STANGLER: Doctor nurse will see you now

By | Sunday, July 20, 2008

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In April, a tiny step was taken that may have costly consequences for American health care. The Council for the Advancement of Comprehensive Care (CACC) and the National Board of Medical Examiners announced that, beginning this autumn, they will offer a voluntary exam for nurse practitioners (NPs) to gain certification as a DNP - a doctor of nursing practice. The aim is to replace the nurse practitioner with the DNP by 2015.

This is a bad idea. (Full disclosure: my wife is studying to be a pediatric nurse practitioner.) Proponents of making the DNP mandatory say it will alleviate the shortage of primary care physicians (PCPs). In the 1960s, a booming population boosted health-care demand, causing a PCP crunch. In response, the University of Colorado and the Commonwealth Fund conceived of the nurse practitioner - training nurses in clinical care. By filling an underserved gap, the nurse practitioner expanded supply.

Today, we no longer face a shortage of physicians but, instead, a misallocation. Partly because of cost pressures, physicians have gravitated toward more lucrative specialty practices. This makes sense; specialization in any industry usually makes society better off, and how many among us wouldn't choose the higher-paying route?

But requiring nurse practitioners to be more like doctors seems like a strange way to mitigate this. Many DNPs (and NPs) already specialize, and requiring more education makes this a narrowing, not an expansion, of supply.

Second, it seems odd that with rising health care costs, we should seek to toughen requirements for health-care providers. That will likely only increase costs; studies show nurse practitioners provide 80 percent of the care a physician provides at a much lower cost. DNPs already command higher prices than NPs. The prospect of tightened supply and higher salaries should put consumers on notice.

Cost reduction probably is not the reason for the effort to mandate the DNP. Look at the organizations behind it: the CACC, the American Association of Colleges of Nursing, and existing DNP programs such as the one at Columbia University - in other words, those who would benefit from a required DNP. This shouldn't surprise anyone; we would be hard-pressed to come up with an instance when established interests sought less money for themselves.

Finally, every year the media report on the pending nursing shortage. Yet every year nursing shows up as one of the most popular college majors. The bottleneck is faculty - there aren't enough nursing professors and, sure enough, proponents of requiring the DNP say it will remedy this.

But if nurse practitioners aren't becoming professors now, will requiring more education produce more instructors? At most schools of nursing, a nurse practitioner could walk right in and teach. But they aren't. So something must not be right with the incentives. Will schools pay more for a DNP to teach?

If that were the case, given the dire faculty straits, schools surely would already be offering extra money. It strains credulity to imagine that nursing schools are waiting for a mandatory DNP so they can raise pay. There already is a Ph.D. in nursing that many prospective professors obtain. Has its existence increased the number of nursing faculty?

In addition to these three reasons, we can mention a fourth, more minor one: an inferiority complex among some nurses and NPs, especially within the professional associations. Many nurses and NPs choose their career path because they don't want to be doctors. Why should nurse practitioners be forced to rescind that choice? A recent story about the move to the DNP even mentioned that some see this as "validation" of what they do.

This isn't about quality of care: One of the leading proponents of the DNP actually published a study finding no difference in care between patients randomly assigned to nurse practitioners and physicians. And NPs can already do all of the things a DNP would do anyway, including hospital admittance.

Those pushing the doctorate of nursing practice have failed to present a convincing case. Anyone interested in both access to health care and health-care cost - that is, everyone - should not let this small but consequential step proceed.

Dane Stangler is a senior research analyst at the Ewing Marion Kauffman Foundation in Kansas City.

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