Nurse Practitioners are Filling the Gap

Early in her career as a hospital administrator and nurse in New York City and Westchester County, Darcel Reyes cared for patients in emergency rooms and intensive-care units who had not seen a physician in years. Reyes, who had grown up in the South Bronx, understood the obstacles impoverished residents faced in navigating the health care system. As a health care professional, she wanted to do more.

Over a period of 10 years, she earned a master’s degree and a PhD. in nursing. Today, she is chief clinical officer of the Rutgers Community Health Center, which provides primary care for residents of four public housing projects in Newark.

Reyes is among the growing population of nurse practitioners who are helping close a crucial gap in the health care system in New Jersey and across the nation as the number of family doctors declines.

In 2017, there were 13,699 primary care physicians—including family practitioners and specialists in internal medicine, pediatrics, obstetrics/gynecology and geriatrics—among the state’s 27,923 licensed doctors, reports the Henry Kaiser Family Foundation. That’s down from 15,932 in 2008.

Consequently, some residents, especially those in rural areas, must travel long distances for primary physicians for routine care and ongoing treatments for diabetes, hypertension and other chronic conditions. Similarly, residents of inner cities depend upon emergency rooms for diagnosis and treatment of minor illnesses and injuries.

The shortage is expected to escalate. In 2014, 32 percent of practicing physicians in New Jersey were over the age of 60—the third highest percentage in the nation—and were expected to retire in the next decade. Only 13 percent of the state’s physicians are under 40, the fifth lowest in the nation, according to the Association of American Medical Colleges (AAMC).

Education costs make it impractical for medical school graduates to become primary care doctors. In 2016, the median education debt was $190,000, up from $90,000 in 2000, the AAMC survey shows. To facilitate repayment, an increasing number are opting for specialties like orthopedic surgery and cardiology, which pay on average more than $400,000 a year, compared to $222,000 for internists and $207,000 for family medicine specialists.

“Fortunately, nurse practitioners—RNs who have a master’s or doctoral degree and advanced clinical training—are filling the gap,” says Joyce Knestric, president of the American Association of Nurse Practitioners, the largest national professional organization of nurse practitioners.

Based on the National Resident Matching Report, 41.2 percent of the nation’s medical graduates are enrolled in primary care residency programs compared to 89 percent of nurse practitioners, she notes. Today, there are 234,000 nurse practitioners across the United States, including 5,600 in New Jersey, who are working in primary care fields such as family medicine, geriatrics, pediatrics and women’s health. Other advanced-practice nurses work in specialties such as anesthesia and midwifery.

In addition to assessing patients, Knestric says, nurse practitioners—unlike RNs—can, with a collaborating physician, order and interpret diagnostic tests and initiate and manage treatment plans, including prescribing medications. In 2016, their median base salary was $100,910.

The demand for nurse practitioners in New Jersey is expected to increase 28.2 percent from 2016 to 2026, predicts Edna Cadmus, executive director of the New Jersey Collaborating Center for Nursing, which was established by the state Legislature to make recommendations on the nursing workforce and its impact on patient care.

“As people age, they develop chronic conditions that require two to three times the number of health-care services that younger people do,” Cadmus says. “About 15 percent of New Jersey residents are over 65. That percentage will increase as the baby boomers retire.”

Although the fate of the Affordable Care Act is unknown, the thousands of New Jersey residents who became insured since 2010 will continue to require primary care services, she says.

“Because their training focuses on treating the whole patient, not just a symptom like shortness of breath, nurse practitioners are ideal primary care providers for the elderly and people in underserved areas,” Cadmus says.

To prepare nurse practitioners for advanced-practice roles, the Rutgers School of Nursing recently transitioned its master’s of science program into a doctorate in nursing practice. Most of the approximately 300 students in the doctoral program are veteran nurses seeking increased professional responsibility. “Health care has become increasingly complex,” says Susan Salmond, executive vice dean and professor at the Rutgers School of Nursing. “It is not enough for nurse practitioners to note that the treatment plan for a patient with diabetes lowered the measure for elevated blood sugar; [he or she] has to be able to pull together all the data, analyze it and demonstrate how this plan will benefit other patients, too.”

For some nurse practitioners like Jon Sugarman, a successful businessman, the profession is a second career. “I wanted to help older patients meet the challenges my aging parents had faced,” says Sugarman, who spent seven years working toward his master’s in nursing and doctorate in nursing practice. He is now a member of the Summit Medical Group Behavioral Health and Cognitive Therapy Center team.

“Emergency room visits are not only common, but disorienting and often frightening for older people,” adds Sugarman, a gerontological nurse practitioner. “Every elderly person needs an advocate in an emergency department who can help patients and their families clarify the goals for care and shape the treatment plans accordingly.”

In 2013, people over 65 had the highest rate of emergency room visits—47.8 percent—in the United States, according to the National Hospital Ambulatory Medical Care Survey.

“Unlike younger people, many older patients are not going to get better, so we must consider what can be done to give them the best quality of life,” says Sugarman. “Palliative care that focuses on comfort may be better than aggressive treatments. End-of-life issues must also be addressed.”

Like Sugarman, Dodi Iannaco, manager of clinical practitioners at Virtua Express Urgent Care, became a nurse practitioner because she wanted to empower patients. One of the largest nonprofit health care systems in southern New Jersey, Virtua includes nine urgent-care centers, which treat about 40,000 patients a year.

“I loved being a staff nurse at a hospital, but I didn’t see myself doing that forever,” says Iannaco. “I wanted to work in a setting that would demand not only advanced skills in diagnosis and treatment, but also the friendliness and compassion that nurses bring to health care.”

On a typical day, Iannaco sees patients ranging in age from six months to over 65 years old who have upper respiratory problems, sore throats or urinary tract infections, as well as those who have cuts, sprains or athletic injuries. She orders rapid strep-throat tests, urinalyses and pregnancy tests and interprets the results of EKGs and X-rays.

“It is important to get these patients on a treatment regimen before their problems escalate and cause serious complications,” she says. “Continuity of care is also important. We line up specialists if necessary and suggest primary care providers who can help the patients tackle conditions like hypertension and elevated blood sugars.”

The same sense of urgency drives Reyes at the Rutgers Community Health Center. “Our goal is to get patients into the system,” says Reyes. “To encourage people who have been reluctant to seek care, we build bonds with the community.” There are no medical doctors on staff, but the center has agreements with outside collaborating physicians who review patients’ charts and advise the staff on treatment.

The center offers chair yoga, as well as classes in management of asthma, diabetes, healthy eating and stress. The staff also conducts sessions to help patients understand Medicare and Medicaid.

To achieve positive outcomes, the staff looks beyond test results to determine what the patient needs in order to adhere to the treatment plan and adopt the lifestyle changes that will promote wellness. In addition to multiple chronic illnesses, some patients have substance-abuse problems, mental health disorders, limited incomes and language difficulties.

Reyes cited the example of a patient with diabetes who was in and out of the emergency room.

“He wanted to stay on his medications, but couldn’t read, so we gave him a box with different-colored slots that enabled him to take the medications at the right times,” she says. “Instead of advising him to avoid eating rice, we located a neighborhood store that sold low-cost fruits and vegetables that he could afford to buy with food stamps.”

Data shows that these interventions pay off. From January to December 2013, the average blood pressure reading of treated patients decreased significantly; the vaccination rate for pediatric patients was 100 percent.

Judith E. Schmidt, CEO of the New Jersey State Nurses Association, hopes that outstanding outcomes will encourage the Legislature to grant nurse practitioners more autonomy.

“Currently, New Jersey practitioners,” says Schmidt, “are required to have a formal, signed collaboration agreement with a physician.” A bill that would allow nurse practitioners “to practice to the full extent of their education and training” was introduced in both houses of the state Legislature in 2016, but has languished in committee, she explains. Currently, nurse practitioners can open autonomous practices, and if the legislation is approved, says Schmidt, there would no longer be a requirement for a collaborating agreement with a physician, and nurse practitioners would also be able to prescribe medication.

Twenty-two states have passed similar legislation, but only a small percentage of nurses have opened autonomous practices across the nation. Still, physicians’ groups vigorously oppose the idea. The American Medical Association has called for retention of laws mandating physician-led care teams and physician oversight of nurse practitioners. The AMA says the longer training of physicians ensures patient safety.

“Granting independent practice to nurse practitioners would be creating two classes of care, one run by a physician-led team and one run by less-qualified health professionals,” the American Academy of Family Physicians said in a 2012 report. “Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor.”

Not so, claims the National Academy of Medicine (formerly the Institute of Medicine), which was founded by Congress under the National Academy of Sciences charter to provide recommendations on public health policy. Citing several studies showing the virtues of nurse-practitioner care, the institute has argued since 2010 that overly restrictive scope-of-practice regulations of nurse practitioners in some states cause serious barriers to accessible care.

The National Governors Association, which has explored ways to fill the gap in primary care, supported the institute’s recommendation that nurses be allowed to lead teams and practices.

“The greatest allies nurse practitioners have in convincing state legislatures to give them more autonomy are the patients they serve,” says Schmidt. “Thanks to nurse practitioners, people in New Jersey who would otherwise go without care are thriving.”

Sharon Johnson is a New York City freelance reporter specializing in health care.