Nurse Practitioners Face Barriers Providing Primary Care


Nurse Practitioners Face Barriers Providing Primary Care | primary care, nurse practitioner, advanced practice nurse, Medicaid, Medicare, shortage of primary care physicians, Cynthia Howington, B. Darlene Byrd, Mary Meyer

Mary Meyer
With the current shortage of primary care physicians in Arkansas expected to grow from 514 today to 860 in five years, the role of Advanced Practice Nurses (APN) including nurse practitioners (NP) in providing primary care is critical. The need is particularly acute in rural areas. But for NPs to better fill the gap in primary care, a number of barriers need to be removed.

“There is a huge need for primary care in our rural areas, and the NP is filling the need for care in these areas with the lower populations where physicians are willing to work with a APNs,” said Mary Meyer, APN, treasurer, Northeast Arkansas Nurse Practitioner Association. “It is a great service. But there is a problem in our area that even though NPs are allowed to write orders for tests and procedures, our larger hospitals will still not recognize an NP as an independent prescribing authority.”

That is not a regulatory issue, but one dealing with hospital policies. The problem is magnified, Meyer said, because in Northeast Arkansas the larger hospitals regulate some of the small hospitals. Not allowing NPs to order tests and procedures makes it harder for NPs to be effective.

“It limits the prescribing role of the NP,” Meyer said. “What happens is we have to go to a physician to write the order, and the report comes back to the physician, who has never seen the patient, instead of the NP.”

Under state and federal regulations, NPs also aren’t allowed to write orders for home healthcare.

“That should be done,” Meyer said. “And then reimbursement should be brought up equal to primary care physicians. We are reimbursed 80 percent of what a primary care physician is paid, yet we spend a longer time on average with the patient.”

Arkansas Nursing Association Health Policy Committee Chair Darlene Byrd, DNP, APN, said in addition to lower reimbursements for covered care, there are some procedures that primary care physicians can charge for, but APNs can not. That puts APNs in the position of considering whether they provide the service and forego payment, provide the service and charge the patient, or don’t provide the service.

Byrd said federal Medicaid regulations allows APNs to be primary care providers and requires APN reimbursement for all Medicaid covered services that are within the APN’s scope of practice, but the State of Arkansas has chosen not to do this.

Current law that requires APNs to work in collaboration with a physician is also a barrier.

“The barrier of a collaborative practice agreement is one that prevents APNs from going farther out in the rural communities to practice than physicians are willing to go,” Byrd said. “It is a tether to physicians that limits access for patients. Of the 75 counties in Arkansas, 72 are designated, all or part, as health professional shortage areas. We don’t have enough providers for delivering primary healthcare. Removing some of these barriers won’t fix all the problems of access to primary care, but it will go a long way in helping to provide better access for Arkansans.”

Lives are at stake. An example she gives is that in 2005, Arkansas was first in the nation in the death rate from pneumonia. That indicates there are some difficulties with accessing healthcare.

“Arkansas, like other states, has regulatory barriers that prevent NPs from practicing to the full scope of practice,” Byrd said. “For example, if you look at Medicaid, Medicaid right now is a managed care model. Arkansas can choose who can be the primary care provider for Medicaid beneficiaries. Although from a national perspective, Medicaid allows NPs to be primary care providers, the state chose to have physicians only.”

Arkansas doesn’t have enough primary care physicians to take care of all the Medicaid beneficiaries as it is, and an additional 250,000 people are expected to join the Medicaid rolls by 2014 as a result of healthcare reform.

“If there are not enough physicians now, why can’t APNs be allowed to be primary care providers?” Byrd asks. “We are educated, licensed and certified to provide primary care, so why can’t we be recognized by Medicaid as primary care providers?”

Patients report a high satisfaction with NPs.

“Patients accept us very well,” she said. “We don’t have problems with patients wanting to see us.”