Health care is expensive and scarce. These problems will only grow with the recent decline in the number of new physicians pursuing careers as general practitioners, leaving patients competing for fewer available appointment slots. Faced with reaching the capacity limits associated with the traditional physician-centric primary care model, focus is increasingly shifting toward improving efficiency in the delivery of care, thereby addressing both cost and access concerns. One of the most promising avenues for expanding the primary care capacity of the health care system is to look beyond physicians to other categories of health care professionals in order to fill the primary care ranks—namely nurse practitioners (NPs). In addition to increasing the supply of available primary care, greater utilization of NPs as primary care providers would also achieve cost savings due to lower labor costs associated with nonphysician providers.
This is the foundational concept underlying the rapidly expanding “convenient care” industry: that with a willingness to depart from the traditional physician-centric primary care model, certain categories of care can be administered not only safely by NPs, but also conveniently and inexpensively. The focal point of the industry are what are known as “retail health clinics” (RHCs), which are small clinics offering a limited range of basic health services, usually located within large retail stores such as pharmacies and grocery stores. By staffing the clinics almost entirely with NPs, RHCs are able to provide wider access at a lower cost.
The potential for utilizing NPs in this independent manner is the culmination of a long, steady evolution of NPs from nurses with advanced training to professionals capable of independent practice. Despite the promise of innovative health care delivery structures possible with independent NP practice, some professionals claim that certain regulatory constraints on NPs in many states keep this potential from being fully realized. Web Golinkin, CEO of RediClinic, has been quoted as saying that “[i]f clinics are going to realize their full potential to provide people with easier access to high-quality, routine health care at affordable and transparent prices, some of the regulatory barriers in some states will have to be torn down.”
In addition to the education, accreditation, and licensing requirements faced by most professions, NPs are also subject to a host of additional state-imposed regulations and limitations, which, despite being framed as safety-based, have the effect of perpetuating the traditional dominance of physicians over all other health care professions. The most common examples of these types of laws are physician supervision or collaboration requirements, corporate practice of medicine prohibitions, and restrictive scope of practice definitions. In states with supervision and collaboration requirements, an NP’s authority to practice is conditioned upon some level of physician involvement—usually physician review of a proportion of the NP’s charts, physician on-site time requirements, or mandatory collaboration between the NP and a physician in developing detailed care protocols. With the significant gains made by NPs in education, training, and qualifications, the necessity of these requirements in ensuring that NPs provide high quality care comes into question. In light of the reality of modern NP practice, the issue becomes whether these rules do more harm by impeding the evolution towards a more efficient delivery system (including the independent provision of care by NPs) while providing only nominal gains in quality (if any at all).
In particular, the persistence of supervision and collaboration requirements must be weighed against the costs of less vigorous competition. Independent NPs are generally able to provide basic clinical services at a lower cost than physicians, thereby imposing significant economic pressures on general practitioners. Additionally, a stream of income for physicians who currently assume supervisory or collaborative roles relative to NPs would be eliminated since such roles generally receive compensation under the current system.
Although the medical establishment has long opposed NP independence, this opposition has further intensified with the advent of innovative, nonphysician based health care delivery structures such as RHCs, which increase the financial viability of NPs as low-cost competitors to physicians in certain categories of care. In response to this growth, a number of states have either already imposed, or are considering, legislation specifically regulating RHCs. One common thread to much of this legislation are provisions imposing more rigorous NP supervision requirements. Intensive collaboration and supervision requirements detract from the vitality of RHCs as a low-cost delivery method capable of increasing access to care by threatening RHC financial viability, because they constitute one of the risks that must be addressed in opening an RHC. These requirements add to the cost and complexity of operating RHCs, which are sensitive to cost changes such as these given the already complex environment in which they operate.