Abstract

This study analyzes the roles of nurse practitioners and the extent to which they practice them in the United States as well as individual States. In the beginning, it explores the restrictions which Medicare, Federal as well as States government subjects advanced practice registered nurses (APRN) to, in their practices. Also, there is an analysis of the roles which APRN plays to help patients and hospitals save treatment costs. APRN goes through education programs, which equips them with skills to practice primary health care. They can diagnose, treat and make prescriptions similar to specialists. However, the Federal and States governments restrict most of those roles. For example, there are some states, which allow APRN to prescribe drugs while others do not. The few roles which remain for the nurses like managing patient’s conditions helps to save costs of regular visits as well as an admission in hospitals. There are still chances available to make the cost of health care low, once Medicare gives APRN freedom to practice within their abilities.

Keywords: Nurse, Specialist, Doctor, Treatment, Patient, Hospital, Practitioner, Services, Diseases

 

Exploring the Role of Nurse Practitioners; Are Services Limited by at the State or Federate Level?

Advanced practice registered nurses (APRN) are nurses with advanced education and specialization in different health care areas. The categories include nurse anesthetists who work in the surgical field and nurse midwives who work in women and the related field of reproduction. US regulations on health require nurses to have at least a master’s degree for them to qualify as APRN. They train on assessment, prescription of medicine, diagnose as well as managing patients. The training is similar to those of physicians and therefore, can offer primary health care. Despite their abilities to carry out such duties, there are restrictions from different authorities. In the US, the federal and States governments, as well as Medicare, regulates treatments, diagnosis and prescriptive roles of the nurses. The regulations disadvantage the hospitals and patients because of the limited number of doctors whose salary is high in comparison to APRNs. This study analyzes the restrictions of APRN from Medicare, Federal and States governments as well as their roles to see how they would save patients and hospitals treatments cost as well as improve health outcomes.

Restrictions for APRN

Although the federal state has laws restricting APRN from some practices, individual states make their policies. Individual hospitals also institute regulations on the scope of APRN. There are some states, which recognizes APRN as primary healthcare providers and therefore, allows them to carry out any duty without restriction (Andrew Scanlon et al., 2014). Some states on the other hand partially acknowledge the ability of the nurses and thus give them partial right to carry out doctor’s roles. They only allow them to perform the duties when the attending doctor allocates them. Also, the APRN in those states can perform some duties up to certain levels. The last category is that of states which do not allow APRN to play specific roles regardless of the circumstance. APRN can only be present when their supervisors are attending the patients to help them.

Drug administration Prescriptive Authority

One of the limited perceptive roles is on drugs. The federal and various states have different levels through which NP can prescribe, administer, administer or even dispense drugs to Patients. The Drug Enforcement Administration (DEA) divides prescription drugs into four categories on the bases of their effect and addiction in human. The classes are schedule 2/2N, 3/3N, 4/4N as well as 5/5N. The first category 2/2N is highest in dependence with a probability of having severe mental and physical side effects (Subramanian, & Moreno, 2014). The intensity of addiction and side effects reduces with numbers, 5/N5 being the list in effect. Different states have different regulations on the level of drugs NP should prescribe. There are those states, which allow APRN to administer, procure and even prescribe all of the four categories without restrictions. Such states include Hawaii, Arizona, and Colorado (Subramanian, & Moreno, 2014). Those states like Colorado consider APRN as primary healthcare providers and therefore have full right to prescribe any of the drugs. However, for the nurses to work independently without supervision, they must work under preceptorship within a given duration of time given in terms of hours. In Colorado, for example, nurses are supposed to work under supervisions for 1800 hours after which they can prescribe any drug without restrictions.

There are other states which only allow NP to prescribe only when in collaboration with a physician. One such state is Florida where the ARNP prescribes drugs subject to practitioner approval (Phillips, 2016). Where the ARNP need to order or dispense controlled substances, they must make those arrangements with their supervisors. Another regulation to prescription is based on the level of academic qualifications. APRN should have a certificate that leads to a master’s degree in a clinical specialty area and training in a particular practitioner skill. The state also restricts the prescription of substances related to psychiatric mental health. Other States do not allow APRN to prescribe drugs at all. Examples of such states include Missouri and Georgia (Phillips, 2016).   In those states, APRN must collaborate with their supervisors to prescribe the controlled substances.

Physical Examination and Admission

The federal government allows APRN to see new patients without any restrictions. However, different states have different policies on the issue. There are some states, which enable the APRN to see new patients without any restrictions. Some of those states include Hawaii, Idaho, and Colorado. However, there are other states, which will only allow APRN to attend to new patients with authority form their supervisors (Saria et al., 2014). The nurses can call the supervisor and request to see the patient on behalf. In those states, doctors can authorize nurses to see patients when they are not available. Examples of such states with reduced responsibility to attend patients for the first time include Pennsylvania, New York, and New Jersey. There is another category of states, which do not allow APRN to see patients for the first time even with authority from the supervisors. The only time when the APRN can see patients in such states is when they collaborate with the doctor (Mumford, 2018). The doctor must be present and make a diagnosis for the patient alongside the one done by the APRN. Such states with full restrictions include North Carolina, Oklahoma, Michigan, and Massachusetts (Yee, Boukus, Cross, & Samuel, 2013).

 

Referrals and Orders

The federal government, through the Medicare & Medicaid Services, does not allow APRN to write orders or make referrals for patients (Yee et al., 2013). The claim from the two bodies is that nurses write prescriptions and make referrals that create financial and logistic challenges when it comes to reimbursements. However, there are some states, which allow the APRN to make orders and referrals without restrictions. The states recognize APRN to have the ability to handle such cases have gone through the required training. Once the nurses make such requests, doctors do not have to check and confirm them. Examples of such states include Wyomia, Washington, and Vermont (Yee et al., 2013).

In other states, APRN has partial right to admit and write laboratory orders related to patients. The APRN can admit with directions from the supervising doctor. The attending doctor gives an order or delegation to the nurse through word of mouth or writing (Yee et al., 2013). In addition to the delegation, the doctor signs the admission forms at the time of patient discharge. Where there are no such signs, the APRN and the attending doctor can fail to get their payments through the Medicare (Yee et al., 2013). Examples of such states include Pennsylvania, Ohio and New York. The third category of states is those, which do not give APRN any right to make patient orders or referrals. Medicare does not make payments of such requests made by the nurses. However, they can be present or collaborate with doctors to make orders and referrals.

Treatment

Restrictions under the examination and treatment category include initiation of emergency treatment, lumbar puncture, and bone marrow aspirations. The federal government does not allow the APRN to make such treatments although they might issue privileges of independent performance when the nurses show competence and adequate training.  (Woolbert, Ziegler, Wynne & Zdanuk, 2013). At the state level, different states have different views and policies on APRN treatment of patients. The first category of states is those, which allows the nurses to offer primary health care without any regulation. They include Lowe, Idaho, and Hawaii. There is another category of states that allow only nurses with competency to carry out treatment. However, even in those treatments, the nurses should have authority from the attending doctor. Among those states includes Mississippi, Louisiana, and Kentucky (Yee et al., 2013). Other states like  Florida, Georgia, Michigan, and Massachusetts do not allow APRN to make treatments on patients even with a delegation from the attending doctor.

Certification and Commitments

There are several certificates and declarations, which doctors make or issue within the medical field. They include death and birth certificates. Also, doctors are supposed to declare the death of a patient to the family and other concerned parties as well as issue marriage health rules. The federal government does not allow APRN to issue or sign thosesuch declarations or certificates. However, there are some states, which enable the APRN to carry out such duties without limitations, for example, Arizona and Alaska (Yee et al., 2013). Other states allow nurses to assume such tasks with a delegation from the attending doctors for example Arkansas. Despite the ability and capacity of the APRN to carry out such declaration and issuance of certificates, some states like California and Georgia restricts nurses from such roles.

Medicare Law

The federal government carries out regulation of the APRN practices through policies and Medicare. Medicare offers insurance to patients who apply for medical services. It also sets some guidelines on those medical services it can reward depending on who performs them similar to the federal and states governments. The insurance group restricts APRN to carry out some roles, which includes certifying patients to access coverage on hospice and home health services (Yee et al., 2013). Home and hospice services, which Medicare covers for the beneficiaries, include monitoring of serious illness at home, education for the caregiver and the patient, as well as wound care. APRN, therefore, cannot admit patients for such services because their admission will not receive remunerations form the insurance organization. However, the insurance organization allows APRN to document the home health services and deliver them to the attending doctor who will make a narrative and later certification.

Medicare allows APRN to offer post-hospitalization care services in facilities. The insurance gives APRN to sign certificates, which will enable patients under Medicare program to get to post-acute care for medical conditions, which are complex including heart failure, stroke as well as joint replacement. Other restrictions, which Medicare places on APRT, are those, which the state law also recognizes.  Medicare requires APRN to have specific academic qualification and accreditations to perform the services, which the state or the federal governments allow. One of them is a master’s degree in a particular clinical field and from an institution with accreditation (Hooker & Muchow, 2015). The nurses should also have a certificate from the American Nurses Credentialing Center to show that they are specialists. The nurses should have a license to operate from the states they practice.

Medicare allows APRN to perform all doctors’ roles which require an independent treatment and evaluation of the patient situation. Such services include X-rays interpretations and minor surgeries (Yee et al., 2013). Also, APRN can perform any duty in collaboration with the supervising doctor as long as the state or federal law allows. The doctor can delegate the responsibility with instructions on how to handle the situation such that they do not have to be present. However, even without a state law, Medicare will recognize the collaboration but only after the APRN documents the kind of relationship they have with the doctor to handle such a variety of issues outside the practice (Hooker & Muchow, 2015).

There are some duties which Medicare restricts APRN from performing regardless of whether the state or federal governments restriction or acceptance. They include regular foot care as well as physical checkups (Yee et al., 2013). NPs are not supposed to offer services which are not meant to diagnose or treat injuries and illness and also to improve the functionality of a twisted part of the body. Although nurses may have qualifications and right to perform such duties, Medicare does not compensate them unless a doctor is in charge.

Valuable Services from APRN

One of the APRN roles, which the federal and state governments do not restrict, is education provision to caregivers and patients on strategies to prevent diseases. According to Bodenheimer & Smith (2013), APRN role in preventive health saves clinician’s time to concentrate on primary care and increase the number of those who access the service. While the doctors diagnose and treat a specific disease, APRNs looks at the holistic health of the patient’s and smooth recovery without cases of readmission. The nurses compliment and strengthen federal and most states governments’ strategies on disease prevention as the best focus towards public health. One advantage is saving money for the treatment of minor diseases, which are preventable. Through education on disease prevention, APRN is, therefore, able to save hospitals money, which they would use to research and treat an outbreak (Coyne et al., 2016). Diseases such as cholera, tuberculosis, arthritis are preventable. APTN teaches people on how to avoid the agents of such illness and therefore, prevent outbreaks.

Education on lifestyle is essential to improve the health outcomes of patients and therefore, save patient and hospital’s money (Colvin et al., 2014). One on one dialogue with people and the community influence them to change their behaviors towards healthy ones. The nurses carry out the roles of social marketers.  There are some diseases and conditions, which require lifestyle changes to contain them. An example is diabetes where a patient should avoid some food substances, which have much cholesterol and instead take enough iron and other minerals. The foods are better in comparison to drugs, which increase insulin in the body. The APRN saves patient’s money, which they would use to buy the expensive insulin control and other drugs. Others do not have a specific cure, but patients can control them through the adoption of a particular lifestyle. Specific lifestyle behaviors for example dietary ensure that the patient’s leave hospital earlier than it would be without practices such as physical exercises and dietary. Also, the methods help to avoid readmission due to worse conditions. Hospitals can save money and time they would focus on patients for a long time while patients save money they would pay for readmission.

APRN manage different chronic conditions like diabetes and high blood pressure. Such chronic diseases do not have a permanent cure, and patients leave with them for the rest of their lives (Moore, 2017). However, there are some situations when they become severe, threatening patients’ lives or making them experience much pain. APRN help the patients to manage those conditions in ways that will not reach to severe conditions (Schadewaldt, McInnes, Hiller & Gardner, 2016). They regularly check patients to evaluate the need for a different drug in every stage of their lives. The continuous taking of one particular medication may lead to other conditions in patients. APRN checks the patients to ensure that there are no other conditions, which would arise because of the current disease and treatment (Moore, 2017). Also, most of those diseases require a regular change of diet to control the different minerals like iodine and iron in those people with gastric disorders. Managing such diseases helps the patient to avoid readmission for severe conditions and instead, maintain a healthy outcome. Also, hospitals do not incur much money in treating readmissions from the severity of such diseases.

In the process of management of patient’s conditions, nurses can establish other potential factors which may reverse the illness (Contandriopoulos et al., 2015). Some diseases are brought about by risks that doctors do not pay attention to during the time of treatment. APRN goes ahead to evaluate other conditions present or leading to the illness. Management of such conditions helps to ensure complete recovery of patient’s. They support the patients to avoid revisiting the hospital for the same state in the future thereby saving costs.

APRN supervises and manages the health and well-being of women from preconception to parental, gynecological issues among other primary needs (Fraser & Melillo, 2018). Women have different regular health conditions which most of them do not understand and therefore seek medical advice. Nurses assist attending doctors in the examination of such minor issues, which would require the hospital to incur much money paying a specialist doctor attending such women.  Also, patient’s save money through APRN which they would pay when a specialist serves them. Some of those conditions may be a foundation of complex illnesses once they fail to have proper early management. The nurses help and advice patients early on how to manage the conditions (Connect Your Care, 2019). They determine the need for a specialist early thereby avoiding the severity of the illness later. Early monitoring and management of the conditions help to prevent cases where the disease requires specialized treatment. They save the hospital and patient’s money, which they would spend in treating a complex condition later.

Management and supervision of women and the fetus health early help to avoid unnecessary charges like CS during delivery. There are some cases when the midwives and doctors may order for a CS, which was manageable early. High blood pressure for example, which would prevent standard delivery, is manageable to the right levels before the due date to avoid an operation. APRN guides women through their reproduction to prevent such high charges thereby saving them from spending a lot. Also, hospitals do not spend much money in severe conditions of women when nurses control them early. The health of women improves well and quickly after delivery when nurses manage them throughout their gestation period.  APRN also supervise the fetus growth to ensure healthy development. The advantage of supervision is to allow early management of conditions, which may arise at the time of birth. Initial management saves mothers and hospitals money that they would use to treat the conditions at advanced stages. The nurses can control the baby weight to avoid keeping them in nurseries after delivery, which would cost the mother and the hospital.

Another unregulated role of APRN is the treatment of minor injuries. The nurses can pay more attention to the injuries compared to specialized doctors because they have enough time. Over 80 percent of patients trust treatment form APRN compared to doctors (Waugh, Voyles, & Thomas, 2015). Nurses can listen to patients better and pay more attention. Such trusts enable the patients to adhere to drugs and therefore improve their health outcome as well as avoid frequent visits, which would be costly. They offer better treatment and follow up on such patients thereby helping to improve their health outcomes (Hebert, 2017). The nurses are readily available to attend the patients immediately other than making a queue or appointment with limited doctors (Safriet, 2011). Immediate treatment helps to manage the injuries early and avoid additional complications, which would cost the patient’s health and money. Also, through follow up, they ensure that the patients do not make frequent visits to the hospital thereby saving them money. Such minor injuries would cost the patient and the hospital more money when contacting a specialist. APRN costs are low, and therefore patients and hospitals do not spend a lot.

Effect of Reduced APRN Restrictions by Medicare

In one of the limitation, Medicare does not allow APRN to carry out hospice services. Doctors provide hospice services to those patients with a terminal illness at home or as impatiens. Medicare does not let any nurse practitioner make narrations and therefore follow up of such patients. The organization insists that a doctor must be present and APRN can only collaborate with their supervisors. In their billing reimbursement schedule, Medicare does not accept any from hospice service that APRN signs. Having a doctor make follow up of such patients is very expensive since the remuneration is almost twice as that of a nurse practitioner. Charges, when APRN are making follow up, are low because their salaries are also low. Hospitals can keep wages of nurse practitioners low because their education program is 20 to 25 cheaper compared to that of physicians in the US (Connect Your Care, 2019).  However, it is good to note that the study fee difference does not mean that APRNs are under qualified. Their training and competencies are similar to those of doctors (Westgate, 2015). Most of them have experience of at least two years before they enroll for masters in their areas of specialization.

Allowing APRN to make hospice follow-ups will save hospitals much money they pay doctors to carry out such roles.  There are so many visits that these doctors make to patient’s home which nurses can do to lower the amount of money the hospital charges patients (Warner Stidham, 2014). Families of such patients will, therefore, save much money when an APRN attends them. Apart from attending to the patients, APRN will educate the families of such patients on strategies of giving care. They have the training to cover an all-round program and not diagnosis and treatment alone. Training families on how to take care of the patient reduce the number of visits, which the hospital requires to offer. The cost of follow up for the family and the hospital will therefore reduce.

Another area through which the patients lose much money in treatment is when they seek private therapy because they cannot get a doctor who can admit them through the Medicare program (Kurtzman et al., 2017). Medicare restricts APRN from admitting several cases into their programs. For example, a nurse practitioner cannot carry out physical and first time examination, make referrals and specific orders as well as prescribe particular categories of drugs (Waugh, Voyles, & Thomas, 2015). There are few doctors in the US compared to the population they are supposed to serve. It means that patients have to queue waiting for one specialist. The patients in chronic pain and cannot wait decides to seek private services which do not offer or cannot treat through Medicare support.  They end up using much money, which they could save through the insurance organization. Changes, which allow APRN to admit patients through Medicare, would ensure that every patient in the program benefits at every hospital visit.

Another regulation on APRN that Medicare can lift is a restriction on regular checkups, which do not aim at treating or diagnosis of a condition or examine injuries but improve body functions. Checkups reduce admissions of patients from severe and chronic diseases (Hariharan, 2015). Such regular checkups are essential to identify any symptoms of a disease or improve patient’s health and recovery process. APRN have training on such services, but the Medicare restricts them. Allowing such services will minimize admissions from conditions which nurses can control their symptoms (Quallich, 2017). APRN can advise patients on the right thing to do in case they discover any signs such as those of high blood pressure. One of the APRN roles is to prevent diseases. The only way they can exercise that duty is when they meet patients. Through regular checkups, nurses will be able to advise patients depending on how they have found the body condition. They can advise on regular exercise to lower body weight, which would cause blood pressure, or dietary to take more iron which to prevent gastric conditions. Patient’s will cost which would come as a result of such conditions. Also, hospitals save since they will not have the burden of getting a specialist when such patients suffer from prevented conditions.

APRN can reduce the number of days, which patients stay in hospitals once Medicare allows them to sign different forms (Hariharan, 2015).  Medicare restricts the nurses to sigh most of the certificates and forms, which patients require to leave hospitals. The forms include prescription, discharge, and birth. Medicare only recognizes forms signed by doctors even in those cases there was collaboration or delegation with the nurse to write a narrative about the patient. Patients extend their days in hospital until the doctor is available to sign the forms. Doctors in the US are few, and therefore, their availability is low (Markit, 2017). The extended duration can reduce once APRN gets the right to sign the forms. Nurse practitioners are many and always available to the patient, and therefore, they would discharge patients on time. The patients will save the money they pay for extended days, and the hospital will lower the cost of taking care of them.

Allowing nurses to handle the initial examination, diagnosis as well as prescription will increase their services at the community clinics making health services more affordable and less time consuming to the Patients (Bodenheimer, & Smith, 2013). its and congestions because APRN will handle health conditions before they get worse thereby reducing emergency room visits and congestions. Also, they will be able to manage patient’s conditions thereby minimizing the chances of readmissions. Reduced readmissions come with an advantage of low cost on health. According to Connect Your Care (2019), Also, APRN offer services at low cost compared to physicians which further makes health services to patients affordable. The charged from doctors are more compared to what the nurses charge. The charges will attract more patients to go for preventive services and therefore save money which they could use to treat a health condition at an elaborate stage. On the other hand, hospitals will also save money when the number of readmissions and emergency room visits reduce. They will have few patients to attend to who do not crate burden to the available health facilities.

Conclusion

APRN have restrictions to their roles, which they are capable of carrying out. Their training offers skills, which can allow them, carry out similar primary care duties as doctors. However, the barriers from different authorities make them as assistant to doctors and can only engage in such roles with the delegation, collaboration or under supervisions. Their skills would help patients and hospitals in many different ways were there no restrictions. They can help to solve the challenge of a few doctors, and cost of treatment because their charges are low compared to cure under a specialized doctor. The authorities restricting them should take an initiative of understanding their abilities to expand the scope of the duties they perform. They will help to save patients and hospitals much money by reducing the length of admission, emergency visits, and readmissions among other costs.

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