The Real Threat?
Issue: May/June 2018
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
“These are the times that try men’s souls” — Thomas Paine
Emergency medicine will face many significant challenges in the coming years. Our specialty is certainly not unique in this regard. Like all medical specialties, we will need to be organized and vigilant in protecting our profession as a whole as well as our individual careers. Some of the challenges are well known and hopefully recognized by all in our field. These very issues were at the forefront of why the Academy was founded in the first place. The threat to board certification by ABEM/ABOEM for America’s emergency physicians has stood the tallest among these issues. Notwithstanding the recent ACEP election of a surgeon as President-Elect, I hope that this issue is finally being put to bed forever. I would hope that ACEP will amend their election rules and hold board certification as an absolute requirement for any leadership role in their organization. However, as a specialty we must face other challenges.
The house of medicine in general, and the specialty of emergency medicine in particular, must face the increasing involvement of mid-level or advanced practice providers (APP’s). Most, if not all, of us have been exposed to nurse practitioners or physician assistants in our emergency departments. Many of us have very successful and useful collaborations and interactions with them. How many of you now speak to APP’s answering consults or doing history and physical exams as hospitalists? How many of you work closely with APP’s on a daily basis in your emergency department? Certainly, probably all of us have interacted with APP’s who are very intelligent and helpful, and can be faster and more efficient than some of the emergency physicians with whom we work. These APP’s have increasingly diverse roles and responsibilities in all aspects of our health care system. The current physician shortage and the aging of the Baby Boomer generation will require us to be creative if we are to meet the health care needs of the aging population. The (hopefully) universally accepted value of board-certified emergency physicians will not mean much if your emergency department is really staffed by APP’s who work as independent practitioners. What will your role be in this business model? Our health care system is being severely challenged on multiple levels. The appeal to government, insurance companies, and health care systems of cheaper providers who assert comparable quality is obvious. We must consider our response to this issue, or it will pass us by and others will once again decide what is best for our patients.
The American Association of Nurse Practitioners (AANP) has categorized nurse practitioners by their degree of independence. They can be full practice (entirely independent), reduced practice (partially independent), or have a restricted practice (non-independent). These determinations are usually made by each state, with politics involved. Many different stake holders and interest groups support the full practice rights of nurse practitioners, including the Institute of Medicine, the Robert Wood Johnson Foundation, the National Council of State Boards of Nursing, and AARP.
The variety of opinion on the ability and appropriate level of responsibility and authority of APP’s is not going to generate consensus. Some will say that APP’s should always be totally independent practitioners with little or no physician oversight. What should we do? The American Medical Association (AMA) has stepped into this fray with resolution 214. This resolution calls for the AMA to create a national strategy that would “effectively oppose the continual, nationwide efforts to grant independent practice to non-physician providers.” This resolution is encouraging the AMA to create a strategy to oppose model legislation, and national and state-level campaigns, which would allow non-physician practitioners to practice independent of doctor supervision. Most physicians might think this is a common-sense point of view. We as individuals should reflect on this issue and decide what we individually think before we step into this fray.
Pamela F. Cipriano, PhD RN, president of the American Nurses Association (ANA), is certainly supportive of nurse practitioners having independent practice. She responded to the AMA’s resolution by stating “this divisive tactic will directly impact the nation’s advanced practice registered nurses, and perpetuate the dangerous and erroneous narrative that APRNs are trying to 'act' as physicians and are unqualified to provide timely, effective, and efficient care.” The ANA represents the 3.6 million registered nurses in America. How did the nurse practitioners themselves respond to the AMA’s resolution? In a press release, Joyce Knestrick, PhD, the president of the American Association of Nurse Practitioners stated “the American Medical Association has asserted, once again, its commitment to put the profit of its physician membership ahead of patients and their access to high-quality health care.” Is this simply a financial issue? Do we fear competition or is our concern for our patients and their safety?
The Veterans Administration has added its support for APP’s practicing independently. In 2016, the VA granted full practice authority to their advance practice registered nurses. The Centers for Medicare and Medicaid Services had a program to spend $200 million to help train APPs, stating that it costs about $30,000 to train an APP — about one fifth the cost of training a primary care physician. CMS has also determined that nurse practitioners are paid at 85% of the amount a physician is paid under the Medicare Physician Fee Schedule. Are you getting scared yet? The government wants to train more APP’s for a fifth the cost, pay them less, and let them work independently at all Veterans Administration hospitals and clinics.
What about the states? Currently about 40% of the states have adopted a full practice model for nurse practitioners. There is also something called the Advanced Practice Registered Nurse Compact, which would allow an APRN with one valid state license reciprocity to practice in other states in the compact. This compact will go into effect when ten states have passed it. Idaho, North Dakota, and Wyoming have passed it, with pending legislation in Nebraska and West Virginia. This fight is really more in our state legislatures. Can you play a role in this at the state level? The APP’s will certainly be there, strongly lobbying for their cause. How much effort will be expended by organized medicine?
How about emergency medicine? There is a current proposal to amend the bylaws of the American College of Osteopathic Emergency Medicine, to add a representative from the American Academy of Emergency Nurse Practitioners (AAENP) to their board of directors. I understand this is causing some controversy. There is always a desire by medical organizations to increase their membership. Adding the legions of APP’s to their rolls may seem an attractive way to add revenue and numbers.
What about the Academy? Here is AAEM's 2017 position statement:
Position Statement on Advanced Practice Providers (APPs)
- It is the concern of AAEM that emergency patients have timely access to the most appropriate and qualified practitioners.
- Properly trained APPs may provide emergency medical care as members of an emergency department team and should be supervised by a physician who is board certified in emergency medicine (ABEM, AOBEM).
- On-site supervision of APPs should be provided by board certified (ABEM, AOBEM) emergency physicians. These physicians should be permitted adequate time to be directly involved in supervision of care.
- As a member of the emergency department team, an APP should augment (not replace) the unencumbered access to quality emergency care provided by a specialist in emergency medicine as defined in the AAEM Mission Statement.
I think that emergency physicians should come together and form a consensus, and develop a unified strategy to face this challenge. APP’s are here to stay, but we should play a leading role in defining the scope of practice and level of responsibility for these providers. This issue is one in which all organizations and societies in emergency medicine should have common interests and goals.