Southern States Could Benefit From Using More Nurse Practitioners, Certified Nurse-Midwives and Physician Assistants
The southern states have the highest proportion of citizens living in areas that have a shortage of health professionals. Evidence suggests that certified nurse-midwives, nurse practitioners, and physician assistants can provide high-quality, cost-effective care, but their use is limited in the South.
From 1994 to 1997, the Council of State Governments, Lexington, Ky, conducted a survey of more than 800 key stakeholders to document barriers to practice for these health professionals in the South.
It also assembled a state-by-state "snapshot" detailing the specific numbers of these practitioners in each state, the educational and training resources available for them, and the current regulatory climate affecting their practice.
The project culminated in a 64-page report that was disseminated to more than 3,500 governors, legislators, and policymakers throughout the South.
- The report concluded that nurse practitioners, certified nurse-midwives, and physician assistants can provide selected medical services equivalent to those provided by primary care physicians and at lower cost.
- Southern states could improve the health care of women and children, particularly in rural areas if they made greater use of these practitioners.
These health professionals, however, face a number of common barriers to practice in the South, including:
- Poor public awareness about their training and scope of practice;
- Exclusion from lists of health providers maintained by managed care companies;
- Lower Medicaid reimbursement than that offered to physicians who provide the same services.
In addition, nurse practitioners and certified nurse-midwives face organized opposition from physicians to their practice.
The Robert Wood Johnson Foundation (RWJF) funded the project between December 1994 and March 1997 with a grant of $152,516.
The states in the South have the highest proportion of their citizens living in areas with shortages of physicians and other health professionals. Despite research demonstrating that nurse practitioners, certified nurse-midwives, and physician assistants are capable of performing high-quality and cost-effective care routinely performed by primary care physicians, this region does not frequently use these professionals except for a few states such as North Carolina and Florida. Of the 10 states that do not provide Medicaid reimbursement for physician assistants, 7 are in the South. Of nine states that do not allow certified nurse-midwives to prescribe medications, six are in the South. Twelve of 19 southern jurisdictions do not have training programs offering a midwifery certificate or master's level nursing programs; eight states do not have training programs for physician assistants.
Until this project, there had been no effort to analyze the practice patterns of these three health professions in the South or to educate policymakers in the region about the value of their services. At the same time, two other Robert Wood Johnson Foundation national programs, Practice Sights and Partnerships for Training, also were addressing issues involving these health professionals.
Practice Sights is a 10-site program designed to help states improve their ability to recruit and retain primary care doctors and nurse practitioners in underserved areas.
Partnerships for Training focuses on creating regional educational systems to improve training of nurse practitioners, certified nurse-midwives, and physician assistants, with particular emphasis on training these practitioners in their home communities.
RWJF believed the project funded by this grant would complement these two programs. An earlier RWJF-funded initiative involving the Southern Regional Project on Infant Mortality (SRPIM) of the Council of State Governments stimulated southern leaders to make policy changes designed to reduce barriers to perinatal and well-child services (Grant ID# 010045).
The project was designed to help southern states better integrate nurse practitioners, certified nurse-midwives, and physicians into their health-care delivery systems. Its four goals were:
- to educate southern policymakers about the benefits of using nurse practitioners, certified nurse-midwives, and physician assistants;
- to document barriers to practice for these practitioners as well as highlight factors that can help to integrate them successfully into the health care delivery system;
- to assist southern states to improve the legal and regulatory environment for these practitioners;
- to act as an information clearinghouse for state policymakers, health care providers, and advocates.
The grantee formed a technical advisory group (see Appendix) that identified 848 key stakeholders in each of the targeted states and territories who could provide insight into the practice environment for the three health professions. It then conducted a 10-page mail-in survey of the 848 stakeholders about state practice environments. It included questions regarding barriers to practice, changes that occurred between 1991 and 1996 that improved the states' practice environments, and changes that were still needed to improve it further. 472 surveys were returned, for a 56 percent response rate.
The surveys and supplemental research were used to create "snapshots" of each of 18 southern states that summarized the numbers of these professionals, the availability of training and educational programs for these professionals, and the steps necessary to improve the practice environment in each state. Site visits were also made to Florida (a state with a favorable practice environment), Georgia (a moderately restrictive practice environment), and Louisiana (a restrictive practice environment) in order to enhance understanding of the range of practice issues affecting these health professionals. Finally, a comprehensive review of the literature on history, education, certification and/or licensing, scope of practice, practice settings, and market forecast for each of the professions was conducted.
The literature review. The literature review highlighted the following findings:
- High-quality care. Nurse practitioners, certified nurse-midwives, and physician assistants provide primary medical care that is equivalent to that provided by physicians, according to an extensive Office of Technology Assessment review.
- Improving access to care. Southern states could improve the health care of mothers and children, particularly in rural areas, if they made greater use of these health care professionals.
- Cost-effective care. These health care professionals prescribe fewer drugs and select lower cost treatments than do physicians. The average cost per similar visit for patients of nurse practitioners was $12.36 compared with $20.11 for physicians.
- Cost-effective education. Primary care physicians earn four times as much, and cost four to five times more to educate than do these health practitioners.
- States with favorable practice environments are strongly associated with a larger supply of these practitioners.
The survey of stakeholders. Despite differences among the three professions, the survey findings reveal that all face certain common barriers to practice:
- Public awareness is poor. The public is not well educated about the roles of these health professionals.
- Participation in managed care is limited. Nurse practitioners, certified nurse-midwives, and physician assistants are excluded from lists of health care providers maintained by managed care networks. This may be because southern states are behind other states in managed care penetration.
- Medicaid reimbursement is lower than that offered physicians even when they provide the same services.
- The three professions face different barriers. Nurse practitioners and certified nurse-midwives face greater organized opposition to their practice from physicians than do physician assistants. Physician assistants faced opposition from nurses.
Case Studies. Among the findings of the case studies:
- Florida has a fairly high per-capita rates of nurse practitioners, certified nurse-midwives, and physician assistants. Training programs for these practitioners and a shortage of practicing obstetricians were among the factors identified as contributing to a favorable practice environment.
- Georgia ranked fairly well when compared with other southern states. Nevertheless, certified nurse-midwives and nurse practitioners cannot prescribe medications, and certified nurse-midwives cannot obtain admitting privileges at hospitals. Physician assistants have won limited authority to prescribe, but they believe it remains too restrictive.
- Louisiana had among the lowest number of these health practitioners in the country. Certified nurse-midwives and nurse practitioners cannot prescribe medications, and their low numbers and lack of training options make it difficult for them to establish independent practices. Physician assistants face a similar lack of training opportunities and perceive additional impediments in state legislation authorizing their practice in the state.
The project's findings were published in a 64-page report entitled Increasing the Utilization of Certified Nurse-Midwives, Nurse Practitioners, and Physician Assistants in the South. It summarizes the roles of nurse practitioners, certified nurse-midwives, and physician assistants; presents the findings of the literature review; details findings from the survey, explores in greater depth the practice environment in the three representative states; provides snapshots on the 18 southern states, and offers recommendations for improving the practice environment on a state-by state basis.
The report provides the first comprehensive picture of state-by-state changes that have improved practice for these health professionals, and suggestions of further changes needed to improve the practice environment. It was distributed in May 1997 to more than 3,500 individuals and institutions, including state legislators, governors, health policy organizations, researchers, and the media. The report is also included in the Council of State Governments publications brochure and two articles on the project appeared in the SRPIM quarterly newsletter, which was distributed to more than 2,000 health care organizations and legislators.
In January 1996, project personnel briefed southern governors at the Southern Governor's Association. In 1997, presentations on the survey were also made at the annual meeting of the American College of Nurse Midwives in May and at the Southern Legislative Conference meeting in August.
AFTER THE GRANT
The Southern Regional Project on Infant Mortality ceased operation in December 1997, nine months after the close of the grant. The Council of State Governments (Lexington, Ky.) continues to distribute the project report through its publication office, but it has not expanded the project's focus to the national level, as it had considered doing at one time. An RWJF national program, Southern Rural Access Program (August 1997 through March 2006), incorporated the information provided by this project.
GRANT DETAILS & CONTACT INFORMATION
Education of Southern Policymakers About the Use of Nurse Practitioners
Council of State Governments (Lexington, KY)
Dates: December 1994 to March 1997
Shelly Gehshan, deputy director of the Southern Regional Project on Infant Mortality (SRPIM) was the original project director. Stephanie Harrison was executive director of SRPIM. Ms. Harrison is now with the American Federation of State County and Municipal Employees, Washington, D.C.
Technical Advisory Group
Judy Castleman, R.N.C.
Leonard J. Finocchio, M.P.H.
University of California at San Francisco
American Academy of Physician Assistants
*Tim Henderson, M.P.H.
National Conference of State Legislatures
Senator Paula Hollinger
Maryland General Assembly
*Wayne Meyers, M.D.
University of Kentucky
*Anne Richter, C.N.M., M.P.H.
Florida Midwifery Resource Center
*Justine Strand, PA-C
Duke Family Medical Center
*Sally Austen Tom, M.S., M.P.A., C.N.M.
Association of Academic Health Centers
*Carolyn Williams, C.N.M., M.S.
American College of Nurse-Midwives
*Louise Wulf, R.N., Sc.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Schuch, Allison. Increasing the Utilization of Certified Nurse-Midwives, Nurse Practitioners, and Physician Assistants in the South. Lexington, Ky.: The Council of State Governments, 1997.
Presentations and Testimony
Harrison, Stephanie. Southern Governors' Association Winter Meeting, Washington, D.C., January 1996.
Kreinin, Tamara. Southern Legislative Conference, Nashville, Tenn., August 1996.
Troccoli, Karen. Southern Legislative Conference, Atlanta, Ga., August 1997.
Troccoli, Karen. American College of Nurse-Midwives, Boston, Mass., May 1997.
"Project Mounts New Initiative on Advanced Practice Nursing," Special Delivery, Spring 1995.
"Midwifery is a Southern Tradition," Quickening, May/June 1997.
"More Training Opportunities Will Bolster Health Care," Asheville Citizen-Times, September 19, 1997.
Report prepared by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Michael P. Beachler