Medical Monopoly and its Effect on the Emerging Role of the Nurse Practitioner

A wide variety of licensing laws and other regulatory restrictions limits the scope of practice of nonphysician professionals and restricts access to their services. At the same time that it is restricting the practices of nontraditional health care professionals, government is providing subsidies for the education and training of physicians who fit the medical orthodoxy. The result is the creation of a veritable medical monopoly, leading to less choice and higher prices for consumers.

Battle for Domination: Historical perspective
As early as 1971 public health specialists were suggesting that productivity in health care could be improved by realigning overlapping duties of physicians and nurses. Research results indicated that non-physicians could safely handle a substantial proportion of patients’ problems and that physicians were therefore monopolizing tasks that nurses could do.

Although the emergence of nurse practitioners and clinical nurse specialists had occurred by the end of the 1960’s, hospitals and physicians were not willing to pay more for these highly trained nurses. They were placed in administrative positions rather than assigned to jobs where they could use their advanced clinical skills with patients. Physicians were now facing a shortage of peers due to a self-imposed restriction on medical school admissions. Further compounding this shortage they found themselves facing increased technological demands and excessive specialization. The solution was to get rid of the “scut” work, not by giving nurses more independent authority but by creating the physicians assistant (PA), who would be responsible not to nursing but to medicine. The PA is delegated a defined set of tasks to be carried out only under medical supervision. Thus by name, definition, and practice, the PA is dependent on physicians. The economic rewards for physicians who hire PA’s could be very substantial. The rewards for nurses who took on more medical functions were questionable at best.

The Devaluation of Women
Historically the gendered system has resulted in low economic status for nurses; erroneous expectations that their primary responsibility is to follow physicians’ orders; acceptance of any tasks and hours allotted; and lack of authority in policies and decision making. Jacox warned that without role restructuring nursing would remain a “low level, poorly reimbursed occupation capable of attracting primarily those persons who have limited options for pursuing more interesting and satisfying work”.

Thirty percent of nurses provide intensive care, which requires substantial technical and clinical knowledge. For example coronary unit nurses must be able to diagnose six to eight different common conditions, take appropriate immediate action with medication, resuscitation, and other measures. All of these must often be accomplished before calling a physician for assistance. These actions are normal expectations for nurses in all intensive care units. From 5 p.m. onward nurses are likely to take on the tasks of many other professionals, including the tasks of physicians.

The devaluation of women’s work continues as in previous decades. Other professionals continue to receive reimbursement for what nurses do. Under third-party indirect payment, physicians can earn up to 54 percent profit from employees who are nurse practitioners and at the same time ensure their dependence by virtue of the states requirement of a protocol physician. Another way to make money from women is to make nurses do admission histories, order routine medications, and carry out diagnostic and treatment procedures in hospitals; however, these acts must be “validated” by the physician, who countersigns and then collects a fee for “authorizing” the work of the nurse, who is paid by the hospital. Hospitals classify diagnostic treatment and procedures as revenue-generating, while skilled nursing care is classified as a cost or liability. Is it not interesting that hospitals provide both diagnostic and nursing care as the very reason for their existence?

Although nurses’ salaries are increasing, nurses remained devalued economically relative to others, especially physicians. Nurse’s aids salaries have increased from 65 percent to 71 percent of registered nurses’ salaries. While relative to physicians’ incomes we see just the opposite. In 1945 a nurse earned one third of the physician’s income but in the beginning of the twenty first century a nurse earns only one fifth of a physicians salary. It is hard to justify this when a nurse with a BS degree ha an average salary equal to that of a secretary with no college education.

Physicians Perspective on the Advanced Practice Nurse
The state of Florida along with most other states include medical functions in addition to nursing functions within their scope of practice for ARNP’s. In general physicians perceive many of these medical functions as helpful. ARNP’s shouldering of more routine medical responsibilities has allowed physicians to concentrate their time on the higher level skills required as medical technology increases. This has not only lessened the burden on the busy primary care physician but also proved to be cost effective for the patient and in general beneficial for the entire health care system. However, this evolution has not occurred with out controversy. One of the most controversial in the state of Florida has proven to be the prescribing of controlled substances by ARNP’s.

To be able to prescribe controlled substances practitioners must have a federally issued Drug Enforcement Agency (DEA) number and the Attorney General of each state must submit an application to the DEA stipulating the state laws that authorize the prescribing of controlled substances. Acceptance of this application for ARNP’s would therefore allow the prescribing of controlled substances by Nurse Practitioners. Nurse Practitioners are granted general prescriptive authority in Florida by the Nurse Practice Act (Chapter 464, Florida Statutes). The Nurse Practice Act does not exclude ARNP’s from prescribing controlled substances. However, the Drug Abuse Prevention and Control Act (Chapter 893, Florida Statues) does not include advanced practice nurse practitioners among those practitioners allowed to prescribe controlled substances. This discrepancy in Florida law is the primary legal barrier to preventing the state from making application to the DEA to allow ARNP’s to prescribe controlled substances (Florida Prescribing of Controlled Substances Task Force, 1997).

According to the latest legislative update by The Nurse Practitioner journal published in January 2002, there are forty-three states with some prescriptive rights for controlled substances either at this time or slated to be phased in over the next year. While the permitted schedules vary and some states impose limitations on the duration of prescriptions, 86% of the states in this country grant ARNP’s prescriptive rights of some fashion for controlled substances. This leaves Florida in the company of just 4% of states who do not allow ARNP’s to prescribe controlled substances (Pearson, 2002).

In 1996 the Florida Legislature established a task force to study the prescribing of controlled substances by advanced registered nurse practitioners. Members of the task force were chosen from the Florida Medical Association, Florida Nurses Association, Florida Pharmacy Association, Florida Hospital Association, and the Agency for Health Care Administration. The legislation specified two areas of investigation in the evaluation of the current prohibition. One involved a comparison of the educational and clinical training of physicians and advanced registered nurse practitioners; and the other was a review of the potential liability exposure of physicians, pharmacists and hospitals if advanced registered nurse practitioners are allowed to prescribe controlled substances. During the course of the investigation, other issues emerged as important to the investigation. These included prescriptive authority at the federal level, prescriptive authority of other states, substance abuse and disciplinary actions and access to health care in rural and underserved areas (Florida Prescribing of Controlled Substances Task Force, 1997).

In the area of education and training it was discovered to be very difficult if not impossible to compare education and training as both physicians and nurses receive more instruction relating to prescribing medications than the pharmacology course listings in college catalogs due to prerequisite requirements and integrated courses. It was found that for both professions curricula are reportedly designed by national board standards. One difference and another example of the medical monopoly is while medical schools tend to use their own professionals for pharmacology, schools of nursing tend to use Doctors of Pharmacy. What this writer finds interesting is the lack of any acknowledgment of the importance of undergraduate education or prior work experience for the advanced practice nurse (Florida Prescribing of Controlled Substances Task Force, 1997) .

The second big issue to be explored by the task force is whether the right to prescribe controlled substances would increase liability for physicians with whom they have protocol agreements, pharmacists who have certain responsibilities regarding dispensing of controlled substances or hospitals in which they work. The results found by the task force were that increased liability for physicians, pharmacist and hospitals in general seemed small but not totally absent. Very few claims were found against ARNP’s that involve prescribing drugs(Florida Prescribing of Controlled Substances Task Force, 1997) .

It was found that the physician opting to enter into a protocol agreement with an ARNP that includes prescribing controlled substances could assume some increases in liability, but this increase would most likely be shared with the ARNP, as would be the same for hospitals granting clinical practice to ARNP’s with prescription rights for controlled substances (Florida Prescribing of Controlled Substances Task Force, 1997).
The review conducted by the task force of substance abuse programs and disciplinary actions relating to drugs indicated a very low level of abuse by both physicians and ARNP’s. Further revealed was the fact that although physicians show greater tendency for practice in densely populated areas than ARNP’s, rural areas remain underserved by both groups (Florida Prescribing of Controlled Substances Task Force, 1997) .
After considering all the testimony and findings relevant to their study the task force in December of 1997 made the following recommendations. Step 1: Provision of the appropriate statutory changes under Chapter 893 of the Florida Statutes to allow advance registered nurse practitioners to file for an application to prescribe controlled substance only after completion of course requirements which include the prescribing of controlled substance and documentation of experience prescribing non-controlled substances, as determined appropriate by a multidisciplinary committee from the Board of Nursing, Board of Medicine, Board of Dentistry and Board of Pharmacy. Step 2: Provision of the appropriate statutory changes to grant advances registered nurse practitioners in the state of Florida, with an approved application to prescribe controlled substances under protocol, the authority to prescribe controlled substances, and make application to the U.S. Department of Justice, Drug Enforcement Agency (DEA) for the issuance of a DEA number under a protocol agreement with a practitioner licensed under Chapter 458(physicians), Chapter 459(osteopathic physician), or Chapter 466(dentist), Florida Statutes (Florida Prescribing of Controlled Substances Task Force, 1997).
As of this time the Florida Legislature has failed to pass the appropriate bill to grant prescriptive rights for controlled substances to advanced registered nurse practitioners.

Professional Sovereignty and Subsidies
Physicians have enjoyed a privileged position in society for most of the last century. They have been shielded from competitors by laws granting the profession control over training and licensure and restricting the opportunities for others to practice medicine. This situation has created a veritable “professional sovereignty” and resulted in physicians experiencing great liberty in setting their own fees and in the practice of medicine, with very little external oversight or intrusion.

In addition to using government to restrict competition, the medical monopoly also turns to government for subsidies. The federal government subsidizes most physician training. In 1927 student fees accounted for 34 percent of medical school revenues. Today less than 5 percent of medical school revenues comes from tuition and student fees. Instead, medical schools rely heavily on federal and state support. In 1992 total medical school revenues amounted to $23 billion. State and local governments provided $2.7 billion and the federal government paid at least $10.3 billion to medical schools and hospitals for education and training. Medicare payments to hospitals represent the largest source of federal funding for medical education and training. This is achieved in two ways. Hospitals receive direct payments from Medicare based on the number of full time equivalent residents employed at each hospital. Also Medicare increases a hospital’s diagnostic-related group (DRG) payments according to the “indirect” medical education factor, based on the ratio of residents to hospital beds.

Challenge of the Medical Monopoly
Although medicine has had a long history of protecting physician performance from public scrutiny, ARNP’s have not had the same protection. Fortunately even under the microscope, ARNP’s have proven to be remarkable providers. Research shows that ARNP’s provide high quality, cost effective care and can sometimes surpass the safety and quality of care provided by physicians.

The advent of the managed care revolution has threatened to end this “golden era” for the medical monopoly. Documenting ARNP effectiveness is not enough, as organized medicine, threatened by the loss of control over the health care dollar, continues to attack ARNP practice autonomy. This year, for example, an American Medical Association (AMA) newspaper headline unashamedly boasted about physician attempts to prevent ARNP’s from practicing to their full potential (Pearson, 2002).

Despite widespread dissatisfaction with managed care, payers (insurers, government, employers) clearly have indicated that they will resist increases in the cost of health care. According to the opinion of Catherine Poplin M.D., J.D., payers will not pay physician-level fees for care that can be competently provided by less expensive professionals. Eventually if physicians continue to do nurse practitioner-level work they will have to be satisfied with nurse practitioner-level reimbursement. Dr. Poplin suggests that since physicians cannot compete with nurse practitioners on price then they had better adopt another strategy – working in teams. She suggests this team approach would involve physicians moving from high-volume, low margin services to low-volume, high-margin services and benefit from the integrating of care. While she admits relinquishing some work to nurse practitioners may reduce the demand for physicians she further points out that the public is under no obligation to support whatever number of physicians is produced. By decreasing admissions to medical school, the supply of physicians can be reduced without triggering antitrust laws. Since the cost of medical education is an expensive drain on the system, this strategy would save everyone money.

Advanced registered nurse practitioners have an important contribution to make, and collaboration between physicians and ARNP’s holds promise for improved models of care. The challenge of the health professions in the coming years will be to develop models that promote this complementary relationship while mitigating the harsh competition.

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