings.l7

One author compared nurse practitioner and clinical
nurse specialist roles in light of five parameters: range of
knowledge and skills, practice domain, professional autonomy,
interdisciplinary collaboration, and directness of service.
While both practitioners approach patient care from a
perspective of holistic care, the certified nurse specialist
has what could be characterized as less breadth and more
depth. The specialist focuses on a narrower population, such
as pediatrics or geriatrics, and therefore, "...had a
narrower range of advanced assessment skills and has
intervened in greater depth with a narrower spectrum of

18 It is,

problems within the defined population served."
however, interesting and enlightening to note that the
clinical nurse specialist defines her specialty in terms of a
population of people, and not in terms of a disease entity or
an organ system. The clinical nurse specialist role is also
more closely associated with secondary and tertiary care

settings. For example, a gerontological nurse specialist may

8

serve her clients totally within the confines of a nursing
home.

A degree of difference was found in the histories of
professional autonomy between the two practice areas. While
the role of the nurse practitioner was developed as a
"physician extender", and therefore required physician
approval and supervision, the role of clinical nurse
specialist was developed as a practice specifically within
the nursing domain. In spite of this difference in origin
and role development as regards professional autonomy,
Harriet Kitzman notes, "...both the NP and CNS require
professional autonomy and collegial relationships with
physicians if the communication required to plan, implement,
and evaluate clinical services is to be effective."19

Another difference is highlighted when one looks at the
goals of the two practices. While nurse practitioners are
more oriented to providing direct patient care, the clinical
nurse specialist has several orientations. These include
research, education, and consultation, what are referred to
as indirect services. Kitzman observes:

"Inherent in master's preparation, whether NP or

CNS, is a specialization in clinical nursing, which

forms the base for the expertise that is demonstrated
through multiple direct and indirect care and

leadership roles. These include practitioner, staff
educator, patient advocate, and collaborative
practitioner. The expertise in clinical nursing
provides thezsontent through which these activities are
undertaken."

It seems that despite all the ambiguity regarding these

roles, the end result is unchanged. That is, both nurse

practitioners and certified nurse specialists are an untapped
source of primary care providers. Kitzman, like many other
experts in the field, calls for a conceptual meeting of these
two roles. Both nurse practitioners and certified nurse
specialists are oriented toward and capable of providing
primary care. However, the CNS may be more narrowly oriented
to providing primary care to a specific population of

individuals.

II. HISTORICAL CONTEXT

Now that we have a grasp of primary care and how
nursing, specifically those nurses in advanced practice, fits
into this concept, we need to look at the profession of
medicine itself. We do this to see if we can come to some
understanding of how the health care system came to have the
shape that it does today. It is a system that is
overwhelmingly dominated by physicians who, in large part,
determine what roles other health care professionals are
allowed to play, who determine in large part what health care
will cost, and also have great influence over who receives
that care and in what form.

I am going to examine three main events to illuminate
and aid in the understanding of how the monopoly of power
over the health care system became so physician centered.
Further, I will tease out the contingency of each of these
events. The idea of contingency is an important one. The
system evolved into the shape it has today due to the
interaction of many forces, forces which were not rational or

10

coordinated or planned. Instead, the end result of a health
care system that is so totally physician centered and
dominated is a collateral or contingent outcome. For this
reason, we need to look at the position of physicians within
our health care system and ask ourselves, "Does our health
care system, with this hierarchy of power, hays to be this
way? Is there some way in which it can be different and
still be equally if not more effective and responsible to the
health care needs of our country?"

The first area in which the aspect of contingency or
incidentalism is illustrated is in the history of
prescriptive authority. This history demonstrates that, with
each move that the American Medical Association and the
federal government made, the profession benefited from the
incidental increase in power and authority. Note that for
much of the legislative action taken, the intention was not
the bestowal of prescriptive authority solely with the
physician, but was to protect the public from false claims
made by drug manufacturers. The control of drugs moved from
the realm of the consumer to the realm of the physician. But
an equally important effect of this transfer of control was
economic power and the power of professional authority. The
American Medical Association was deeply involved in lobbying
for increased drug regulation. It is instructive to look at
this history and its importance to a professional who
provides primary care because, very simply, one must be able

to prescribe medications if one is to treat patients.

11

"Prescription of drugs has become an act integral to
the assessment, diagnosis, and treatment cycle in the
provision of primary care," says Gene Harkless, R.N.,
M.s.N.21

In the early 1900's, the shift of power from the
consumer to the medical professional began in earnest.
According to Paul Starr, there were three factors involved in
the genesis of this power shift. First, "muckraking"
journalists began to do exposes on patent medicine companies,
calling for increased regulation of these medicines and
publicizing the companies' business practices as being
deceptive. Second, the American Medical Association (AMA)
had grown large enough, mostly in the financial sense of the
word, to mount a campaign against what they called these
"nostrum makers", calling for these companies to reveal their
"secret formulas", and additionally, pressuring the companies
to not market directly to the public. Third, with the drug
companies' realization that the populace was increasingly
relying on physician advice came the parallel realization
that to market their product even more effectively, it would
behoove them to market directly to physicians.22

In response to this combination of events, mainly the
public exposure of the business practices of drug companies,
the Food and Drug Act was enacted in 1906. The Act made it
illegal to make claims about a product that were obviously
false with regard to the contents of the product. The
intention of this Act was to make consumer information more

accurate, essentially so that people would know what they

12

were buying, and so that the consumer wasn't misled into
buying a false product. Coinciding with this, the AMA
established the Council on Pharmacy and Chemistry to, "...set
standards for drugs, evaluate them, and head the battle

against nostrums."23

The Council wanted drug companies to
apply to them for their Seal of Approval for their medicines.
Further, they refused to approve any drug that was marketed
to the public, no matter how honestly. This forced drug
companies to make a crucial choice--either market to
consumers or market to physicians. An additional benefit for
physicians was the elimination of these drug companies as a
source of free advice for the public. These events all
interacted to ensure that physicians had increasing power
over the world of pharmaceuticals.

The second decade brought further strength to the
position of physicians with respect to the drug companies and
the public. In 1912, the Act was enlarged to proscribe not
only all fraudulent claims about composition, but about
efficacy as well. The AMA Council, once again in concert
with the federal government, enlarged their position of power
by denying approval to specific drugs if any other drug made
by a manufacturer was marketed to the public. Now companies
had to choose not only how to market a single drug based on
AMA approval, but their entire corporation!

"The AMA's regulatory system did not merely
augment the federal effort. The logic of the 1906 law
was to improve the functioning of the market by making
consumer information more accurate. The logic of the
AMA's regulatory system was to withhold information

from consumers and rechannel drug purchasing through

13

physicians."24

Throughout the next four decades, regulation of drugs
increased. The legal right to prescribe pharmaceuticals came
to rest solely within the profession of medicine. That power
of prescriptive authority, as Harkless so eloquently pointed
out earlier, is what enables health care providers to take
care of patients.

Harkless makes some astute observations with regard to
this history of prescriptive authority and the profession of
nursing. Nurses, in the late 19th century and the early 20th
century, made drug recommendations as part of their healing
and caring function. This was especially true for those
nurses who practiced within the domains of public health
nursing and private duty nursing. Gradually, this aspect of
nursing was eroded. In fact, in 1955, the American Nurses
Association published a model nurse practice act that,
"...explicitly excluded the acts of diagnosis and

25 It wasn't until as

prescription as nursing functions."
recently as 1970 that the model definition was amended. So
nurses seemed to have, at least to some extent, participated
in giving away some of that power. While the public's
perception may be that physicians have always been in control
of drugs, Harkless comes to the conclusion that, "...the
authority for prescribing treatment 1) has not always rested
with the M.D., 2) developed with little challenge and
examination, and 3) may be competently carried out by

26

others." Further, Harkless states:

14

"Patterns of authority tend to take on the status
of objective social fact. Patterns of authority are
perpetuated because people come to believe that this is
how things always were, always will be, and always
should be...The stability of the medical hierarchy,
M.D.'s' perceived role as experts, the rise in
technological development, and the support of
government agencies have created a value-generating
system that has servedzto §§rengthen the hierarchical
structure of medicine." '

In addition to the forces outlined above, there was
another factor to be considered in the evaluation of this
outcome of sole prescriptive authority residing with
physicians. That is the rise of therapeutic efficacy, which
are those pharmocologic and surgical interventions that were
truly effective as treatments and cures and not merely the
provision of symptomatic relief. Joseph A. Califano, Jr.,
former Secretary of Health, Education, and Welfare, states
that physicians began to exercise control over
pharmaceuticals even before the advent of therapeutic
efficacy in the 1930's. The simple fact that the medications
being prescribed actually worked just added to this position
of and public perception of power. Once we entered the era
of wonder drugs, most specifically, the antibiotics, this
further bolstered the position of physicians. The events
that occurred in the 1900's essentially made "...the doctor's
prescription the indispensable key to patient access to most
drugs. The doctors were perfectly positioned with the keys
to the miracle drug kingdom, the exclusive power to
prescribe."29

The public perception of the profession of medicine as

the only competent prescribers of pharmaceuticals, the added

15

bonus of therapeutic efficacy, the lobbying efforts of the
AMA, and regulation by the government had all interacted to
yield sole prescriptive authority by physicians. Was this an
intentional outcome of all these events? More importantly,
was it a necessary outcome? Certainly, it was intentional on
the part of the AMA, but I contend that a factor of
contingency played a strong role in the development which
added to the hierarchical power of medicine within the health
care system. Although the AMA effectively exercised
political power to protect and enlarge the scope of authority
for the profession, the result is not a necessary component
of the structure of the health care system.

The second area to be explored is that of the
development of third party payers, specifically that of Blue
Cross and Blue Shield. It is impossible to deliver health
care services without the recognition by these third party
payers of the legitimacy of the practice. That recognition
is made concrete by reimbursement. As the health care
industry began to grown in America, the AMA and the medical
profession played an integral role in shaping it. However,
other forces played just as strong a role, including the
Depression, the federal government, corporations and labor
unions, and even the second World War. The result of these
many interacting forces was a system that recognized only
physicians as reimbursable providers of health care.
Institutions could be reimbursed, procedures could be
reimbursed, but no other service offered by a provider was
reimbursed.

16

Before the 1930's, about 90 percent of hospital and
doctor bills were paid for out of pocket by most Americans.30
During the Depression, hospitals were hit hard. "Between
1929 and 1930, average hospital revenues plummeted from more
than $200 per patient to less than $60."31

This was only one of the reasons that the American
Hospital Association began to look at pre-paid
hospitalization plans. Another was purported to be a concern
for increasing access for the middle class to the technology
that the hospitals had to offer. "The primary political
issue of hospital financing in the mid-1930's was
affordability of care to the majority of those with low
incomes, who were the backbone of growing productivity--that

is, to working class white Americans."32

A third and equally
powerful reason was the fact that, if the hospitals actively
stepped in and did something about increasing access for this
middle class who couldn't afford to pay out of pocket and yet
weren't quite poor enough to quality for charity care, they
would stop the government from making a similar move and
therefore retain control over these pre-paid plans. Most
historians cite Baylor University Hospital in Texas as the
site of the birth of the Blue Cross concept. The essence of
these plans was that a specified number of days of
hospitalization were provided in exchange for a yearly
premium.

The AMA first was highly suspicious of these plans,

thinking that they somehow reinforced the idea that hospitals

17

practice medicine instead of physicians. The AHA knew that
they were highly dependent on physicians for patients to fill
their beds and so were very careful not to alienate or
antagonize them. So the AHA agreed to a distinct separation
of hospital services from medical services. Another factor
influencing physician acceptance of pre-paid hospitalization
plans was the realization that, if the hospital bills were
paid by the plan, then the patient would have that much more
money available to pay the physician fees. However, just to
make sure that there was no misunderstanding about the issue
of who could legitimately practice medicine, in 1934, the AMA
published ten principles regarding these pre-paid
hospitalization plans. The principles addressed issues of
control of medical practice, choice of physician, and patient
confidentiality. These issues, in and of themselves, were
not controversial. But the economic implications of these
principles were. Paul Starr states, "The doctors took
professional authority, patient confidentiality, and free
choice to require a specific set of economic relations..."
Principle 6 essentially "...meant that except for the poor,
no form of health insurance was acceptable that paid doctor's
bills as opposed to indemnifying patients...In other words,
doctors would not accept any system of payment that
confronted them with an organized payer." Principle 8
prevented "...a group of doctors from offering care to
patients at any lower price than their colleagues. In the
name of free choice, it effectively eliminated the
possibility of competition and the right of patients to

18

choose among competing physician groups."33 Starr sums up

his analysis of these principles with the final observation
that, "in short, the AMA insisted that all health insurance
plans accept the private physicians' monopoly control of the
medical market and complete authority over all aspects of
medical institutions."34

Despite these admonitions, or more strongly,
proscriptions, by the AMA to physicians so that they would
remain aloof from pre-paid medical plans, they existed
anyway. Corporations and employee associations often sought
out contracts with physicians or with groups of physicians
for the provision of medical care. Most historians cite the
Ross-Loss Clinic of Los Angeles as the forerunner in pre-
payment for medical care.

How did the profession respond to these challenges to
the delivery of medical care? With force and anger. They
lobbied, successfully, for many states to enact laws that
specifically prohibited "consumer-controlled" plans. The AMA
did not even approve of direct service pre-paid plans when
they were controlled by physicians at this point in time.
The medical society expelled the founders of the previously
mentioned Ross-Loss Clinic. "If these physician-controlled
plans were unacceptable to the AMA because they created
'unfair' competition, the medical cooperatives were doubly
anathems because they subjected doctors' incomes and working
35

conditions to direct control by their clients," says Starr.

It wasn't until 1942 that the AMA began to change its stance

19

toward service benefits, when it gave its approval only if
the state medical society sponsored it. Starr says, "A plan
that paid doctors directly was all right if the doctors ran

36 Once again, this response by physicians was

the plan."
prompted by the realization that, if the profession didn't
take control of these plans, the federal government would.
As with any other form of external control on the profession,
control by the government was considered unacceptable. If
physicians assumed the initiative, they could keep the
government out and maintain control over these plans.

The end result of the interaction of all these forces
is an insurance industry that, by and large, is controlled
by the very profession that provides the service. Eli
Ginzberg writes, "...The boards of directors of most of the
Blue Cross and Blue Shield insuring organizations around the
country are controlled by physicians and hospital
administrators, who often hold the majority or set percentage

37

of seats on the board by law." Both of these programs, in

addition, act as an intermediary for the federal and state
government programs, Medicare and Medicaid. In the American
Nurses Association's position statement on reimbursement for
nursing services, the observation is made that:

"In their fiscal intermediary role, the Blues have
been subject to criticism that they not only negotiate
the prices of their services with themselves, they have
also been permitted to audit their own transactions!
In no other industry have the providers of goods and
services been accorded such favorable treatment as that
given health care 3providers under the evolving
reimbursement system."

Ginzberg puts it another way:

20

"In short, the nation's physicians and hospitals
have had an advantage over most other providers of
services. To a large extent, they or people close to
them have sat in judgment on their own incomes, because
the insurers decide which fees and rates to accept and
to pay; 39 other words, they have been their own
barriers."

This impacts the system not only financially, but has
some obvious implications for which of the practitioners and
providers get reimbursed. Physicians have a long history of
operating in a very anti-competitive mode, and control of the
pocketbook of health care gives them an enormous amount of
power over their competitors or any profession that they
perceive as competitors.

The third event that illuminates the aspect of
contingency in the development of the power of the medical
profession can be found in the story of the Flexner report of
1910. Anne Stoline, M.D. and Jonathan Weiner, Ph.D. say,
"Based on a study sponsored by the Rockefeller and Carnegie
Foundations, the Flexner report has been called the single
most important document in the history of American health

40 The Flexner report served several functions, but

care."
in terms of this discussion, the issues of power and control
are most relevant. The most commonly cited impetus behind
the Flexner report was the raising and standardization of
medical education. However, another result was control by
the physicians themselves of the number of both medical
schools and physicians. Ginzberg comments, "What needs to be
emphasized is that the AMA took the lead, through the
establishment of the Council on Medical Education in 1903, to

reduce the number of medical schools and the numbers of

21

41 In addition to this

physicians entering the profession."
aspect of control of the profession, some other interesting
aspects of control emerged as well. The increased
educational and financial requirements mandated by the
Flexner report:

"...made it much harder for a relatively poor
person to obtain a medical education and thus altered
the social structure of the profession...In addition,
from that point on, all medical schools took a common
approach to the study of patients and disease: The AMA
and allopathic medicine had emerged the victors of the
competition among sects."

Through this event, the medical profession was able to
remain a relatively small and homogeneous group. The AMA
skillfully lobbied state legislatures to enact these
recommendations into law. L.S. Aaronson notes, "Medicine
secured its power vis-a-vis society not on the basis of
scientific knowledge, but rather through monopoly over the
means of health care."43

Further restriction on the numbers of physicians
entering the profession occurred during the 1930's. Ginzberg
observes:

"Although the thrust of the AMA's initial
efforts to raise the quality of medical education in
the early years of this century was not aimed at
enhancing the economic position of its members through
reductions in the supply of physicians, such a cartel-
like objective was clearly manifest in its actions in
the 1930's, a posture that carried over in the post
World War II years."

Many authors focus solely on the Flexner report.
However, some note that this increasing control by physicians
began as early as 1903. Through the efforts of the AMA's
Council on Medical Education, the state medical licensing

22

boards began to raise their standards for licensure. Megali
Larson states:

"In 1906, the Council surveyed all the medical
schools in the country, ranking them according to
diverse criteria...The effects were immediate: Rather
than face the publication of the rankings, many
commercial schools closed, and others consolidated or
sought university affiliation; homeopathic and eclectic
schools were even more advegsely affected than the
regular commercial schools."

But it was the changes in medical education, along with
increasing therapeutic efficacy, that seemed to increase the
public's confidence level in the medical profession. The
Flexner report also played a large role in determining which
of the medical schools that remained got the lion's share 'of
money from foundations, further cementing the financial
closed doors of the profession. Members of the profession
itself, in large part, were leery of the "scientific" reforms
sought by the Flexner report. But they did know that there
were too many physicians, and they did know that competition
for patients was fierce, and most cooperated with the reform
measures with the end result being a bettering of their own
economic position. Larson highlights two of the main motives
for cooperative. "The 'qualitative' argument of the reform
leaders--get better doctors--fused, therefore, with the
'quantitative' and practical concerns of the rank-and-file--

permit fewer doctors and provide more secure incomes."46

23

Analogous to the Flexner report, for nursing was the
Goldmark report of 1923. Aaronson says, "It attempted to do
for nursing what the Flexner report did for medicine.
Unfortunately, it did not challenge physicians' and hospital
administrators' right to rule over the health sector."47
Nursing, unlike medicine, was unsuccessful in its attempt to
control its numbers, as was the attempt to increase the
homogeneity of the membership as was done in medicine. Susan
Reverby states:

"As physicians had for medicine, nursing leaders
sought to document the reasons for nursing's ills, to
define professional nursing, and to gain from the
foundations ideological and financial support for their
goals. They hoped to create a unified, well-educated
work force by severing nursing education from hospital
nursing service demands. They wanted to develop
collegiate programs for an elite, close the weaker
schools, and8 define poorly trained nurses out of the
profession."

The Goldmark report received little support, not only
from hospital administrators, superintendents, and
physicians, but also from nurses themselves. The complaints
of hospital administrators and physicians centered around the
separation of nursing education from nursing service, around
issues of "over-educating" the nurse. Nurses, especially
those trained in the smaller schools, were fearful of being
"defined out" of the profession and were also fearful of the
report's call for the training of a "subsidiary nurse."
Another major difference between the two reports of Flexner
and Goldmark was the ranking and classifying of schools.

Reverby says, "Goldmark's report, in contrast to Flexner's,

had neither applauded the best programs nor sought to

24

discredit the worst by name."49 Lauren Aaronson, who also
analyzed the effects both reports had on these two
professions, says:

"Unlike medicine, however, nursing has never
questioned the wisdom of 'grandfather' clauses. When
the Flexner report was implemented, medical practice by
those not educated in AMA-approved schools was
immediately outlawed and over half of all medical

schools in operation at that time were closed. In
contrast, nursing's protracted struggle to establish a
bachelor's degree requirement for beginning

professional nursing practice grandfathers in all
current registered nurses for pracgace as professional
nurses. When will nursing learn?"

Ginzberg's comments are:

"Every occupational group or profession frequently
faces a simple dilemma. On the one hard, to improve
the economic circumstances of its members, it is
sensible to control its numbers. The medical
profession, surely through the 1930's and even later,
followed such a policy. On the other hand, an inherent
obligation of a responsible profession is to respond to
the public's need for services, and that frequently
means increasing the supply of practitioners. Yet the
biggest barrier to improving the economic returns of
its members is for a group to press for increases in
the supply. The nursing prgfession has never faced
this problem in these terms."

The result of this missed opportunity was that the
control of nursing was not in the hands of nurses themselves,
but was placed, beginning in 1903, within the state
regulatory boards.52

What these three events show is that the reason our
health care system is set up, especially in terms of the
roles within the system, is based on contingency--that is, an
arbitrary historical evolution. None of the many events
which led to this degree of physician control were mapped out
ahead of time in a coordinated plan. Each separate step

simply added on to the last, with an aggregate outcome of

25

substantial power. It is not the result of rational and
thoughtful policy making or assignation of duties and
responsibilities and power. The distribution of authority in
health care may have made more sense in an older model of the
health care system. It is becoming increasingly apparent,
however, that it does not work optimally in today's context.
The system does not aaya to be this way. There are not
enough good reasons to support this current set-up within the
system. It gag be different. We need to rethink this
distribution of authority and power using nursing,
specifically advanced practice nurses, in a more central
role. I will show what this difference would mean to the
health care system and provide thoughtful and reasoned

support for this plan.

III. "CAN NURSES DO THAT?"

As I demonstrated in the previous portion of this
paper, there exists insufficient justification for
maintaining the current balance of authority of our health
care system. I am going to explore how this system could be
different, arguing that advanced practice nurses can serve as
the impetus for this difference--that is, increased access to
and affordability of that very important piece of our health
care system, primary care. First, I will look at how the
federal government has turned to advanced practice nurses to
assist with many of the problems that exist within our system

today. This is important because the federal government has

26

a responsibility for the populace as a whole, and also
because they have no vested interest in a battle for
professional "turf". Although one may not regard these
governmental decisions as entirely objective, one can
certainly regard them as necessary because of this
responsibility. Second, I will explore a moral argument with
regard to the medical profession's response to the use of
advanced practice nurses in these problem areas, and show
that their current response, that of passivity, is either
immoral from the point of view of the populace, or immoral
from the point of view of advanced patient nurses.

Author Ellen Beer states:

"The central issues blocking the widespread use of
autonomous nursing to meet the primary health care
needs are political and hidden behind protests of
whether nursing is a true profession that is capable g;
safely caring for patients in an independent manner."
She continues:

"When nursing asserts its claim to occupy the
primary health care role, which is more obviously
occupied by medicine, it invites comparisons to
medicine in the extent of its authority to act in that
role. In that comparison...nursing is seen as having
less authority. But that is a false issue. In
comparison to medicine, every profession or group is
seen as having less authority. The important question
is, does nursing have appropriate authority to act in
the primary health care role?"

We have more than thirty years of studies that more
than adequately document the efficacy and high quality care
that can be provided by advanced practice nurses. The most
extensive and politically powerful study of how nurse
practitioners as providers can influence access to the health

care system was conducted by the the Office of Technology

27

Assessment (OTA) in 1986 in response to a request by the
Senate Committee on Appropriations. As was noted in my
introductory comments regarding primary care, some analysts
include ease of access as an integral part of primary care by
definition. The case study used most extensively in this

paper is Case Stuay #37: Nurse Practitioners, Physicians

 

 

 

 

Assistants, and Certified Nurse Midwives: a Policy Analysis.

 

Historically, the two populations of concern regarding access
to health care were rural populations and the
socioeconomically deprived populations of the inner city.

The OTA found that nurse practitioners have improved
geographic distribution of care, due mainly to the fact that
they are more willing than physicians to locate in rural and
inner city areas. It was this very fact that led to the
Rural Health Clinic Services Act of 1977, an act that waived
the previous restriction for direct supervision of nurse
practitioners by a physician in certified rural health
clinics located in designated underserved areas.

The OTA also concluded that, "In addition to improving
access to care in rural areas, N.P.'s...increase access to
primary care in a variety of nongeographic settings and for

55 This was

populations not adequately served by physicians."
found to occur in several ways--by increasing access for
underserved children in school settings, by increasing access
for patients in nursing homes, by increasing access for
socioeconomically deprived pregnant women and pregnant teens,
by increasing access for the chronically ill and homebound,

and by adding to the scope of primary health services

28

available to patients.56

Studies done by various researchers find that 60% to
80% of the tasks performed by physicians can be performed by

56-58 Even more powerful than this is a

nurse practitioners.
recent study that suggests that, "R.N.‘s often perform CPT-
coded services with little or no supervision by

physicians..."59

So not only aaa these services be provided
by professionals other than physicians, these services aga
provided by professionals other than physicians. Yet, it is
the physician who is reimbursed for these services. A study
which looked at the savings that the Canadian Health Care
System hypothetically could have incurred from the use of
nurse practitioners in place of physicians for the provision
of many types of primary care found that 10% to 15% of all
medical costs or 16% to 24% of all ambulatory costs could
have been saved by the widespread use of nurse

practitioners.60

Health Maintenance Organizations (HMO's)
are one of the largest utilizers of advanced practice nurses.
This is due, I believe, to two very important factors. HMO's
are not set up as fee-for-service entities, but rather as
pre-paid plans. Providers are salaried and are not
reimbursed on a procedure or per-service basis. Nurse
practitioners" salaries are often less than physicians'
salaries, and this makes them very effective providers from a
financial point of view of the organization. Also, very few

outside payers must be billed for the services provided

within an HMO, so the issue of third party reimbursement

29

becomes less problematic in this arena. The second reason
for the high rate of utilization of advanced practice nurses
within this setting is that one of the first and best known
clinical trials was conducted by the Kaiser Foundation in
1973 concerning the increase use of nurse practitioners in an
HMO setting. The trial found that the use of N.P.'s
increased the number of patients seen, saved the M.D. time,

51' 62 Another study comparing

and generally decreased costs.
a single nurse practitioner and a single physician found that
the quality of care provided by these two professionals was
comparable, but ' that the care provided by the nurse

practitioner was less costly.63

A study at Johns Hopkins
University showed that an HMO staffed by a physician and a
nurse practitioner could reduce costs in the provision of

pediatric care.64

The list goes on and on.

We, as a nation, are increasingly using advanced
practice nurses to help us out of the trouble spots. These
nurses can only gain reimbursement and authority in the midst
of what is perceived to be a crisis, a crisis that the
profession of medicine has chosen not to attend to or has not
been able to attend to. This is analogous to the old saw
that the greatest advances in medicine are a result of war.
In these circumstances of crisis, and only in these
circumstances, have we allowed advanced practice nurses to
provide the care that they are trained to provide.

The first example of this crisis situation is access to
health care for rural populations. This is an issue that

President Johnson so strongly addressed in the 1960's.

30

Current legislation addresses this increasingly desperate

problem of access to care for rural populations, as did the

previously mentioned Rural Health Clinics Act of 1977.
"Included in the Omnibus Reconciliation Act

(OBRA) of 1990...signed into law in November of 1990,
P.L. 101-508 is a Medicare provision to directly
reimburse nurse practitioners and clinical nurse
specialists working in collaboration with a physician
for services provided in rural health areas. The nurse
practitioners and clinical nurse specialists will be
reimbursed for providing 'physician services' covered
by Medicare that the nurses are lggally authorized to
deliver according the state law."

American Nurses Association President Lucille Joel,
Ed.D., R.N., F.A.A.N., was quoted in a recent issue of The
American Nurse: "The passage of this bill is testimony to a
new and long overdue trend in health care...improved access
and acknowledgment of the high quality, cost effective care
delivered by nonphysician providers." She continues,
"Congress' willingness to commit to this bill illustrates its
belief that the reimbursement and utilization of nurses is a
good investment for the future of our nation's health."66

Another example of using advanced practice nurses to
stave off a crisis situation can be found in the ongoing
debate regarding reimbursement reform for physicians by
Medicare. This discussion revolves around the innovation and
implementation of one of the more interesting and important
payment reform issues since the advent of Medicaid and
Medicare in the 1960's. This payment reform follows on the
heels of a similar system, called Diagnosis Related Groups,
that was implemented in 1983 for hospitals. It is a system

that is devised mainly for federal dollars, but most health

31

care analysts feel that private insurance companies will also
begin to use such a system. This strategy for controlling
health care costs through physician payment reform is known
as the Resource Based Relative Value Scale (RBRVS). "The
American Public Health Association reports that our nation's
health tab will hit $661.2 billion this year. Payments to
physicians have risen as much as 17% per year, compared with
a 9% rise in hospital costs and a 4% rise in other aspects of
our economy."67

The Resource Based Relative Value Scale is slated to
begin in 1992. The reform is aimed at de-emphasizing the
importance of procedures and re-emphasizing the importance of
primary care. What the medical profession finds
objectionable about these reforms is that there will be
increasing limitations on what practitioners can charge their
patients. Physicians are therefore leaving the Medicare
programs, and/or refusing to accept Medicare patients. This
is an opportunity for advanced practice nurses to step in.
When physicians abdicate a position within the health care
system, they lose any claim, historical or otherwise, that
they arguably could have made.

Another reason that this reform system is so important
to advanced practice nurses is that it is the resource that
will be reimbursed, regardless of specialty. If advanced
practice nurses are providing the same resource as a
physician in the provision of primary care, then the

reimbursement should be the same. Other factors are also

32

taken into account in this formula for reimbursement.

"The ANA task force affirmed that payment to
nonphysician providers (NPP's) be based on a resource-
based relative value scale (RBRVS) and that the value
of the service or work component of the RBRVS should Ea
the same for the same service, regardless of whether it
is delivered by physicians or nonphysician
practitioners. The actual payment may differ, as it
includes adjustments for practice costs and malpractice
liability costs which may differ for nonphysician
providers and physicians."

 

Yet another example of increasing governmental reliance
on advanced practice nurses within our health care system can
be found in the Omnibus Reconciliation Act (OBRA) of 1989,
section 6405. According to the Medical Assistance Program
Bulletin issued May 1, 1991 by the State of Michigan, "The
intent of Congress in enacting this legislation was to
improve access to primary care for children and pregnant
women by expanding the number of providers eligible to be

69 Initially, in February of

reimbursed under Medicaid."
1991, the MSA noted that the Medicaid Program would directly
reimburse certified pediatric and family nurse practitioners
for services that they can legally provide under state law,
"whether or not the certified nurse practitioner is under the
supervision of, or associated with, a physician or other

70 For those services not considered

health care provider."
within the scope of practice, a Nurse Practitioner/Physician
Agreement would have to be in place. (See P.A. 280 for
consultation draft of the list of procedures that are
reimbursed within the scope of practice for Certified

Pediatric and Family Nurse practitioners pursuant to the

Omnibus Budget Reconciliation Act of 1989.)

33

The point is this: If advanced practice nurses are
good enough to deliver health care in governmentally defined
rural areas, and if the federal government finds that the
care delivered by advanced practice nurses merits
reimbursement under a whole system designed to take care of
the health needs of our elderly, and if the federal
government finds that the services provided by advanced
practice nurses are of high enough quality to merit direct
reimbursement under the Federal Employment Health Benefit
Plan (with no call for physician supervision), then who are
we protecting by keeping these providers, in essence,
unavailable to the rest of our populace? If these providers
were in some way dangerous, or gave care that was in some
measurable or noticeable way inferior to the care provided by
physicians, would the federal government be making the use of
them that they are today? Who actually is being protected
here? I contend that the only thing being protected is the
"turf" of the medical profession. Ellen Beer observes:

"The incongruity of this reaction by medicine to
nursing as nursing asserts its claim to occupy primary
health care roles is that firstly, all that is really
changing is the overtness of the nursing primary care
activities, and, secondly, the physician practitioners
being 'threatened' do not exist. Physicians are not
providing primary care services in needy areas or in

adequate numbers, but71they do not want nursing to
provide them either..."

34

Given the fact that a health care system that has, as
one of its major characteristics almost totalitarian
physician dominance, is no longer rationally operative in
today's context, and given that advanced practice nurses have
a well documented, very solid track record of providing high
quality, affordable and accessible primary care, and given
that nurses have responded and can respond effectively to the
aforementioned problems within the health care delivery
system, I therefore propose that these advanced practice
nurses be given the due authority and compensation for

service as providers of primary care.

IV. THE RESPONSE OF THE MEDICAL PROFESSION

At this point, I want to focus on the response of the
medical profession to the proposed and actual utilization of
advanced practice nurses as providers of primary care. It
seems to me that the profession of medicine could have
responded in one of two ways. The first response could have
been vociferous protest regarding the dangers of allowing
advanced practice nurses to provide primary health services
to underserved populations. However, had the profession
responded in this way, the next logical step would have been
that the onus of providing care to these people would have
fallen on the shoulders of the medical profession. In some
fashion, physicians would have to be directed to make
themselves available to provide care for these populations.
This concept flies in the face of a tenet of non-interference
in determining where and how physicians practice medicine,

35

whether this interference comes from the government of from
within the profession itself.

The alternative response would be one of passive
acquiescence. By this, I mean that the profession voices no
protest, but at the same time, does not openly acknowledge
that the solution is acceptable. In fact, in large part, the
medical profession chooses to ignore the situation.

Here's the problem. If, in fact, advanced practice
nurses are somehow substandard providers of primary care,
then it seems that the medical profession has a moral
obligation to vociferously protest their use as primary care
providers. This obligation arises out of their claim to the
privilege and the responsibility to ensure that the health
care that is provided is quality health care and meets their
own internally defined standard of care. On the other hand,
if advanced practice nurses aga, at the very least,
acceptable providers of primary care, then these nurses are
being wronged by the position taken of passive acquiescence.
Further, if the profession cannot deny that advanced practice
nurses are able to provide primary care to underserved
populations that is of acceptable quality and reasonable
cost, then the profession has no moral basis from which to
exclude these nurses from providing these same services to
the non-rural and non-poor. The only reasons for these
exclusions are political and self serving in nature. A

recent item in The American Nurse ran as follows:

 

36

"In an American Medical News commentary headlined
'Let's not hand over primary care to nurses', Susan
Hirshberg Adelman, M.D., points to increasing instances
in which government or private health insurers make
direct payment to nurse practitioners or nurse
midwives. Adelman predicts that nurses will argue
successfully for equal pay for equal work. As the
disparity between the nurse practitioner and physician
income narrows, the public will use nurse practitioners
more frequently, she says, resulting in a net increase
in the cost of care. Adelman concludes, 'We cannot
afford to be perceived by the public as unwilling to
care for them at Medicaid rates, nor can we7afford to
have nurses seen as the only ones who will.'"

 

 

Dr. Adelman's argument regarding increased costs of
care due to increased health care liability issues seems weak
at best. What strikes me most strongly about this stance is
that the important factor here is the public's perception,
not the actual delivery of care. If physicians were really
intent on preserving their position as the only legitimate
providers of primary care, then the most sensible thing for

them to do would be to provide the care. Further, to provide

 

the care at a reasonable cost to everyone-~individua1s, the
government, and third party payers. This is what advanced
practice nurses propose to do and have done in the past.

The response of the medical profession to the use of
advanced practice nurses as providers of primary care can
also be found within a discussion of collaboration. Nursing
literature frequently and very comfortably discusses and
acknowledges the aspect of collaboration in the provision of
health care services. Barbara R. McClain, R.N., states:

"An extensive literature published primary by
nurses strongly advocates collaborative joint practice
between nurses and physicians. Descriptors used to
explore the nature of the collaborative relationship
include such terms as co-equality, shared clients,

interdependence, collegiality, shared accountability,

37

complementary, cooperative73 mutual trust and respect,
and joint decision making."

These definitions of collaboration are much different
when viewed from the other half of the relationship, the more
powerful half, that of physicians. Joyce E. Roberts writes:

"On the one hand, interdisciplinary collaboration
has been considered a key variable in explaining and
enhancing patient outcomes. On the other,
collaboration between nurses and physicians has been
characterized as co-optation because what nurses 7yiew
as collaboration, physicians view as supervision."

Ellen Beer expands on this point:

"Despite some recent proposals and some model
legislation, nursing has most commonly been defined
legally as a dependent practice that delivers health
care services under the supervision of a duly
authorized physician or dentist. As the demand for
primary health care services expanded, many
institutions inaugurated solutions in which nurses,
under such titles as nurse practitioner, are utilized
in the primary care role, but operate in part under a
system of protocols of practice or taxonomies of
accepted nursing behaviors designed in advance by
physicians. Such compromises may make everyone feel
better, but in fact they serve to further cloud the
issue, in that protocols are external restraints that
suggest the inability of the nurse to correctly choose

among 'alternative possibilities of action...in
accordance with (appropriate) inner motives and
ideals...’ Protocols merely extend the distance
between the nurse in practice and the physician in
supervision. They act essentially as 'standing' or

'PRN' orders and implicitly reinforce the dependent
model of practice for nursing."

It is this issue of "collaboration" versus
"supervision" that has become the core of the problem in
implementing the legislation in the State of Michigan
regarding reimbursement of pediatric and family nurse
practitioners. The interpretation by the medical profession
of collaboration put forth in this legislation is another

invisible means of undermining the authority of advanced

38

practice nurses. The Michigan State Medical Society recently
released a document entitled "Implications for Physicians of
Medicaid Reimbursement to Certified Pediatric and Family
Nurse Practitioners" which reinforces the idea that
collaboration is supervision. In addressing issues of
vicarious liability, the document states, "...the element of
control may result in vicarious liability on the part of the
physician, even though it might be assumed that the nurse
practitioner is an independent contractor rather than an

76

employee or agent of the physician." The document further

goes on to say, "One of the elements of collaboration is

supervision."77

If the profession of medicine can continue
to maintain the perception that collaboration in this sense
is supervision, then they are also able to keep nurses in a
position where they are perceived as not having the
competence and ability to function autonomously. It allows
physicians to continue to occupy their position of dominance
within the health care system as being the only appropriate
providers of care. If one seeks care from an advanced
practice nurse, one is vicariously seeking the care of a
physician because the advanced practice nurse is really only
a delegate of the physician. This is not only a falsehood,
but an indefensible tool for the profession of medicine to

use in its ongoing struggle to maintain its power over the

health care system.

39

V. CONCLUSION

Finally, I want to conclude with an observation
regarding reimbursement for advanced practice nurses, to
ensure that my point is not misunderstood. This is not an
argument that will aid nurses in getting rich from the
provision of their services. It is not an argument that
calls for the perpetuation of the current system, only with
different providers. It is, however, an argument that
supports the overt recognition of advanced practice nurses in
the role of primary care provider. It is, additionally, an
argument that supports equal pay for equal work.

First, when I speak of third party reimbursement, and
the importance therein, I speak primarily from a position of
the importance of the symbolism that this recognition imparts
rather than from a position of moral support for a fee-for-
service, supposedly "market driven", competitive system. It
is my belief, or rather my hope, that this sort of procedure
driven, wide-open system has seen its heyday and is now on
the wane in lieu of a more rational and just system.
Increasingly, providers will find themselves negotiating more
reasonable fee schedules with payers. Advanced practice
nurses can help themselves and help us, as patients and
purchasers, by approaching payers and negotiating fai; and
iaag fee schedules for the provision of primary care.

Second, I have a strong inclination against arguing for
the fact that nurses ought to be reimbursed at a lesser

amount than physicians for the same services. Let's face it:

40

Culturally, we value things in relation to what we paid for
them. If advanced practice nurses deliver the same kind and
quality of care, but at a lower cost, then it will be
perceived by the public as second rate care aaa aaly to the
fact that it costs less. I guarantee it. On the other hand,
I have strong reservations about how primary care is
remunerated in our system today. Is it permissible for one
provider, for example a Family Practice physician, to receive
$30 for a well patient physical exam, while an Internist
receives $60 and a Cardiologist receives $125 for this very
same service? Don't we need to take a hard look at an issue
of justice in this discrepancy? Can we afford to expend
resources on such a disparate basis within an increasingly
strident milieu of cost containment strategies? Is this a
fair way to spend our dollars when this same system excludes
a frightfully large number of individuals from receiving
these services? These are the questions and observations
that are beginning to be addressed in the concept of the
Resource Based Relative Value Scale, and they are the
characteristics that I find most exciting and sensible about
it. Within this context, I would not support or expect
advanced practice nurses to vary fees for the same service by
specialty, but expect reimbursement of an equal nature based
on resource or service.

By no means do I think that this proposal is a panacea
for the ills of the health care system. What this proposal
is, however, is a means by which primary care can be provided
more equitably, more accessibly, most cost efficiently, and

41

still be provided in a consistently high quality manner.
Advanced practice nurses have "done their time" or "paid
their dues." They have proved over and over again that they,
as professionals, have something valuable to offer. We, as
members of society, as participants in the legislative
process, and as purchasers and users of health care, would do

ourselves a favor by accepting this offering.

42

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10.

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I do not want to leave the reader with the impression
that I believe the response of the medical profession
is the only reason our society has not made greater
use of advanced practice nurses in the provision of
primary care. There are also the powerful and
persuasive issues of gender and class. The American
culture does not have a history of women as healers
that many other cultures have. As an overwhelming
majority of nurses are women, this factor cannot be
ignored. There is also the issue of divisiveness
within the profession itself. Although this area

was touched upon in the process of differentiating
the nurse practitioner and the clinical nurse
specialist, it is important to realize the lack of
cohesiveness within the profession itself.

47

 

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