Appendix G.  Field Work Details

This appendix contains a discussion of some of the details of the field work conducted in seven States as part of this study. It includes the following subsections:

• Introduction
• The Field Work
• Detailed Discussion of the Fieldwork
• Summary of the Statutes and Regulations

Separate reports describing the fieldwork in each of the seven States in more detail are available by request.

To understand the growth of NPs, PAs, and CNMs and their impact on the health of the American public, the Health Resources and Services Administration commissioned the Center for Health Workforce Studies at the State University of New York at Albany to perform research and report on the changes in the three professions across the decade. As pert of this study, the Albany Center contracted with the Regional Center for Health Workforce Studies in Illinois, the North Carolina Center for Nursing, the WWAMI Center for Health Workforce Studies, and the Center for Health Economics and Policy at the University of Texas Health Science Center at San Antonio to conduct field work to help understand how the three professions had changed between 1992 and 2000. The fieldwork was conducted in seven States (California, Illinois, New York, North Carolina, Ohio, Oregon and Texas) chosen for their geographic diversity and for the variety of legal and regulatory climates for the three professions. Of significant interest was the impact of the three professions on delivery of care to underserved populations. The fieldwork was also intended to inform and confirm the findings of the work on the  research.

Fieldwork was conducted by the centers in a variety of formats. Focus groups were convened in State capitals, large urban settings, and in rural locations across the fieldwork states to discuss legal and professional practice issues for the three professions. In some cases, individual telephone interviews occurred and in others, written communication was involved.

Those interviewed in the fieldwork included State legislators and government regulators, State and local policymakers, educators of the three professions, representatives of primary care coordinating councils and area health education centers, representatives of the physician, nurse practitioner, certified nurse midwife and physician assistant provider communities, directors of community health clinics, mobile clinics, hospital systems, long term care facilities, and rural health projects. Participants were identified through a variety of means including identification by the Project Advisory Committee, by professional associations, by educational programs, through Internet resources and literature searches, and through other identified peers. Although the general experience of the research centers was that the physician profession was underrepresented in the fieldwork process, that professional group was invited to participate in all States and in all venues. Participants in the focus groups and interview process represented a wide range of constituents and provided broad based perspectives on the professions and their contributions to health care delivery.

The fieldwork was structured by a list of questions generated by the cooperating research centers and by the Project Advisory Committee that was convened to monitor and direct the study process. A list of the questions can be found at the end of this appendix.

In most cases, the fieldwork was conducted at defined locations through invitation by the project research staff. Discussions were structured to last over a morning or afternoon session and generally involved mixed groups of participants. However, the composition of the groups varied. For instance, in New York City, individual professional focus groups were hosted that included only nurse practitioners in one session, physician assistants in another, and certified nurse midwives in a third. In other locations, participants included representatives from a range of professional, regulatory, and organizational groups. One center found that individual physician interviews were the most convenient way to obtain the insights from that constituent group.

Individual State fieldwork reports relied on a variety of published data for background information on the supply of the professions in the States, the educational programs available to the professions, the numbers of recent graduates from those educational programs, and the demographics of the States involved. The findings of the fieldwork are based heavily on the observations of those who provided insights to the discussions about the professional experiences of NPs, PAs, and CNMs in the various States.

Fieldwork was guided by the following broad objectives:

• To assess the kinds of legislative and regulatory change that has occurred in individual States and to understand the effects of legislative change on actual practice environment;

• To evaluate the process of change and to discover how regulatory change occurs within States;

• To examine and assess the data available about the three professions both locally and nationally;

• To understand how the environment in which the professions practice impacts the supply of the professions in a State;

• To understand the relationships of these professionals to their peers and to other professions within the complex health care delivery systems in which services are provided;

• To understand the influence of the three professions on delivery of health care;

• To investigate how practice by the three professions affects care to underserved populations;

• To understand what enables and conversely, what impedes provision of care by the professions within the individual State legal scopes of practice.

A number of topics were covered in the interviews, discussions, and communications conducted as part of the field work. The primary topics were:

The Elements of the Scoring System

• Changes in Professional Practice
• Economic Positioning and Reimbursement
• Prescriptive Authority

Relationships

• Relationships with Physicians
• Relationships Between the Professions

The Professions

• Effects on access to Care
• Education of the Professions
• Supply of the Profession

Important themes and concepts covered in the seven states are summarized below. This summary is not meant to be exhaustive, but rather to introduce what the field work staff and the project staff seem to be the most important themes that inform the goals of the study.

Informants underscored the importance that patient safety issues can have in motivating changes in professional practice for the three professions. Political and economic constituents who have a variety of interests to protect also heavily influence change. Both external and internal stakeholders can effectively move the legislative process with persistence and support.

Achieving a workable balance among all constituents affected by change is often difficult with the process requiring compromise by many stakeholders. The resulting legislation may not be as comprehensive as interested parties might have initially advocated. Therefore, change often occurs incrementally.

What is actually allowed in legislation may differ markedly from what actually happens when the new features are implemented in medical practice. Although legislation may enable practice, the conditions under which these professions actually work may be more confined than what is permitted in law.

When statutes are permissive in nature, actual practice possibilities may not be fully used. Informants in Oregon cited certified nurse midwives who are, by law, permitted to practice autonomously in the State. However, in actual practice, autonomous practice rarely happens. Standards of patient care dictate that CNMs work collaboratively with a physician to provide back-up care in emergency situations so CNMs practice collaboratively. This is a State where actual practice is not generally as expansive as legislation allows. The needs of the patient and the provider moderate practice configurations within the legal parameters.

On the other hand, established legal parameters may create restrictive boundaries. Fieldwork participants indicated that legislated professional practice impacts practice quite directly and definitively. The extent to which professional practice is defined in law is an example.

In some practice acts, professional practice is broadly defined or expansively defined, as in Oregon. In others, it is so highly detailed in law that the performance of daily tasks is restricted. Statutes or rules which list, by task, the services that can be performed by a professional in practice provide no latitude for that practitioner or for his/her supervising or collaborating physician to make determinations about additional competencies that might be used within a practice to enhance provision of care for patients. In the State of Ohio, physician assistants are restricted by a very defined professional practice in statute and regulations. Physicians in the State were previously able to delegate tasks to untrained medical assistants that they were not permitted to delegate to physician assistants because of the restrictive language in law describing PA professional work. The State addressed this rather confusing situation with a recent opinion by the Attorney General that addresses medical delegation to licensed and unlicensed personnel. However, the situation provides an illuminating example of how detailed legislation can complicate actual practice.

In some States, the PA, NP, or CNM and the cooperating, employing, or supervising physician define professional practice. These States require written or verbal agreements that detail the conditions and standards of practice for these professionals. In Ohio, in addition to the statutory and regulatory description of professional practice, physician assistants must work under protocols that are called “standard utilization plans” or under expanded “supplemental utilization plans” that further define and proscribe their practice. In California, NPs, PAs, and CNMs work under directives called “standardized procedures”.

Actual provision of care to patients informs efforts to expand professional practice legislation in many States. Prescriptive authority for nurse practitioners in Ohio provides an example of how practice and legislation interface. NPs had no prescriptive authority in the State until quite recently. This prevented the State of Ohio from accessing Federal money available for targeted initiatives to increase access to care for underserved populations. In order to take advantage of these existing funding streams, the Ohio legislature enacted remedial enabling legislation in 1993 to create a “pilot” program for NPs. Administered by three schools of nursing in the State and supervised through standard care arrangements, this program permitted qualified nurse practitioners to have prescriptive privileges in certain underserved settings in the State. This enabled practice in extended locations with broader populations. When NPs sought expanded prescriptive privilege in all practice venues several years later, the path to legislative approval was informed by the positive experiences from the pilot project. The demonstration project experience enabled change in legislation so that in 2002, NPs who meet certain requirements are granted prescriptive privileges for controlled substances in Schedule III to V within the parameters of a formulary and when supervised by a physician in all settings in the State. The pilot program also eased the expansion of Medicaid reimbursement for NPs in the State so that Medicaid now reimburses non-pilot program NPs for services to Medicaid eligible patients. Now that these privileges have been extended to all qualified NPs in the State, the pilot program will sunset.

Practice acts are in need of refinement on a continuing basis as practice changes. New York informants indicate that enabling legislation for the three professions in the State was enacted about 30 years ago with the main purpose of enhancing primary care services for underserved populations. Informants suggest that now that the professions have moved to provision of specialty care in addition to primary health services, statutes and regulations should be revised to reflect the different conditions of more specialized practice. Since the existing laws and regulations mainly address the provision of primary care, they are not always applicable to practice in specialty areas.

Professional practice legislation in a State can provide a competitive edge for one profession over another. In New York State, PAs must have all prescription orders co-signed by their supervising physician within 24 hours of issuance. This is not true for nurse practitioners working in the same State. Rural providers in New York suggest that it is easier to hire a nurse practitioner for remote practice because the conditions for practice are less demanding of the cooperating physician. In Ohio, the countersignature requirement for medical orders written by a physician assistant may be a deterrent to hiring. A physician considering the benefits of hiring one kind of professional or another might consider a nurse practitioner over a physician assistant since a NP is not subject to that same strict review requirement as a PA in Ohio. In California, other interesting circumstances affect hiring practices. The unionization of nurses (and therefore, nurse practitioners) in hospitals has led some hospitals to show a preference for hiring physician assistants who are not subject to strict union rules.

Changes in professional practice have occurred at varying rates across the States and with varying emphasis. The practice environment for the professions has only recently evolved as substantially in Illinois as it has in other States over the last decade. Illinois is a State where a strong medical lobby represented by the national presence of the American Medical Association and the American Hospital Association has been more reluctant to provide expansion of practice in law for these professions. In 1998, Illinois was the last State to enact advanced practice nursing legislation that directly addressed practice by nurse practitioners and certified nurse midwives. Prior to that time, the professions had been regulated under the nurse practice act as registered nurses. Prescriptive authority for CNMs and NPs in the State is still “delegated” authority. Physician assistants in Illinois received delegated authority to prescribe some controlled substances in the year 2000.

There are also variations in professional practice within States across the professions. Nurse midwives in New York were previously more confined by the language within their professional practice legislation than were nurse practitioners. Sekscenski rated New York as among the most hospitable environments for physician assistants and nurse practitioners in 1992 and these favorable conditions for PAs and NPs continue to prevail today. Nurse practitioners can own independent practices in the State and collaborate with physicians in many healthcare settings. Physician assistants work with physicians under indirect supervision guided by verbal or written agreements. In 1992, however, the practice environment for Certified Nurse Midwives was much more limited. CNMs have made significant progress within the State both legislatively and operationally. Presently, Certified Nurse Midwives in New York experience one of the top ranked practice environments in the 2000 index created as part of this study. In fact, New York State presently has more licensed midwives than any other State in the country except California.

The privileges allowed the three professions within States also vary. In Ohio, Nurse Practitioners have been granted prescriptive authority for controlled substances in Schedule III to V if the NP meets certain educational and training requirements. Physician Assistants who practice more consistently with physicians in a medical paradigm rather than a nursing model have yet to attain these same privileges. Physician assistants have no prescriptive authority and may only convey a doctor’s medication orders in the State. The legislative dynamics in Ohio are particularly interesting since there is a strong medical lobby bolstered by the presence of seven medical education programs and the presence of a world-renowned medical center, the Cleveland Clinic. These political forces have seemingly been historically resistant to the expansion of privileges for the three professions.

Another concern of informants in the seven States was that significant expansion of privileges for many professions over the last decade might actually result in some backlash from regulatory and medical communities. At times, physicians and their professional organizations react as if threatened by the incursions on their professional practice. Some wariness was expressed about continuing to seek further expansion of legal scope for these professions by some of the informants. At times, the physician community seems to be entrenched in resistance to further change because of the pressure on physicians to continually grant more privileges to other professions.

Fieldwork participants suggested that researchers examine the differences in how professional practice legislation affects provision of and access to care in outpatient versus inpatient settings. Variation in requirements by setting results in different styles of practice for the professions depending on the location where services are provided. Informants indicated that they felt that the three professions were often viewed as being most appropriate in primary care outpatient settings where practice is differently configured than in acute care settings. In fact, all three professions practice in all kinds of settings, types of practice, and types of facilities.

Hospital privileges (inpatient environments) provide an example of how complex the interplay between enabling legislation and practice environments can be. Although the law may permit hospitals to provide NPs, PAs, and CNMs with admitting privileges and may prohibit hospitals from discrimination in the awarding of admitting or staff privileges, in actual practice there is tremendous variation in the granting of privileges to the three professions. Even though legal supports are present in law, hospitals may choose, in voluntary environments, not to provide privileges to the professions. In situations where privileges are mandated, they may impose a co-admission regulation that requires a physician to co-admit with the NP, PA, or CNM. Such requirements effectively restrict direct patient admissions by the professions. Some hospitals offer admission privileges but require that every patient have a physician of record on file. Again, this requires direct physician involvement and restricts practice for the professionals.

In Oregon, hospitals may not discriminate against NPs, PAs, and CNMs, but they may impose a co-admission requirement. Informants in the State suggest that obtaining staff privileges in rural hospitals is a major challenge. The standards to qualify for admitting privileges may require an internship. Nurse practitioners and nurse midwives do not meet those requirements since their educational process differs from that of physicians and PAs who are trained in a medical model, and often in inpatient settings.

PAs also seem to have fewer problems gaining hospital privileges because of their traditional rapport with physicians. The relationship between physician and physician assistant is supervisory in nature and PAs are often viewed as members of a two-person team. This perception seems to help them to more easily gain hospital admitting privileges. As one informant suggested, PAs gain “more independence from their dependence on physicians”. Physician acceptance of PAs may actually result in more autonomy in practice since PAs are seen as less threatening. NP professional practice, although legally more autonomous than that for PAs, may cause more resistance or wariness from physicians when certain privileges, such as hospital admissions, are involved.

PAs in New York suggest that external regulatory groups have some influence over how admitting privileges in hospitals are awarded. JCAHO, for instance, influences how hospitals credential staff. PAs and NPs are increasingly working in hospital environments where the numbers of resident physicians have been reduced by funding changes over the last decade. NPs and PAs are also working increasingly in specialty practices that admit to inpatient beds. Informants expressed concern that hospitals might potentially restrict professional practice for NPs and PAs in inpatient settings in order to comply with regulatory guidelines. Regulations from certifying and accrediting bodies could result in the creation of an environment that is too restrictive for effective practice for PAs and NPs. Examples of such restriction include authority to write medical or prescription orders for inpatients.

The importance of these professions to the provision of inpatient care should not be ignored. PAs are substituting in some hospitals for residents who are no longer working on service for as many hours as was historically the custom. Additionally, Departments of Medicine are giving up residency positions in some medical education programs and physician assistants are filling the gaps in care caused by the lower number of resident positions. Restricted practice in hospitals can affect the efficiency of care in inpatient environments. As an example, a PA in Ohio cited the difficulties in ordering medication for inpatients as a burdensome process since, in that State, PAs may only convey physician’s direct orders. The example of a patient needing Tylenol and having to call the doctor in the early hours of the morning for authorization was offered as an instance where practice may be unduly restrictive.

Fieldwork participants in North Carolina suggested that the view of NPs, PAs, and CNMs as “providers of less expensive care” positions the professions poorly and puts them in competition with family practice doctors and other primary care physicians. There was consensus across the fieldwork States that this economic emphasis places the three professions at a disadvantage. The professions prefer, instead, to foster a public image that emphasizes quality care provided efficiently and effectively.

To completely ignore the economic advantage in hiring these professions would, however, be specious in an economy seeking reduction in cost as a primary objective. Cost of care is a universal concern for all stakeholders. The cost effectiveness of the professions is indisputable. Nurse practitioners, physician assistants, and certified nurse midwives are paid lower salaries than physicians. At certain levels of care when reimbursement is equal, the “profits” of a provider organization are increased when services are provided by lower paid and therefore, less costly providers. NPs, PAs, and CNMs suggest that placing only this kind of value on their work ignores the quality of the services they provide. One Texas informant described this as viewing these professions as “cash cows” to be used only to increase the volume of patient visits resulting in increased reimbursement and net profit. A more comprehensive view of the professions as providing “cost effective in a cost conscious health care environment” more accurately reflects the benefits of the care provided.

The refusal of many managed care organizations to empanel these professionals (contract with NPs, PAs, and CNMs as participating providers) was another recurring issue across States in the various fieldwork experiences. The issue of managed care organizations providing ambivalent responses to these professions was discussed. Of particular note at this juncture in our report is the consistency between the philosophies advanced in nursing education and the managed care mantra of prevention and early diagnosis. Nursing professions have long fostered, as a primary goal, education of patients about prevention of illness and careful management of diagnosed illnesses. This nursing paradigm is precisely that espoused by the managed care model, which is constructed on the fundamental premise that prevention, early diagnosis of illness, and appropriate intervention with effective medical management is less expensive for the system. Although the motivations vary, positive patient outcomes achieved through provision of preventive services and effective management of chronic illness are the ultimate goal for both nursing professionals and MCOs (managed care organizations). However, even though the nursing professions and HMOs are in philosophical agreement about desired outcomes, there is a disconnect in the paths defined to achieve those goals. Managed care and preferred provider organizations have been reluctant to embrace NPs, PAs, and CNMs as full participants in the process of achieving these commonly valued outcomes by providing them with participation agreements as contracted approved professionals on provider panels.

The educational aspects of medical encounters are part of the problem. Although patient education is an important part of prevention and management, payers have been reluctant to pay for those services. The economic accent in provision of care is on treating an acute or emergent condition as quickly and effectively as possible. There is little financial incentive in current reimbursement methodologies to address chronic issues or to provide patient management services. This emphasis is contrary to the practice paradigm for advanced nursing professions. Patient education requires extra time during an encounter and reduces the number of patients seen in a day. New York State informants indicate that this is an example of reimbursement driving the delivery of health care when delivery should be driven by best practices and patient need. The importance of finding a way to reimburse for educational services was a recurrent theme in all seven States. The expertise of nurses in providing education services is recognized by physicians as one of the many incentives to hire NPs and CNMs.

The lack of available reimbursement for patient education affects the clinical precepting of professionals in training in addition to the nature and duration of patient encounters. Training a student requires time from the clinical preceptor and many physicians and other professional providers feel they can no longer afford to take time from patient visits to educate clinicians in training. Clinicians who precept students often see reduced patient volumes with a concomitant reduction in reimbursable services. This situation contributes to the lack of available clinical rotations for students of the professions.

Direct reimbursement to NPs and CNMs was another recurrent issue among fieldwork participants. Of the three professions, physician assistants were the least concerned about current reimbursement methodologies. Physician assistants are more aligned with supervising physicians and the profession is generally comfortable with current reimbursement mechanisms.

Informants suggested that the prevailing reluctance by managed care organizations to pay NPs, PAs, and CNMs directly may be an indirect reverberation from the physician community. Many health maintenance organizations are associated with independent practice associations and managing boards dominated by physicians. These physicians recommend and establish the standards for participation by and payment of providers and they have been reluctant to place professions that are perceived as “lesser” on the same provider panels, which positions them with similar privileges as the physician community.

There were some contradictions in the private and public behavior of physicians noted by fieldwork participants. Many physicians in private practice will hire NPs, CNMs, and PAs to augment their professional practice and their profits. An employing physician will lament that these employees are paid at lower rates by public payers, such as Medicare and Medicaid, who require that NPs, PAs and CNMs bill directly for the services they provide to patients. (Medicare only reimburses NPs and PAs at 85 percent of the physician fee schedule and CNMs at 65 percent of that same schedule. Midwives are actively working to increase the Medicare reimbursement rate to make it more proportionately equal. Medicaid reimbursements vary by State from a low of about 70 percent of the physician fee schedule for these professions to as much as 100 percent in some locales.) Physicians express discontent with these proportionate reimbursements.

However, physician attitudes are more ambivalent when payment is solicited from private third party insurers who allow NP, PA and CNM services to be billed using the physician identifier. This practice results in the actual provider of the service becoming effectively invisible to the payer. The need for change in this regard is seen as pressing by NPs and CNMs. Physicians, in this context, seem content with the status quo since they receive full reimbursement through their HMO participation regardless of who provided the service.

Placing PAs, CNMs, and NPs on approved provider panels, raises some significant questions. Should these providers be paid at the same rates as physicians for services rendered at the same level of care? Lower payment rates would directly impact the income of their practices. And would such recognition foster moves to “independent” practice? These issues are surfacing in several States and are occupying a dominant place among practice issues for the professions across States. In New York, reimbursement was a common issue throughout all fieldwork discussions. This is a more complex issue than might appear, because lack of reimbursement is often a major barrier to access to and provision of care.

The inability to identify the actual provider of services on claims has implications for analysis of the practice characteristics and patterns of providing care. Such billing practices affect the ability of researchers to assess the effect of NPs, PAs, and CNMs on access to care for underserved populations. Data on the kinds of services provided and on the patient populations served are largely unavailable because NPs, PAs, and CNMs are not identified in billing documents as providers. Federal legislation under HIPAA will require a provider identifier for each professional involved in diagnosis or treatment. However, until third party payers actually require use of those provider identifiers and/or change participation and payment policies across the States, the lack of visibility for these professions will continue as will the inability to assess to whom care is provided, at what level of service, in what locations.

This situation is further complicated when public and private payers contract in cooperative agreements to provide Medicaid Managed Care Plans, Child Health Insurance Plans, and Medicare risk contracts. In indemnity models, in which government payers traditionally operate, access to NPs, PAs, and CNMs is generally unimpeded. However, when government contracts with MCOs to administer these public programs, access is affected. MCOs limit patient access to a defined list of participating providers. If NPs, PAs, and CNMs are not on the lists, access to them is prohibited.

In Oregon where the Oregon Health Plan engaged a number of insurers in their Medicaid Managed Care Plan, NPs were particularly well positioned by their autonomous professional practice to provide care in that system. They were able to contract with the managed care organizations as participating providers. Several of these insurers are now abandoning their contracts with Oregon Health, and NP practices in the State are jeopardized by the change in payers. If they do not have contracts with the remaining MCOs in the program, patients will be unable to access them.

Throughout the fieldwork States, private payers appear to limit participation by NPs, PAs, and CNMs in their preferred provider plans or HMOs. This is an interesting issue since this study demonstrates direct statistical correlation between the growth of these professions within States and HMO penetration rates. One of the findings of this study is that the growth of the professions is directly correlated with the increasing penetration of HMOs during the decade.

Even when insurance reimbursement is mandated in law through “any willing provider” legislation or through State insurance law providing that qualified providers must be paid for services provided if a physician would have been paid for the same service, the actual implementation of the law may differ from the legislative intent. There are many factors that affect compliance. For instance, ERISA, which is a Federal law, exempts companies who self-insure from having to meet State insurance mandates. Federal law supersedes State legislation and ERISA-protected plans are not required to comply with State insurance mandates.

Implementation of law is circumvented in a variety of other ways. HMOs may avoid the full force of insurance law by not contracting with NPs, PAs, and CNMs as plan providers. Insurance law does not require that HMOs contract with NPs, PAs, and CNMs, only that they pay them equitably when they are participating. This is another example of legislation providing supportive pathways for professions, but actual practice environments have an influence on the implementation of the law. There is significant variation in interpretation and application of law across States in regards to reimbursement.

North Carolina was cited as a good example of a State where private insurance policy and public health policy vary. Whereas there is strong public support and financial incentives in the public sector for these professions to practice in public health settings, private insurance carriers have been less willing to embrace the professions as participating providers. Although there was acknowledgement within the State that managed care penetration had fostered growth of the professions, there is still significant resistance by private payers to full recognition and empanelment.

Prescriptive authority is an important aspect of practice when meeting patient needs. Prescriptive authority includes writing prescriptions as well as the ability to provide samples or dispense medication in certain practice settings. Prescriptive authority has been a major focus for all of the professions over the decade since it enhances the efficiency of patient encounters. The ability to provide sample medications or to dispense medications also contributes to increased access. Dispensing authority for samples or other pharmaceuticals is particularly critical when services are provided to populations who cannot afford to buy needed drugs or when travel to a pharmacy is difficult because a drug store is not conveniently located.

Expanded prescriptive authority was seen as a major issue for NPs in Texas. A restrictive formulary and the inability to prescribe controlled substances were identified as barriers to effective practice. NPs in the State have no prescriptive authority for scheduled drugs and work from a limited formulary when prescribing legend drugs. This is seen as an impediment to effective care.

Physician Assistants in Ohio also view the lack of prescriptive authority as a major impediment in practice particularly in inpatient environments. The requirements for physician participation were seen as unduly restrictive. Physician assistants have only delegated prescriptive authority in the State.

The reluctance of HMOs to empanel NPs, PAs, and CNMs occasionally impedes the use of their prescriptive authority in States where they have been granted those privileges. When an HMO provides coverage for prescriptions, there may be a requirement that the script be written or signed by a participating physician. Scripts authored by professionals, such as NPs, PAs, and CNMs, who are not listed on the panels of MCOs may not be reimbursed to the pharmacy or the patient. These circumstances often force a countersignature by the collaborating physician. This is the kind of detail in practice environments that impedes and complicates provision of care.

In New York State, informants suggested that prescriptive authority is important to many professions and that NPs were fortunate to have the privilege. NP educators cited the example of licensed psychologists studying in NP programs in the State in order to gain prescriptive privileges for their practices. In Ohio, when prescriptive authority was discussed, informants suggested that prescriptive authority was difficult to obtain and that physician advocacy groups are inclined to favor permitting only professions which require graduate education to have prescriptive authority.

There was general agreement in the fieldwork States that professional acceptance for nurse practitioners, certified nurse midwives and physician assistants is important to efficient and effective practice. The ideal relationships in health care environments were seen as symbiotic, interdependent, and team based. However, it is considered important that physicians are not always positioned as leaders of the team. Representatives of the three professions recognize that physicians have advanced training and education that qualifies them for more complex medical decision-making. However, the professions, jointly and individually, seek recognition for the special expertise they have developed through defined education, special training, and (often) extensive experience. Independence versus dependence was seen as an archaic way of framing relationships within the system. Interdependence seemed a preferable descriptive term.

The impact of the professions on the character of health care practices varies. Physicians suggest that they sometimes end up with different, more complicated practices when they collaborate with NPs, PAs, and CNMs who are providing acute and preventive care to patients. Since these services tend to be largely primary and straightforward, physicians in practices that include NPs, PAs, or CNMs often see greater numbers of patients with complex medical conditions and co-morbidities that may be more chronic in nature and more difficult to manage. This has ramifications for the practice and for the professionals who are providing care.

Of concern to informants in several States was the legal relationship between physicians and NPs, PAs, and CNMs. In both Ohio and New York, informants were concerned about the assumption that doctors are liable for the acts of the professionals in their employ. Representatives of the three professions in those States indicate that they are licensed professionals with independent responsibility for their work performed within the scope of their training and education. The assumption of “vicarious liability” by physicians for the practice of NPs, PAs, and CNMs jeopardizes positive relationships between the professions and physicians and alters their participation in patient care.

Professional informants suggest that, although there are similarities in their interactions with physicians, each of the professions has a unique relationship that is affected by their particular training and skills. Whereas NPs and PAs tend to fill complementary roles in physician practices, CNMs, although also complementary to physicians, often have a somewhat more competitive relationship with physicians. In certain locations they compete both directly and indirectly with family care physicians for patients.

Primary care physicians who provide obstetrical services and CNMs compete indirectly for the same target population of childbearing women who are at minimum risk for complications in both rural and urban settings. CNMs also compete with family physicians for back-up obstetrical specialist physicians to provide help with difficult deliveries and at-risk obstetrical patients.

Another source of competition is the requirement by health maintenance organizations that each patient have a primary care gatekeeper who will screen and refer for higher-level services only as needed. This issue was discussed in the Texas and North Carolina fieldwork as an aspect of the present health care delivery system that affects the provider of care. HMO gatekeepers include family practice doctors who may be reluctant to refer obstetrical patients to Ob/Gyn practices for normal obstetrical care or for well woman gynecological care, since they can provide those services. These patients are traditionally the patients seen by CNMs. Since CNMs are most often employed in Ob/Gyn practices, this further limits CNM access to patients. This is not as important in some States, such as New York, where direct access to obstetrician/gynecologists without referral by their primary care physician is legislated by the State. Women can determine independently from whom they will seek maternity or gynecological care.

The same issues arise with Medicaid insured patients in States where Medicaid contracts to HMOs. Access to nurse midwives may be limited under those circumstances. This would not seem to be an issue because Medicaid insured patients often have difficulty finding providers because of the generally lower reimbursement rates. However, in some States, the opposite is true. Interestingly, informants in both Ohio and New York suggest that State Medicaid programs have built waivers for at-risk childbearing women that reimburse providers at very close to the commercial rates, which makes Medicaid-insured pregnant women attractive to private practice doctors. This experience suggests that an increase in Medicaid rates for other services might also enhance access for Medicaid-eligible patients needing other kinds of services.

NPs and PAs are more likely to compete between themselves for available practice positions. Although the three professions have many common attributes that are made more obvious by their positioning in the health care delivery system, they are undoubtedly different professions. Each of the professions is affected variously by the environments in which work is performed, by the education and training of the professional, and by the relationships with other providers. The greatest overlap in function seems to occur between PAs and NPs whose roles in private practice and hospital settings are somewhat similar. However, the models on which they base their practices are quite distinct.

An informant in Oregon described these differences as “diverging practice paradigms – independence from physicians and adherence to the nursing model for NPs versus dependence and adoption of the medical model for PAs.” However, the variations in practice orientation may only be apparent to those with extensive knowledge of the differences between NP and PA training and education. Informants suggest that most patients receiving care from an NP or PA would find it difficult initially to differentiate the kind of services being provided.

CNMs are less competitive with NPs and PAs. Although CNMs are legally enabled by advanced practice nurse (APN) legislation in many States, their practices are usually more limited than that of NPs. Certified nurse midwives generally treat women of childbearing age. This positions them to be less competitive with physician assistants and nurse practitioners for practice positions than NPs and PAs are with each other. Although women’s health nurse practitioners provide similar services, the numbers in this NP specialty are not yet substantial. NPs and PAs often work with a more diverse population than CNMs, i.e., both males and females, pediatric populations, etc. This helps to reduce the competition.

It must be noted that this competition is often subtle. The individual professions understand there is danger inherent in undermining another of the similar professions. There is recognition that competition needs to be kept in check. However, informants commented that competition for clinical training sites currently exists between NPs and PAs. Additionally, concern was expressed in several States that, should an oversupply of these providers be present, there is likelihood of competition developing in the workplace for jobs. Some of that competition may already exist in a variety of markets across the States as noted variously by fieldwork informants.

Participants in the fieldwork discussions in the various States indicate that it is important that these professions be given recognition and appropriate positioning within the delivery system. Providers who encounter resistance to their roles from peers, other providers, payers or the public are more likely to leave the professions because of lack of acceptance. It is important for these professionals to work in cooperative, collaborative environments where their skills and talents are understood and used effectively.

Definitive assessment of the impact of these professions on access to care continues to be elusive. In all States, professionals suggest that access to care is enhanced by the use of these providers in a myriad of settings. Researchers were reminded by representatives of the professions in the various States that the professions share common roots grounded in the provision of primary health care to patients with limited access. The professions were all conceived and legally enabled because of national policy concerns about meeting the health care needs of underserved populations. In fact, informants suggested that for many years NPs, PAs, and CNMs worked in underserved settings in greater numbers proportionately than physicians. For instance, in North Carolina, NPs and PAs originally practiced only in health clinics and public health settings. They have subsequently moved into more mainstream practice environments as the professions have become more recognized.

Initially, Federal reimbursement policy encouraged practice in underserved settings by limiting public reimbursement for services to special public health, institutional and clinic settings. The 1997 Balanced Budget Act (BBA) equalized reimbursement across all settings providing less of an incentive to remain in locations designated as underserved. The BBA extended a 10 percent bonus for physicians practicing in identified underserved locations but did not extend that same benefit to NPs, PAs, and CNMs practicing in the same settings. Informants suggested that this is counterproductive to Federal policy, which is to encourage NPs, PAs, and CNMs to work with populations who have limited access to health services.

The present increase in specialization for PAs and NPs was cited as concerning. As these professions move to specialty and sub-specialty care, the opportunities for practice with needy populations are reduced. Since specialist physicians are not found in great numbers among the medically underserved or in health professional shortage areas, NPs, PAs, and CNM s with whom specialist physicians collaborate are also less likely to be found in those settings.

Determining if care is being provided to the underserved by NPs, PAs, and CNMs is a complex undertaking, which has less than satisfying results. Informants suggest that underserved populations can be found in almost any medical setting and limiting assessment of provision of care to particular locations was of concern. As an example, in New York, PAs discussed institutionally-based care in a non-HPSA certified facility. This is not identified as care to the underserved even though there is a significant provision of care to underserved individuals in such settings. There are many “needy” patients who would be classified as underserved who receive treatment in community hospitals, major medical centers, and even private physician offices. Care to patients who are uninsured or publicly insured is provided by medical professionals who work in settings not traditionally identified as meeting the needs of underserved populations. However, the care provided is often considerable and should be identified as contributing to access. Evaluating to whom, by whom, where, and how this care is provided is difficult and may involve the need to track patients on public assistance rather than provider data to ascertain care patterns. In any case, when considering the issue of how to increase access, these settings should not be ignored.

Once again, informants reiterate that reimbursement affects access to care. Uninsured populations and publicly insured populations do not always have the same access as privately insured patients. One informant described the Balanced Budget Act of 1997 as “a house of cards”. Rural health was greatly affected by its implementation since clinics with greater than 50 beds were no longer supported. Larger clinics closed causing some professionals working in underserved areas to leave for other positions.

In Texas, informants indicate that reimbursement is an especially difficult issue in rural areas. Lack of funding for services to needy populations is a disincentive to practice in locations where those populations are located. Reimbursement policies impact both utilization by patients and recruitment of professionals since payment for services is a fundamental issue for all medical professionals.

Informants suggest that many newer graduates are not interested in working with underserved populations. They are more interested in practicing where the money is. Students were viewed as being savvier and more aggressive than they had been in the past. This change in orientation affects the pool of providers who might have traditionally sought work with the underserved.

According to informants, public initiatives that encourage professionals to work in health professions shortage areas encounter difficulty because decisions about where to practice are often driven by personal preferences. Individuals make decisions about where they will practice based on personal background, personal goals, family obligations, and practice opportunities. Economics is an important factor, for instance, for new graduates who have loans to repay. Educational indebtedness may obligate the new professional to find a position that is lucrative versus one that may be more professionally satisfying but doesn’t pay as well. These are exogenous factors over which policymakers have little control.

However, there was a feeling among fieldwork participants that there are several policy initiatives that encourage professionals with potential interest to practice in underserved environments. Examples of valued inducements would be expanded loan repayment programs, expansion of the number of clinical rotations for student professionals available in underserved settings, and targeted efforts to recruit new professionals into underserved areas. These are considered important strategies for increasing the numbers of NPs, CNMs, and PAs available to provide primary care to underserved populations.

An example of a successful collaborative effort to increase the numbers of PAs, CNMs, and NPs in underserved settings, is an educational initiative called Partnerships in Training, funded by the Robert Wood Johnson Foundation. The program has as its objectives, “the development and implementation of a regional educational system for nurse practitioners, physician assistants, and certified nurse midwives involving a culturally competent interdisciplinary curriculum, distance learning modalities, and shared resources among the education partners.”^[39] The program presently operates in eight States, Arkansas, California, Colorado, Michigan, Minnesota, New Mexico, North Carolina, and Wisconsin.^[40] In California, the partnership consortium is operated in collaboration with several area health education centers as well as several college and university programs. Potential NPs, PAs, and CNMs are recruited from underserved communities and then educated in or near those same communities. The program encourages students to remain in their home communities after training. A recent survey by the California Center for Health Workforce Studies, indicates that 39 percent of NPs, 39 percent of PAs, and 47 percent of CNMs surveyed in the State presently practice in underserved settings.^[41] Informants credit the program with encouraging new providers who have increased access to care.

Informants were concerned about the move by various States and the Federal government to increase educational requirements for the professions and the concomitant impact on the professional workforce. New York informants suggest that a requirement for graduate education for the professions changes the complexion of the professional programs and places these professional credentials out of the reach of some potential candidates. Concern was expressed that the cost of elevated educational requirements would adversely affect the diversity of graduates from programs and further impede the creation of a culturally competent workforce. Liberal loan repayment programs or scholarship support for diverse students would provide at least a partial remedy.

The environment in which the professional is educated and trained affects employment opportunities and prospects. Changes in educational models may also affect choice of work after graduation. Physician assistants in New York indicate that present educational models affect practice patterns. PA education in New York was initially provided mostly in community programs with clinical rotations provided in community settings. This subtly encouraged graduating PAs to work in community settings by acquainting them with those workplaces. Many PA programs in the State have now turned to the medical training model in which clinical training occurs in hospitals and large medical centers. Graduates from these programs are not as likely to have connections to a community health provider and may be less inclined to return to community healthcare settings when seeking employment.

At Duke University in North Carolina, which housed the first physician assistant training program in the country, the PA program uses Title VII funding to support clinical rotations in medically underserved areas. Several informants suggested that providing clinical rotations in a variety of environments was critical to the process of placing the professions in settings where they are exposed to needy populations. Students sometimes discover that they particularly enjoy working in those environments and will choose to work in them after graduation because of their exposure to the opportunity during training.

Legislation affects access to care in very direct ways. For instance, State requirements for the professions to have supervisory relationships with physicians affects practice in rural locations. In Ohio, a physician assistant or an NP with prescriptive authority must work within 60 minutes travel time of his/her supervising physician. This requirement significantly limits practice opportunities for PAs and NPs in the far reaches of Appalachia where supervising physicians are largely unavailable. PAs and NPs might contribute to care for those populations if the distance limitations did not exist.

Special circumstances tend to influence CNMs and the locations where they choose to practice. CNMs are especially constrained in rural areas because of their need for backup physicians in case of obstetrical emergency. In many areas of very rural North Carolina there are no physicians to provide on-call services, so CNMs are prevented from working in such places. Although the relationship with physicians constrains the NPs and PAs, most patients of NPs and PAs are able to travel to a physician to whom they have been referred for more complex care, even if distance is great. However, obstetrical patients are limited by their emergent medical situations from traveling long distances to any provider. Collaborating physicians must be available to come to the obstetrical patient for delivery rather than having the patient come to them. CNMs, therefore, encounter very particular professional difficulties.

In Oregon, informants suggested that CNMs are rarely available in rural practice even though Medicaid guarantees coverage for services provided for the poor in underserved areas in the State. CNMs in Oregon suggested that opportunities to work in rural areas are scarce largely due to opposition from rural physicians who face an oversupply of obstetricians in the State. Some CNMs in Oregon have even chosen not to provide obstetrical services and instead provide only well-woman gynecological services in their practices.

Informants viewed provision of health care in rural environments as a special issue since the physical aspects of the rural environment affect practice. The example of prescriptive authority was provided to illustrate how location can influence practice. Expanded prescriptive authority for nurse practitioners is of no use in a location where there is no pharmacy available to fill the prescription, unless the NP also has the ability to dispense samples or to dispense medications. These conditions require rural providers to be creative and collaborative. A rural provider must establish extensive networks and negotiate a variety of cooperative agreements with other providers including pharmacies in order to operate effectively and provide all needed services. Dispensing authority for nurse practitioners in such locations is one such solution. Clinics could then stock many needed medications to meet the needs of the service population.

The unique circumstances of rural communities require and inspire unique responses to limiting situations. In upstate New York, for instance, emergency rooms in very small, qualifying hospitals (under 15,000 visits per year) are staffed solely by physician assistants. This is effective in providing rural populations with access to care in emergency situations.

Another example of creative collaboration in rural New York State is a health care cooperative which involves the participation of a variety of stakeholders. A family care physician conceived and implemented a creative model for delivery of care to small rural communities in the Adirondack Mountains. Town governments in a variety of locations participate in cooperative arrangements with a medical network, the Hudson Headwaters Health Network, by providing buildings and other support services for the medical practices. The managing healthcare organization staffs the facilities with providers on an ongoing basis. The resulting health consortium provides a range of physician, PA, NP, and CNM professional services in each practice location. This strategy has resulted in an effective delivery system that manages a broad network of providers working cooperatively in an extensive geographic area. Several locations are staffed strictly by one or another of the three professions with physicians traveling to a clinic only on particular day(s) of the week to see complicated cases and to review caseloads with the staff providers. A network of specialist physicians and local hospitals has been developed to provide referral mechanisms for more complicated care for patients living in these remote areas. The consortium covers a significant geographic area and serves a large number of patients.

The characteristics of rural practice dictate different responses to provider resources. In Oregon, informants suggested that rural practices have more difficulty predicting the need for providers and for assuring that they can afford them since patient caseload and insurance is unpredictable and the pool of potential patients is smaller.

In Ohio, physicians in a rural area suggested that employing other providers creates special challenges. Ohio has particularly strict rules about the supervision of PAs. A physician must review the PA’s medical orders for patients on an ongoing basis. One rural physician informant suggested that, although hiring a PA had been wonderful for his patients because it had increased opportunities for them to see a medical provider on a more frequent basis, his caseload had effectively doubled because of record review requirements. He is not only required to document the records of his patients on a daily basis, but he is also required to review his PA’s notations in patient records. Additionally, the severity of his patient caseload has increased since his PA sees many of the patients with routine illness or needing preventive services. The physician’s schedule now includes a high number of patients with more complicated or chronic problems. Although it is helpful that he is more available to these patients, the time required from him for their medical management has also increased. As a result, the physician was finding his practice more burdensome even though he had more help. When considering whether to hire another provider for his practice in the future, the informant felt he would give serious consideration to hiring a physician who would be more independent in practice and not require ongoing supervision.

Rural populations are also seen as having different characteristics. In Texas, informants indicate there are a number of illegal aliens in the State who are afraid to seek care for fear of deportation. Farm and migrant workers are also unable to take time off from work to see a health care provider. In fact, many border workers travel to Mexico for care since medical services are available in that country at more convenient hours for the working poor. Getting to medical appointments is also an issue for people without private transportation. In Texas, mobile health care clinics or clinicians who can travel to the colonias in the evening to provide care and medications enable access.

Cultural competency among providers is also an issue. There are not enough providers and there are even fewer who are culturally diverse or culturally competent. Texas informants cited the shortage of physician providers in underserved areas as a reason for the absence of nurse practitioners, nurse midwives, and physician assistants who must be supervised in practice. If doctors are not available for supervised practice then NPs, PAs, and CNMs are not able to practice.

Some States have implemented special statutory and regulatory provisions that create exceptions for professionals who wish to practice in underserved areas. For purposes of this study, we have identified these states as “dual scope of practice environments”. The legal requirements for supervision or collaboration by a physician, the parameters for prescriptive authority and reimbursement are expanded in defined locations to encourage practice with medically underserved populations or in health professional shortage areas. Texas and Oregon are examples of States where these kinds of provisions exist.

In Oregon, physician assistants are permitted to apply for remote supervision by a physician, which is intended to extend provision of care to medically disadvantaged areas. PAs must apply for this privilege and must have the ability to directly communicate with a supervising physician in case of need. Additionally, the ratio of physician-to-physician assistants is expanded in the State to allow every physician in an underserved area or facility to supervise up to 4 PAs, rather than the 2 PAs allowed in traditional practice settings.

In Texas, physician assistants can practice with underserved populations under special circumstances that permit the PA and supervising physician more latitude. The physician must visit the clinic site every 10 days, perform a review of at least 10 percent of the medical records on a timely basis, and be available by telecommunication on a continuing basis.

Government programs dedicated to increasing access are important. In rural upstate New York, a prenatal program, which initially provided care only in the early stages of pregnancy has been quite successful and has now expanded to include a full range of obstetrical services. CNMs and NPs provide much of the care to pregnant and parenting women in the program, which reaches some of the more remote mountain communities of the State.

Increasing provider incentives to work in rural areas is also important. Oregon provides a $5,000 yearly income tax credit to rural providers including NPs, PAs, and CNMs. Financial incentives might create an inducement to more remote practice.

The following table reflects the number of educational programs in each of the fieldwork States for each of the three professions and includes the total number of graduates from those programs in each of the professions in the year 2000.

An analysis of the educational programs in these seven States indicates that 95.6 percent of the Nurse Practitioner programs award a masters degree, 2.2 percent award a certificate, and 64.8 percent offer a post-master’s certificate. Over 82 percent of the programs offer study to become a family nurse practitioner, with a total of 28 areas of specialization and sub-specialization being offered within the 91 programs examined. These include such areas of study as neonatal, cardiovascular, neurocognitive, palliative care, and child and adolescent health nurse practitioner.

The majority of PA programs in the fieldwork States award bachelor’s degrees (54.1 percent) while 35.1 percent award master’s, 8.1 percent award associate degrees, and 10.8 percent offer a certificate. Most PA programs focus on primary care study, but 5.4 percent of the programs offer specialty study in surgery with a total of 8 possible areas of specialization including orthopedic, cardiothoracic, and neurosurgery physician assistant programs.

The number of education programs for the three professions has grown over the decade. Many States have not, until recently, had education programs for these professions. When programs did exist, they were often insufficient in number or size to supply the needs of the State. PAs have only been educated and trained in Oregon since 1995. Presently, there are two programs providing PA education in that State, and only two programs training NPs. CNMs are trained in a single program. According to the State Area Health Education Center, 52 percent of the NPs in the State were trained elsewhere, largely in California, Washington, or on the east coast. [Oregon fieldwork reference AHECS, 2000].

In North Carolina where the physician assistant profession began, NPs were legally recognized as early as 1970. However, education programs for nurse practitioners lagged in that State. Six programs for NPs have opened there in the past 10 years. North Carolina has implemented some public policy that fosters the use of these professionals in underserved areas, including funding incentives with public dollars for health centers that employ them.

Table G-1

Numbers of Educational Programs and Graduates in 2000 for Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives in the Seven Fieldwork States

+ National Organization of Nurse Practitioner Faculties and the American Association of Colleges of Nursing, 1999-2000 Enrollment and Graduations.
^ American Academy of Physician Assistants
* The American College of Nurse Midwives

Federal programs, which provide funding to train more of these professionals, have contributed to the proliferation of educational programs. One of the conditions for access to and continuation of Federal funding for training programs is documentation of growth in the numbers of students. Several informants across States indicate that an infusion of funds for educational programs occurred at the same time that registered nurses were looking for expanded practice opportunities. These circumstances worked synergistically to create a growing supply of advance practice nurses over the last decade.

Presently, there is concern about further expansion in the number of educational programs for the professions. Containment is seen as desirable for several reasons. Controlling the number of available slots for new students permits education institutions to be more selective in admitting students. This in turn supports the development and implementation of important educational standards which helps to maintain the high quality of practitioners in the professions. These are important considerations in any strategy to avoid an oversupply of competently trained professionals. This strategy may also restrict access to the professions, which could result in higher salaries and therefore higher costs of care.

New York informants discussed the importance of primary health care education to the professions since much of the care provided, regardless of setting or specialty is primary in nature. Discussion among informants revealed that even when NPs and PAs are working in specialty environments, they are still providing a high volume of primary care services to patients. These professionals need to be broadly trained to acquire the sets of skills needed to provide both primary care and specialty care services.

Access to educational programs is a critical issue for potential students according to those who participated in discussions in New York State. Most CNM programs in New York are located in or near New York City making them inaccessible to working nurses in other areas of the State. The need for programs that are geographically dispersed was discussed. A nurse midwifery program located near New York City at the State University of New York, Stony Brook has a distance-learning component, which allows students to visit the school for orientation and then to do their academic work on line while doing their clinical placements in their respective communities under the supervision of regional clinical faculty. Even though the program is located on Long Island, 85 percent of the students are in upstate New York.

Programs for distance learning may be particularly important for increasing the opportunities available to a profession and for encouraging graduates to remain in underserved communities. The Frontier School of Midwifery in Hyden, Kentucky was cited across the fieldwork States as an exemplary model for professional education. The focus of the program is the education of professionals for practice in locations where there is medical need. This is one of the two oldest midwifery schools in the country having been founded in 1925 by Mary Breckenridge, the granddaughter of a U.S. vice-president. Nurse midwives trained in England initially staffed the Frontier Nursing Service that eventually evolved into an educational program.

The educational program component of the Frontier Service, the Community Based Nurse-Midwifery Education Program, is a graduate-level distance-learning program, now associated with Case Western Reserve University in Ohio, which allows students to remain in their own communities for clinical training while completing on-line course work. Several trips to Kentucky for training with clinical faculty are required during the 2 year program. Regional faculty representatives monitor student placements and oversee the clinical practicums in the home communities.

Interdisciplinary training in medical institutions was seen by informants in New York as a desirable way to introduce the professions to each other and to physicians-in-training and to increase understanding of the competencies of the respective professions. Interdisciplinary training is also an important way of educating professionals about effective collaborative relationships and recognizing and respecting the unique skills that each of the professions brings to the delivery of health care. New York and California informants discussed productive interfaces that occurred within interdisciplinary training programs in their States. Nurse midwives who taught resident physicians felt that the experience helped new doctors to understand and respect the profession. A physician assistant working in emergency rooms who trained residents indicated that there were many positive outcomes from her experience including recognition of the substantive skills of the PA by the physicians.

The importance of training in clinical rotations with other professionals was a recurring theme. In Ohio and in Illinois, informants suggested that they encountered more resistance in their professional practices as NPs, CNMs, and PAs from international medical graduates. Many of these physicians come from countries where NPs and PAs do not exist. Foreign grads are unfamiliar with these providers because they have not encountered them in their training and they often lack a clear understanding of the skills and competencies of NPs, PAs, and CNMs.

Finding clinical placements for students is seen as a particularly difficult issue. As previously stated, there is presently no funding mechanism to cover the cost of internships for the three professions. This is especially true for certified nurse midwives. There are not as many institutional supports for midwifery programs as there are for nurse practitioner and physician assistants. These circumstances make it especially difficult to find clinical placements for midwives-in-training. Physician assistant training programs are often located in or affiliated with medical centers where clinical opportunities are readily available. One nurse midwife educator in New York suggested that she had never denied acceptance to her program to a qualified student for lack of space within the program but she had refused acceptance to students because of lack of availability of clinical placements in which to train.

Informants in New York feel that clinical placements in public health clinics are an excellent way of identifying or screening competent and compatible PAs and NPs as prospective hires. However, lack of a source for reimbursement for time spent educating new professionals is a significant impediment for clinics interested in offering clinical rotations. There was strong agreement among informants that time spent precepting should be reimbursable since it requires a substantial investment of resources for the person supervising the clinical rotation. Previously, rate differentials helped professionals absorb some of the costs of clinical precepting. Whereas it was possible, in the past, to cross-subsidize some of these activities under previous health care reimbursement streams, new payment methodologies presently make this impossible. Equalization of payment rates across payers has occurred so that there are no longer higher rates available to help offset unreimbursed education costs in medical settings.

Although Federal policy is important to address the needs of the medically underserved, State policy also has very direct effects on access to care. State responses to the needs of underserved populations vary. North Carolina is a State that identified and responded to some of its public health issues. The Governor of the State convened a conference to address the high maternal-infant mortality and morbidity rates early in the decade. One of the strategies identified to address the problem was to fund nurse midwives to work in critically underserved areas of the State. This initiative resulted in a 1990 mandate for the establishment of a nurse midwifery education program at East Carolina University (ECU) to train professional nurses for this role. The Office of Rural Health manages the program that resulted in improvements to obstetrical care for the targeted populations. Prior to that time, there was no midwifery education program in the State. Nurse midwives are now trained in both the ECU program and through the Frontier School of Nurse Midwifery in Kentucky.

The aging of faculty is a particular problem for educational programs, as is the ongoing need for new PhD faculty to staff graduate programs. This is particularly relevant because so many of the programs were created or grew quickly in response to the availability of increased funding. Faculty may not have been as well prepared as desirable in the years when significant program growth occurred because faculty were needed immediately to staff developing programs.

Another factor that affects the qualifications and the number of faculty is the competing employment environment. It is very difficult to attract NPs from practice in direct care settings to staff educational programs when salaries are not competitive in academic institutions. Another problem for NP faculty is that they are often required to meet the same educational standards as academic faculty in other departments of the college or university where the nursing programs are located. In fact, a nursing professor may need very different competencies than a professor in a purely academic program. A nurse faculty member with significant clinical experience and technical training enhances a nursing education program in much the same way that a professor with an advanced degree might enhance an academic program. Informants supported the concept that clinical experience should be given greater weight in faculty appointment processes.

Elevating the level of required educational attainment for the three professions, although seen as easing the path to such expanded privileges as prescriptive authority, is also seen as an impediment to the education of a culturally competent workforce. A requirement for a graduate degree might limit potential professionals coming from poorer backgrounds who are without the funds for extensive education. However, education at the graduate level is seen as critical for increasing professional practice. In a discussion in Ohio, nurse practitioners suggested that the reason that prescriptive authority was legislated for NPs in the State (and not for other professions) was that master’s education is required for certification for NP practice and legislators and advocates are more comfortable with expanding privilege when professional education is extensive.

Texas informants suggested that the requirement for a master’s education for NPs was an impediment in border towns because it reduces opportunities to recruit a minority workforce. On the other hand, advanced degrees are perceived to provide more credibility and respect for the profession. A solution might be educational loan programs to help bridge the resource gap for some minority populations. Existing loan programs are perceived to be extremely limited in amount of funding and in repayment options.

Educational loan repayment incentives are important for the professions and help to increase access to care. Students with scholarships who are required to work in underserved areas as a condition of repayment sometimes remain in those locations after their commitment is fulfilled. PA informants in New York indicate that clinicians may find greater opportunity to work with a wider variety of patients and more latitude in public health settings and health clinics that serve indigent and underserved populations. This makes employment in those settings more appealing to professionals who are challenged by such environments. PA practice in mainstream or traditional settings may be limited to performing more routine tasks like histories and physicals while in clinic locations, practice is often more varied and challenging. It is important that states not be overly restrictive about the settings in which graduating students work to repay loans. If clinical opportunities are too limited in designated settings, students won’t access the scholarships, further limiting exposure to underserved populations.

Some education programs, like Cornell University’s PA program in New York City, recruit PA students directly from underserved areas. The Cornell program fosters the education of physician assistants who are interested in returning to their home areas to work. The Partnerships in Training Program of the Robert Wood Johnson Foundation also encourages the education of individuals from underserved areas. The program operates in several states including California and North Carolina and targets student recruits from medically underserved areas and diverse populations. Students are encouraged to remain in or return to their home communities to work after graduation.

Another strategy is to place students in settings with underserved populations by offering clinical rotations in community hospitals and health clinics. These opportunities are important because they provide exposure to the special characteristics of those settings. These practice environments are appealing to some graduating professionals because of the expanded practice opportunities available. Informants suggest however, that initially new graduates may want to practice in larger environments to gain some professional experience and to reinforce the skills introduced but not mastered in their educational programs. This does not preclude a professional from eventually choosing to work in an underserved area or with medically underserved populations. However, informants acknowledge that there is some danger that, once established in a practice setting, a professional might be more reluctant to move.

Fieldwork in this project was fueled by the idea that hospitable legal environments foster growth in the supply of these health professions within a State. A greater supply of providers would then, hypothetically, result in an increase in access to care for underserved populations. The issue of the supply of these health professions generated interesting responses from fieldwork participants.

The following counts (the most recent available when the compilation was done) suggest that the numbers of these professionals working in the fieldwork States vary considerably. The mix of the professions is also quite various across the seven States. Counts of Nurse Midwives and Nurse Practitioners in Illinois were unavailable for 1999 since they have only recently been licensed separately in that State. In prior years, they were regulated as registered nurses.

Informants in the fieldwork States indicate that there is presently a relatively sufficient supply of PA, NP, and CNM professionals. Informants suggest that lack of supply is most probably not the issue of concern when discussing access. Rather, it is important to consider how these professionals distribute themselves in health care settings across the States. Statistics gathered for this study suggest that, unlike physicians who demonstrate greater density in urban areas, the three professions appear to be more evenly distributed across States. However, informants also suggest that the practice patterns of NPs, PAs, and CNMs tend to parallel those of physicians. Legal requirements for physician supervision and collaboration tend to support the hypothesis that these professions will be found in the same places as we find physicians. Since legal supervision or collaboration requires the cooperation of physicians, it is to be expected that practice patterns are analogous.

Table G-2

Numbers of Nurse Practitioners, Physician Assistants And Certified Nurse Midwives in the Seven Fieldwork States

* Data obtained by the University of Wisconsin from the National Council of State Boards of Nursing, from individual State Boards of Nursing, or the Regulating Agency within a State.
^ American Academy of Physician Assistants, Census Report 2001.

Complicating the interlinking of the professions in practice settings is the move to specialty certifications within the professions. The development of the three professions mirrors the evolution of the physician workforce. NPs, PAs, and CNMs, although rooted in primary care, are now expanding into specialty practices as the supply of providers has increased and as the demand for their services has become more pervasive across the spectrum of care. Specialty physicians are more likely to be attached to major medical centers located in urban environments where there is a greater population resource. NPs, PAs, and CNMs who collaborate with those specialists are, thus, also in those environments.

The distribution of professionals is difficult to influence or predict. There is a strong element of personal choice that contributes to the selection of work settings. There are several elements that affect personal choice:

• A professional who enjoys an urban environment will probably choose to live and to work in an urban environment, just as one who wishes to be in a rural setting will seek employment there.
• The availability of jobs also affects the distribution of these professions. The location of healthcare delivery facilities and organizations determines job opportunity and there is often a concentration of health systems in urban areas. Obviously, professionals work where the jobs are most available.
• Professionals may distribute differently depending on the legal limitations on practice in a State. Most States require supervision or collaboration with a physician which plainly dictates physical proximity. A few States even place legislated limits on distance or travel time that separates the physician from the professionals with whom collaboration occurs.
• The choice of location in which to practice may be attributed to patient demand. There are greater supplies of potential patients and more opportunities for successful practice in larger metropolitan areas.
• The shortage of nurses has also had an effect on the supply of potential nurse practitioners and nurse midwives. Many RNs presently work overtime to meet the staffing needs of their employers. This prevents them from making the commitment to further their education because they simply do not have the extra time to devote to study. As well, the higher salaries and the overtime pay currently available to an RN diminish the financial incentives of advanced practice.

Whatever the reasons a concentration of professionals may occur in a certain environment, quality healthcare is still unavailable to some populations in rural and urban areas.

The issue of supply of the three professions is also complicated. Some informants in Illinois suggest that there is job market saturation in that State for these professions, but other informants suggest that the situation is not that simplistic. There are significant regional variations in job markets that are difficult to understand and the reasons are many and multi-faceted.

PAs in New York indicate that the profession has addressed the threat of oversupply by moving into new areas of specialization, thereby, creating new demand. PAs in the State have found jobs in pain management, in oncology, and in other specialties where PAs would not traditionally be found, thus moving the profession into new areas of expertise. Contributing to specialization is the fact that there are a number of PAs who have come from other health professions with backgrounds that provide them with special talents. For instance, medical examiners hire physician assistants with medical technology backgrounds since they have a good understanding of laboratory forensics, pathology, etc. PA providers in New York saw the profession in that State as growing with these increased opportunities.

Offsetting this growth is the closure of some education programs New York. PAs expect to see stabilization in the number of graduates over the coming years. There is a feeling that new graduates are more aggressive in finding new opportunities for practice as they begin their careers than had been the case with past PA graduates.

NP informants in New York suggest that there may be job market saturation for NPs in the State. Educators observe that graduates are leaving New York in order to find employment. Some NP informants there expressed concerns that the profession is out-pricing itself and that increased wage compression will create demand for physicians. If an experienced NP is priced at just below the wage level for an inexperienced physician, the employer may consider hiring a physician who is more legally autonomous and can provide care at a higher level. The balance between affordability and extent of professional practice must be maintained.

Also in New York, informants expressed concern about the lower numbers of young people who are entering nursing. Since NPs are often experienced nurses looking for expanded practice opportunities, the reduced numbers of incoming nurses is likely to affect future supply. More supports for nursing staff which encourages new recruits including such things as more autonomy for nurses at patient bedsides, more release time for advanced or continuing nursing education, and fewer mandates requiring compliance by nursing staff would be helpful.

The discussion that follows summarizes the statutes and regulations related to professional practice for the three professions as presented by the various informants contacted during the field work.

Nurse Practitioners

California

• Licensed in California Business and Professional Code
• Regulated by the Board of Registered Nurses in the State Department of Consumer Affairs
• Title Protected 1985
• Professional practice same as that for RNs but expanded by standardized procedures in law contained in written supervisory agreement that is site specific.
• National certification required
• Supervisory relationship with physicians but collaborative practice as well
• Effective in 1997 can “furnish or order” Schedule III (under patient specific protocols) to V controlled substances except for NPs in solo practice
• Maximum of four NPs to one supervising physician
• Medicaid in the State reimburses Family and Pediatric Nurse Practitioners as primary care providers.
• Effective in 2001, the NPs name will appear on drug containers along with the supervising physician’s name.

• Until1998, NPs were regulated as a special class of registered nurses. In that year, the legislature passed the Advanced Practice Nursing Act.
• Licensure available to NPs beginning in 2001.
• Practice is limited to direction from physician but no employment relationship is required
• Periodic review of records is required
• Title protected
• The last State to enact specific legislation regarding Nurse Practitioners
• National certification and master’s degree required for licensure.
• Now regulated by Advanced Practice Nursing Board
• Collaborative agreement with physician determines prescriptive authority but it is delegated authority only. NPs may prescribe, dispense and administer Schedule III to V controlled substances.

• NPs are certified to practice in the State since 1989 and are regulated by the Department of Education and the Board of Nursing (this is unique among State’s regulatory authority)
• National certification is an option but not required
• Nurse Practitioners are defined as independent practitioners
• Collaborative relationship with physicians based on written agreement between the physician and NP
• Collaborative agreement addresses practice coverage, record review and practice protocols and must be kept at the practice site for inspection by the State as requested
• Review of patient records must occur not less than every 3 months
• Nurse Practitioners are qualified as primary care gatekeepers under the State’s Medicaid Managed Care Law
• NPs must obtain a certificate to prescribe in the State after demonstration that they have completed an educational program with a pharmacy component.
• NPs have authority to prescribe Schedule II to V controlled substances in the State

• A joint subcommittee of the Board of Nursing and the Board of Medicine regulates NPs.
• Since 1993, third party reimbursement has been available to NPs
• Rules changed in 1994 to allow NPs to prescribe controlled substances and to expand prescriptive privileges for refills of legend drugs. At that time, the previous formulary was discarded in favor of practice specific drug and device agreements between physician and NP. Controlled substances may be prescribed for a period of only 30 days. NPs can procure, prescribe, order, compound and dispense drugs in the State.
• Since 1999, an NP can sign any form that would require the signature of a physician.
• The statutes contain some collaborative language but a supervising physician is still a legal requirement.
• Review of records is achieved periodically through a Quality Improvement Process between the NP and supervising doctor.

• NPs are regulated by the Board of Nursing
• Licensed since 1997 as a distinct category of Advanced Practice Nurse. Prior to that time they were allowed to use titles obtained from educational program completion but were regulated as registered nurses.
• Certificate of authority to practice as NP issued when all conditions for certification are met.
• Standard care arrangements with physicians are a requirement to practice along with a regular review of patient care outcomes.
• Effective 2001, all new NPs must have a master’s degree.
• Prescriptive authority for controlled substances in Schedule III to V since 2000 but limited to a formulary of drugs and devices. Schedule II may be prescribed under very limited conditions such as to terminally ill patients. Prescriptive authority governed by a Joint Commission of the Boards of Nursing, Medicine, and Pharmacy.
• Since 1997, Medicaid reimbursement is available to Family, Pediatric, Adult and Women’s Health NPs.           

• NPs are title protected
• NPs are issued a certificate of special competency to practice
• A master’s degree is required
• Considered independent providers.
• Prescriptive Authority for Schedule II to V from an exclusionary formulary. NPs may write prescriptions but may dispense medications only in geographically remote areas.
• Mandated third party reimbursement.
• Medicaid reimbursement at 100 percent of physician fee schedule (unusual)
• Fair practice legislation in the State permits hospitals to grant admitting privileges to NPs but hospitals may and often do enforce a co-admission requirement (MD must also admit.)
• NPs can sign death certificates in the State.

• NPs are approved to practice in the State.
• Statutory language is both supervisory and collaborative depending on the setting in which services are to be provided and on whether prescriptive authority is being exercised.
• The Board of Nursing in the State regulates NPs but the Board of Medical Examiners influences their prescriptive authority.
• Effective in 2003, a master’s degree will be required for NPs (this is consistent with Federal legislation implementing the same requirement.)
• A written practice agreement between physician and NP must be maintained on site.
• A physician cannot collaborate with more than three NPs in the State.
• Hospital privileges are defined in law as clinical privileging conditions.
• Prescriptive authority is limited to legend drugs in the State. The supervisory agreement with the physician defines the privilege that is site specific and includes medically underserved areas, health professional shortage areas, facility based sites and private medical practices.

Certified Nurse Midwives

California

• Regulated by the Board of Registered Nursing with a Midwifery Committee in the State Department of Consumer Affairs.
• Title protected.
• Receive a certificate to practice when qualified by education, national certification and licensure as a nurse in the State.
• The Medical Board of California under different rules and regulations regulates non-nurse midwives in the State.
• Professional practice for CNMs in the State includes obstetrical, postpartum, and family planning services.
• Mode of practice is indirect supervision by a physician under standardized procedures and protocols developed between CNM and collaborating physicians and facilities.
• CNMs who meet specific additional criteria may prescribe Schedule III (only under patient specific protocols) to V controlled substances and legend drugs.
• No more than four nurse midwives may collaborate with one physician at any time.
• Mandated reimbursement by third party payers in the State.

• CNMs are regulated as advanced practice nurses in the State.
• Master’s degree is required effective in 2001.
• Delegated prescriptive authority for Schedule III to V controlled substances. CNMS may receive and dispense samples through the authority given them in their collaborative agreement.

• CNMs are regulated under different statutory and regulatory guidelines than NPs in the State of New York.
• They are licensed by a Board of Midwifery in the Department of Education with a broadly defined professional practice that includes not only obstetrical and postpartum care but also well-woman gynecological care.
• Statutory language is collaborative and consultative. It is possible for CNMs to practice independently in the State.
• CNMs can refer directly for other health care services as needed by their patients.
• Direct entry midwives are licensed under the same practice act in the State but are subject to different regulations.
• Public Health Law in the States require that women have direct access to care from ob/gyn physicians and nurse midwives.
• Medicaid provides 100 percent reimbursement of physician fee schedule to CNMs in the State.
• CNMs have prescriptive authority to prescribe Schedule II to V and legend drugs in the State.

• A Midwifery Joint Committee that includes members of the Board of Nursing, the Board of Medicine and CNMs regulates CNMs under the Nurse Midwifery Act of 1983.
• CNMs in the State operate under a professional practice as defined by the professional association.
• The statutes contain collaborative language but CNMs must have supervising physicians in the State.
• Legislation in 1993 required that third party payers reimburse CNMs for services.
• 1994 Legislation gave CNMs prescriptive authority for legend drugs and controlled substances in Schedules II to V. This privilege is defined in the supervisory agreement between the CNM and the physician.
• Medicaid reimbursement for services is at 100 percent of the physician fee schedule.

• Since 1997, CNMs are authorized to practice in the State as a category of advanced practice nurse.
• CNMs are regulated by the Board of Nursing with no specific midwifery representation.
• National certification is required for authorization to practice.
• A master’s degree is required effective in 2001.
• Collaborative language is included in the statutes.
• CNMs practice under standard care arrangements in the State, which are written protocols developed by the CNM and the collaborating physician.
• Professional practice includes well women gynecological care as well as obstetrical and postpartum care.
• Regular review by the physician of care outcomes is required.
• There is a legal prohibition for hospitals to discriminate against midwives if maternity services are provided at the facility.
• Legislation in 2000 gave CNMs prescriptive authority for legend drugs and Schedule II to V controlled substances.
• There is mandated third party reimbursement in the State for nurse midwifery services if an employer provided health benefits to workers.
• It is presently illegal in the State to provide services for compensation as a DEM.

• CNMs are a category of nurse practitioner.
• National certification is not required but licensure as a nurse is.
• CNMs provide independent care in consultation or collaboration with other providers.
• Prescriptive authority, hospital admitting privileges and insurance reimbursement are all governed by NP statutory and regulatory limitations. CNMs may prescribe legend drugs and controlled substances in Schedule III to V and may dispense those drugs in geographically remote locations.
• A master’s degree is required in the State.
• Regulated by the Board of Nursing with no specific midwifery representation.
• The title of Nurse Practitioner is protected in the State, title used is dictated by education.
• CNMS are issued a certificate of special competency when requirements for licensure are met.
• A 1993 statute governs direct entry midwifery.

• CNMs are approved for practice according to the statutory language and authorized to practice in regulation.
• They are required to use the title specified on their authorization and may not call themselves Advanced Practice Nurses.
• The Board of Nursing regulates them with involvement by the Board of Medicine when prescriptive authority is involved.
• Regulations speak of independence or collaboration for nursing aspects of care but require that protocols or written physician authorization provide authority for medical aspects of care. These protocols need not be detailed.
• Midwifery Act of 1993 provides for the regulation of non-nurse midwives by the Texas Board of Midwifery
• A 1999 State law provides due process privileges when hospitals extend privileges to Advanced Practice Nurses.
• Prescriptive authority is limited to legend drugs in eligible sites such as HPSAs, MUAs, primary care locations and health facilities except that Nurse Midwives can provide one or more doses of controlled substances during intrapartum care if so directed by a physician.

Physician Assistants

California

• Enabled to practice in the State since 1971.
• Regulated by a Physician Assistant Committee of the Medical Board of California in the State Department of Consumer Affairs.
• Separate legislation to cover osteopathic physician assistants (this legislation will soon sunset in the State.)
• Title protected since 1996
• Since 1997, PAs are licensed in the State.
• Must practice under continuous supervision of a physician.
• Physician may only supervise two PAs at any one time.
• Physician assistants may transmit a drug order in the State for legend drugs and under patient specific orders from the supervising physician for controlled substances in Schedule II to V.

Illinois

New York

• PAs are registered in the State (RPA-C) but are issued a license.
• Professional practice for PAs in the State is defined by the individual PA and the supervising physician in accordance with the education and training of both.
• PAs are supervised under indirect supervision in all locations
• PAs are reimbursed at 100 percent of the Medicaid fee schedule for physician services.
• PAs may prescribe legend drugs and controlled substances in Schedule II to V.
• A physician may only supervise 2 PAs in private practice. Greater ratios are allowed in special settings.

• PA profession born in North Carolina at Duke University in late 1960s.
• PAs in the State are licensed by and registered with the North Carolina Medical Board.
• A change in rules governing PAs occurred in 1993 easing some of the restriction on practice.
• PAs are not listed on MCO panels and are considered medical assistants in hospitals rather than as part of the medical staff.
• Supervision requirement for PAs requires that all outpatient charts be reviewed within 7 days.
• Payment for services performed by a PA within professional practice is mandated in law.
• Prescriptive authority is defined in the supervisory agreement reached by the physician and PA and may include not only legend drugs but also Schedule II to V controlled substances with Schedule II and III being limited to a 30 day supply only.
• Since 1993, a seat on the North Carolina Medical Board is available to a PA.

• PAs in the State are issued a certificate of registration which is a license to practice.
• A Physician Assistant Committee that is appointed by the medical board regulates PAs in the State.
• National certification is required
• State regulations require that a standard utilization plan be approved for the PA and the supervising physician. Any further extension of that standard plan must be filed with the board for approval as a supplemental utilization plan.
• PAs practice under continuous supervision in the State but may not practice more than 60 minutes travel time from their supervising physician.
• A physician may not supervise more than 2 PAs at any one time.
• PAs may not prescribe, dispense, or order medication in the State but they may carry out physician’s orders for medication.
• Medicaid reimburses PA services at 85 percent of the physician fee schedule in the State.

• PAs are licensed in the State and title protected. They are obligated to register as a PA if they are employed as a PA.
• A PA committee of the Board of Medical Examiners regulates PAs in the State.
• The physician and the PA define the professional practice options for the PA in the State but the Board of Medical Examiners must approve the written agreement between the parties. Under certain circumstances remote supervision is permitted to extend care to medically disadvantaged areas as long as direct communication is available. This privilege must be specifically applied for.
• Physicians may supervise two PAs (up to four in underserved areas) and PAs may have four supervising physicians.
• Prescriptive authority is defined in the written agreement between physician and PA and may include Schedule III to V prescription drugs. PAs may administer and dispense drugs in emergency situations.
• A regular review of the PAs work is required.

• PAs are licensed in the State
• The Texas State Board of PA Examiners regulates PAs.
• The PA and physician must notify the boards of their employment agreement and include their names, addresses, licenses and phone numbers on the notification.
• A physician may supervise up to 3 PAs or their full-time equivalent.
• Prescription authority is limited to legend drugs in the State and must be authorized through delegation of the physician or through standing medical orders and is limited to the primary practice site and certain underserved locations.
• PAs may supply drugs in properly labeled containers in public health clinics.