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April 4, 2013

Nurse practitioners filling the gap

Nurse practitioner Catherine Grant, left, in the waiting room of her Slickville practice, with secretary Sandy Balint.

Nurse practitioner Catherine Grant, left, in the waiting room of her Slickville practice, with secretary Sandy Balint.

When the Affordable Care Act, or “Obamacare,” is fully implemented in 2014, there will be about 35 million people with new health insurance who need primary caregivers. Nurse practitioners are poised to fill that gap, but they may have to fight for the right to use their expertise and training.

Pitt nursing faculty member Catherine Grant is one of the first nurse practitioners with her own practice in the state. There are a variety of nurse practitioner specialties, such as acute-care nurse practitioners who work in hospitals and critical care units, pediatric nurse practitioners and others. Grant and her colleagues are family nurse practitioners, taking care of patients throughout their lives, from infancy to old age. Her practice provides everything from well-patient visits and physical exams to HIV prevention services and laboratory tests.

“I like what I do,” says Grant, sitting during a quiet moment at one of several paper-piled desks in her no-frills office at Associates in Family Health Care in Slickville, Westmoreland County, which she established in 1991. “We’re involved with the community and I do think we take care of the complete patient.”

She shares her office with the practice’s biller and two other nurse practitioners, Don Graham and Jonathan Luker, who work for other private facilities as their main jobs, seeing patients here mostly on Saturdays. When Grant isn’t teaching at Pitt, she sees patients here two or three times a week, sometimes until 7 or 8 p.m. — “whenever we’re done,” she says.

While writing her nursing master’s thesis in the late 1980s, a study of community health-care needs in the Slickville area, Grant discovered that a nurse practitioner-led practice would be very useful here.

“The people said they would accept a nurse practitioner for health-care services,” she reports. “There’s no bus routes, and at the time the closest health-care provider was 10 to 15 minutes away, so it was a little pocket of an area where health-care services were not available.” Her patients are “scattered through the hills. We get a lot of people from the outlying areas.”

Through her practice, she is a preceptor for students in Pitt’s certified registered nurse practitioner program and other local CRNP students, giving them practical experience interviewing, examining and diagnosing some of the practice’s 3,000 patients.

One of the main reasons she wanted to be a preceptor, she says, “was to promote the nurse practitioner profession. We are able to be independent practitioners and I think we can be utilized better when we can be in independent practices and start our own businesses.”

But running a nurse practitioner-only practice has been its own learning experience. “It’s hard,” she allows. “And I can see it getting harder.”


For 22 years, Grant and her fellow nurse practitioners have run into barriers from insurers, government agencies and health-care systems in their attempts to treat all patients, prescribe all treatments and gain reimbursement for all the practice’s work.

Twenty percent of Grant’s patients are on Medicare, which covers older Americans, and a great many more are on medical assistance, or Medicaid, or are uninsured and pay cash. The insured patients are covered by a variety of carriers.

Although Pennsylvania law allows nurse practitioners to prescribe all classes of drugs, the state forces a nurse practitioner-led practice to have “collaborating physicians” who oversee certain procedures. Some insurance companies don’t reimburse nurse practitioners at all, or reimburse for office visits but little else. If Grant wants to prescribe home health equipment — say, something as simple as briefs for a patient with incontinence — “I have to fax it over to my collaborating physician who signs for it and submits it,” she says. “For home visits, for me to go out as an independent nurse practitioner — at this point in time, I don’t get reimbursed for it.” And if her patient is discharged from the hospital by an attending physician who orders visiting nurses, “I’m out of the loop.” She doesn’t receive notification that these nurses are now dealing with her patient, nor notices of that patient’s progress. She also must keep logs on facilities where her patients get tests because she will not receive notice of those procedure results either.

Recently, one of Grant’s patients was treated at Children’s Hospital and Grant had to track down the child’s family and get a parent to sign a release form before UPMC would send her the results.

Several insurance companies have decided in the past year to begin covering nurse practitioner-led clinics. But Grant says she still hears insurers say: “You’re a nurse practitioner and we don’t recognize you.” Even the practice secretary, Sandy Balint, whose family insurance once allowed her to be seen in Slickville, no longer can be a patient here because her family switched insurance carriers.

Medicaid patients, whose care is administered by four different insurance companies locally, sometimes are shut out of Grant’s practice as well. These patients, she says, tend to go on and off Medicaid frequently as their employment and income changes. Grant has resorted to handing advisory cards to Medicaid patients, advising them to pick certain Medicaid insurance companies that cover examinations at Slickville — in the instances when Medicaid offers them a choice.

Not that treating Medicaid patients is a moneymaker for the practice, she says. And Medicare reimburses her practice at 85 percent of what practices led by primary-care physicians receive, she says. If an expected 10 percent cut in Medicare reimbursements is instituted, that will make the situation even worse. She also expects physicians to see fewer Medicare patients, and nurse practitioners more, if that reimbursement cut is enacted.

Overall, says Jan Towers, director of health policy for the American Association of Nurse Practitioners (AANP), “it makes it hard to provide services.” In two states, Florida and Alabama, nurse practitioners can’t prescribe any controlled substances. And while no Pennsylvania laws prevent nurse practitioners from being covered by insurance companies, “we deal a lot with the tradition and we’re still breaking through barriers there,” she notes.

When Grant recently applied for federal funds to ease her practice’s transition from paper to electronic medical records, she discovered that she was eligible for only one-third of the $60,000 offered to physician-run clinics.

“Why should I be in business, financially?” she asks. “That’s why I have another job. The business sustains — paying for the staff, rent, overhead, medications — but that’s about it. The other practitioners get paid, but that’s why they have other jobs too.

“I hope to go to heaven when I’m done,” she says, laughing.


Pitt nursing Dean Jacqueline Dunbar-Jacob notes there is a documented shortage of primary care physicians: “Bringing millions more patients into the health-care system will only make the shortage worse.”

Nurse practitioners are part of the solution, she says. “The care delivery right now is much more complex, but the services nurse practitioners are able to provide are much more complex than they have been in the past.” And Cathy Grant “is a perfect example of where nurse practitioners in primary care are going nationwide.”

Says the AANP’s Jan Towers about her expectations for 2014 and beyond: “We need every primary care provider we can get. There are going to be more people needing primary care services and nurse practitioners are experts in primary care.

“We open our offices many times where there are no physicians around,” she adds — in rural and urban areas. “We have some areas in cities that are very underserved” and could use nurse practitioner-led practices.

As states develop the insurance exchanges to offer new insurance to those previously without coverage, as mandated under the Affordable Care Act, Towers says her organization will be “making sure nurse practitioners are recognized as providers and they are able to be utilized and will be reimbursed for their services. There’s a chance that we’re going to have to go in and argue our case.”

One important bit of ammunition for their argument will be the increasing emphasis at Pitt and elsewhere on nurses earning a Bachelor of Science in Nursing (BSN) degree atop their RN certification, and on nurse practitioners earning the Doctorate of Nursing Practice (DNP) degree.

“There have been years of research showing that patient outcomes, including death rates, are better with more baccalaureate nurses,” says Dunbar-Jacob. The nursing school has expanded its number of BSN recipients by offering the degree at Pitt’s Johns-town campus, with the first class graduating this spring.

For the 2013-14 school year, nursing will finish moving all advanced practice programs for nurse practitioners from master’s to doctoral degrees. Besides answering a national call to raise the education levels of nurses overall, says the dean, the shift will help fulfill the demand for nurse practitioners to expand services in acute care and primary care. It also will help provide the additional caregivers needed as a result of a recent reduction in the number of hours medical residents can work.

“We think we’re ahead of the change,” says Donna Nativio, director of Pitt’s DNP program, which began accepting students in 2005. To the clinical practice gained by clinical registered nurse practitioners, says Nativio, the DNP training adds understanding of other factors, such as policy and politics, the financing of health care and “all of the complicated ways in which health care is delivered,” from free-standing clinics to hospital settings.

“Having a higher level of education for nurse practitioners is good for the patients, it’s good for the profession and it’s driven by the greater responsibility nurse practitioners are taking and hope to take,” concludes Nativio. “It won’t happen overnight. “Our statewide nurse practitioner association is working to have barriers removed so that nurse practitioners in Pennsylvania can practice without  mandatory physician oversight. This is already the case in 14 states and about a dozen other states have introduced legislation to allow full practice privileges for  nurse practitioners.

“We think if they count nurse practitioners among primary care providers, we won’t be as short as they think we are. But that remains to be seen.”

—Marty Levine

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