Like the rest of the country, Arkansas faces a growing primary-care shortage. Last month the Arkansas Democrat-Gazette reported that Arkansas is 46th on the physician per capita list produced by the Association of American Medical Colleges. Arkansans wait longer and driver farther than they should for a health appointment.
As with many issues, the rural areas of Arkansas are hit the hardest. My research at the Arkansas Center for Research in Economics finds that rural Arkansas has a severe shortage of primary-care providers.
Primary care is the first connection between a patient and the health-care system. It's where health concerns are diagnosed, managed, and prevented. Specialist referrals are included. Primary-care providers deal with enduring issues like diabetes, short-lived issues like sinus infections, and everything in between.
Counties with the least access to primary care--like those along the Mississippi Delta--often face difficult population health issues such as obesity and diabetes. These issues are improved by greater access to primary care.
One of the most promising approaches to increase access to care is to empower nurse practitioners and physician's assistants. These advanced-practice clinicians are trained to provide primary care with both graduate classes and clinical hours.
Nurse practitioners (NPs) are registered nurses who then continue for either a master's in nursing or a doctorate in nursing. The Federal Trade Commission found that most nurse practitioners work in primary care, and they are more likely than physicians to work in rural and undeserved areas. That's exactly what Arkansas needs.
Twenty-one other states allow nurse practitioners full practice to provide primary care; Arkansas legislation restricts nurse practitioners from practicing to the full extent of their training. Our scope-of-practice laws require NPs to be supervised by a physician. This adds unnecessary paperwork and expense.
A systematic study of 25 articles relating to 16 studies found that patients assigned to either nurse practitioners or primary-care physicians have comparable health outcomes. That means that nurse practitioners without physician oversight tend to do as well in treating, diagnosing and prescribing medication to patients as those with physical oversight.
States that empower nurse practitioners get more nurse practitioners. More NPs means improved access to care.
Some worry that advanced-practice clinicians like NPs might have worse results than physicians or be practicing inferior medicine. Yet a randomized trial published in The Journal of the American Medical Association (JAMA) between physicians and nurse practitioners showed that nurse practitioners provide equivalent care. JAMA is the premier peer-reviewed medical journal. A follow-up in Medical Care Research and Review confirmed that there was no difference between the groups in terms of primary-care health outcomes.
Others worry that NPs will overprescribe painkillers. But an IMS Institute for Healthcare Informatics National Prescription Audit (2012) found that states that have supervisory or collaborative practice reported the highest number of pain prescriptions per 100 people--Mississippi, West Virginia, Louisiana, Arkansas, and Michigan. NPs in Arkansas aren't allowed to prescribe opioids. The states with the lowest pain-pill prescriptions per 100 people, however, were states where NPs practice to the extent of their training--Nevada, Idaho, Oregon, Connecticut, Hawaii, and Minnesota.
Nurse practitioners also spend more time with patients. An article in the British Medical Journal found that NPs spend an average of 12 minutes face to face as opposed to an average of 7 minutes by primary-care physicians. Moreover, nurse practitioners are more likely to have increased patient communication and follow-up care. I've experienced this myself.
Others believe that nurse practitioners might over-utilize testing and imaging to compensate for less training. Yet the latest in a long list of research appearing in the prestigious Annals of Internal Medicine shows that neither nurse practitioners nor physician's assistants order more unnecessary imaging procedures than doctors.
Not only can nurse practitioners provide great primary care, they are cheaper too. Good primary care reduces costs. Medicare and many private insurers pay NPs 85 percent of the physician rate. This is one way to reduce costs and improve access.
Primary-care providers should be qualified, accessible, and patient-centered. Nurse practitioners are all these things. We can and should change our rules to allow nurse practitioners to do what they have been trained to do: help their patients.
They are needed, they are qualified, and their outcomes have repeatedly been shown to be as good as those of physicians.
Empowering nurse practitioners is a prescription for success, and I hope Arkansans take the medicine.
David T. Mitchell, Ph.D., is director of the Arkansas Center for Research in Economics and associate professor of economics at the University of Central Arkansas. The views expressed are the author's and do not necessarily reflect those of UCA.
Editorial on 12/31/2018