Medical Professionals - Nurse Practitioners: Where They Practice

The map shows the distribution of nurse practitioners (NPs; also called advanced practice nurses) across the nation in 1996. That year, the national average was 26.3 per 100,000 population.

The 1967 establishment of a pediatric nurse practitioner program at the University of Colorado, Boulder, is said to have marked the beginning of the nurse practitioner movement. According to the Bureau of Labor Statistics: "Nurse practitioners provide basic primary health care. They diagnose and treat common acute illnesses and injuries. Nurse practitioners also can prescribe medications (but certification and licensing requirements vary by State). Other advanced practice nurses include clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives. Advanced practice nurses must meet higher educational and clinical practice requirements beyond the basic nursing education and licensing required of all RNs."

Advanced Practice Nurses by Specialty

Title	Number
Nurse Practitioner	48,237
Certified Nurse Midwife	7,400
Clinical Nurse Specialist	58,185
Certified Registered Nurse Anesthetist	25,238

According to NursingWorld, about 140,000 advanced practice nurses deliver health care, primarily to underserved populations (the elderly, the poor, the rural). The table shows the areas of expertise of these 140,000 nurses. NursingWorld asserts that "Some 60% to 80% of primary and preventive care traditionally done by doctors can be done by a nurse for less money" were it not for the fact that there are too many restrictions on their activities.

Nurses performing the tasks of a doctor at a lower cost seems like a concept that the health care finance people could get behind. However, Canavan reports that nurse practitioners have been stymied by physician lobbies and Medicare reimbursement policies, among other things. Even when NPs and clinical nurse specialists performed the same services as doctors, it was not until 1998 that those services became eligible for Medicare Part B coverage and direct payment, regardless of the geographic region where they were performed, if the same services were covered when provided by a physician.¹² Previously, NP services were covered only when provided in nursing homes or rural areas.

With nurses in short supply everywhere, it is not hard to imagine the value of a certified nurse midwife to the poor and to pregnant women in rural areas. Nevertheless, these professionals complain of state policies that constrain their activities: supervision requirements, lack of prescriptive authority, differing third-party reimbursement policies, restrictions on hospital privileges, and excessive malpractice premiums.

Autonomy has also been an issue for nurse anesthetists, who attend some 17 million patients per year. In 2002 President George W. Bush ended a practice dating back more than 35 years when he gave states the freedom to opt out of a Medicare rule requiring that nurse anesthetists work under the supervision of a physician. Bush's supporters pointed to the cost savings to be realized, since nurse anesthetists earn about one-half as much as anesthesiologists (who are in short supply). Critics claim the move will be hazardous to patients' health.

Sources: Map: National Center for Health Workforce Information and Analysis, State Health Workforce Profiles, http://bhpr.hrsa.gov/healthworkforce/profiles/default.htm. "Registered Nurses," http://www.bls.gov/oco/ocos083.htm. Table: "Advanced Practice Nursing: A New Age in Health Care," http://www.nursingworld.org/readroom/fsadvprc.htm. Nurse-Midwifery Position Statement, http://www.nursingworld.org/readroom/position/practice/prmidwif.htm. Kathleen Canavan, "Specialty Fields Practice Differences Spawned by Managed Care," The American Nurse, October 1996, http://www.nursingworld.org/readroom/mgcare5.htm. Lawrence Budd, "Some States Dropping Nurse Anesthetist Oversight Rule, Dayton Daily News, May 29, 2002 p1A. Information retrieved September 30, 2002.