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Running head: House Bill-630- Interpretation of “Physician” – Inclusion of Advanced Practice

Nurse and Physician Assistant

Presented to

[Dr. Philipsen]

In partial fulfillment of the requirements of
NURS 505: Health Policy & Research
Bosede Adedire, BSN, RN

[April 30, 2013]

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There are number of studies that support no difference between care outcome of services
rendered by physicians compared to the ones rendered by nurse practitioners or physician
assistants (Carter & Chochinov, 2007; Green, Savin, & Lu, 2013; Horrocks, Anderson &
Salisbury, 2002; Hooker, & McCaig, 2003). Different attempts have been made to communicate
this issue to highlight reasoning behind this topic. Over the years, the discussion has gained
momentum, but has not received any concrete attention until recently with the introduction of
house bill 630, a bill on the ‘interpretation of physician to include nurse practitioners (NP) and
physician assistants (PA)’. Number of studies has supported the need to implement this
interpretation; they proposed that primary care outcomes do not differ between nurse
practitioners and physician delivery, which create a justification to allow NPs and PAs to practice
to the full length of their education. There is a need to have more studies done to highlight the
importance and rationale for this process which will provide resource for policy makers. There
are different research studies about the significance of the role of NPs and PAs, however, little
studies exist about the need to have them be independent of physicians and have interpretation of
their title be inclusive in the interpretation of a ‘physician’.
House bill 630 – Senate bill 747- was introduced past February, the bill launches rules of
interpretation of “Physician” to comprise Advanced Practice Nurse (NP) and Physician Assistant
(PA). This bill would permit nurse practitioners and physician assistant to practice to the full
magnitude of their education and learned skills. The bill would allow nurse practitioners to
undertake care that they are legally permitted to provide and enable them to make
recommendations that patient needs in the management of their care which they are entitled to.
However, this bill would not change the scope that the nurse practitioner or physician assistant
practice. There are different stirring factors for this bill, however, the Affordable Care Act (ACA)

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has been a significant backbone driving this policy, and it continues to gain momentum in current
public and health discussions. The objective of this policy is to create a logical comparable
avenue that would make health care available to millions of citizens at a low cost to them.
Current statistics documents that “30 million Americans will immediately be eligible for the
ACA once the policy is at its full implementation” (Carter & Chochinov, 2007, para. 6),
however, this increase in health care eligibility reportedly would create a possible inequality in
the demand and supply of primary care providers and people that needs care (Horrocks,
Anderson, & Salisbury, 2009, para. 2) . The policy to increase health care eligibility through
house bill 630 is viewed from different perspectives to be economical, ethical and political. The
policy is economical in the sense that it reduces overall health care cost, especially to the
individual and on a larger scale to government obligatory spendings (Naylor & Kurtzman, 2010,
para. 6).
Likewise, the policy is seen has been ethical because it provides avenue for millions of
Americans and legal residence to have health insurance which will be supported by expansion of
roles of ‘non-physicians’ which in the long run will reduce health inequality (Green, Savin, &
Lu, 2013, para. 8; Cooper, Getzen, & Laud, 2008). A study reports that the number of available
physician will not be able to service the increase number of Americans that will become eligible
under the ACA. Therefore, different proponents have suggested the need to be prepared for the
shortage in primary care by having a system in place that would absorb the increase in the
demand for primary care. Recommendations have been made to have physician be inclusive of
advance nurse practitioners and physician assistant to allow them practice to the full extent of
their training. The need to have an alternative that is immediately comparable for anticipated
future shortage is the focus of recent discussion viewed from different perspective.

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This bill has received quite a number of support, including senator; Nathan-Pulliam,
Eckardt, Elliott, Hubbard, Jones, A. Kelly, Krebs, Murphy, Oaks, Pena-Melnyk, Reznik, Tarrant,
and V. Turner. Supporters of this bill explained the positive influence this bill could have when
the affordable care act is fully introduced and how it could create opportunities for number of
uninsured low income groups, who currently do not have health insurance. They suggested that
this bill would allow all providers to be able to work at the full scope of their training and
proficiency to ensure quality and access to affordable care. However, this bill has been opposed
by a number of physician groups and association, including American Medical Association,
Academy of Family Physicians, both of which advocate to have nurse practitioners and physician
assistants be supervised by physicians. The opposing view recommends not having ‘physician
extenders’ practice without supervision of physicians because their training is not equivalent to
that of a physician (Grumbach, Hart, Mertz, Coffman, & Palazzo, 2003, para. 2).
The rationale for the inclusion of Physician to include advance practice nurse
practitioner and physician assistant is drawn from practice. A number of studies have shown that
“there is no difference between the care outcome provided by a physician and an advanced nurse
practitioner” (Naylor & Kurtzman, 2010; Grumbach, Hart, Mertz, Coffman, & Palazzo, 2003;
Norris, Melby, & MPhil, 2006). Moreover, research indicate that majority of people presently
cannot afford to have health insurance ( Savin, & Lu, 2013) , however, this bill would give a
large number of Americans the opportunity to afford equivalent quality health insurance at a low
cost to them. According to a report from a randomized study, researchers established that “in
situations where nurse practitioners have the same authority as physicians, patient outcomes
were comparable, yet, care reimbursement are not the same for both parties” (Mundinger et al,
2002, para.2; Wing, Langelier, & Continelli, 2004) . A separate study confirms this inequality in

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compensation, and recommends that “equivalent reimbursement be paid for comparable services
regardless of practitioner, and that performance results be publicly reported to maximize the
high-quality care that nurse practitioners provide” (Naylor & Kurtzman, 2010, para. 8;) to
reinforce the need for their inclusion in the interpretation as a physician, which also demonstrate
core leadership and true expertise (Patronis, 2007, p. 78).
Another rationale for house bill 630 is show case in a qualitative study that examined the
practices of physicians and nurse practitioners in reference to treatment and prescribing reports
that “treatment practices and prescribing behavior were consistent between nurse practitioners
and physicians and there is no measurable difference in the quality of basic care services”
( Horrocks, Anderson, & Salisbury, 2002, para. 6; Norris, Melby, & Mphil, 2006). Reports of
different studies have also shown justification for house bill 630 to be considered and
implemented due to future physician shortage envisaged and the need to have a strategy that is
immediately comparable. One study explains that it cost quite a lot of money and approximately
‘twenty years’ to train a doctor, however, “between three and twelve nurse practitioners can be
educated for the price of educating one physician and more quickly” ( Green & Savin, 2013,
para. 6), and we still get similar care outcome.
Furthermore, the objective of the ‘inclusion policy’ of physician to include advance
health practitioners basically is to provide an equivalent approach to provide affordable quality
health to millions of Americans, to avert report findings from studies that have shown that
projected physician shortage by 2020 could result in health crisis if gap created is not filled in a
timely manner (Venning, Durie, Roland, Roberts, & Leese, 2000, para. 6; Horrocks, Anderson,
& Salisbury, 2002, para. 2; Naylor & Kurtzman, 2010, para. 6; Savin & Lu, 2013), and with
“thirty million more patients that would be eligible under the affordable care act, there would be

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increase in the demand for primary health care providers which available physicians will not be
able to care for” (Naylor & Kurtzman, 2010, para. 8) , therefore, this bill will provide a bridge
to this potential problem by given nurse practitioners and physician assistants the ability to
practice at the full scope of their expertise which will allow them to care for the overflow. Green
& Savin, 2013, added that nurse practitioners and physician assistant have the potential to offset
completely the increase in demand for physician services while improving access to care, thereby
preventing a primary care physician shortage (para. 4).
Moreover, this bill is significant because of the elderly population, the prevalence of
chronic diseases and the need to provide affordable quality care makes it pertinent to have a
policy that would allow nurse practitioners and physician assistants to practice to the full extent
of their skills. This bill will nurture and sustain better healthcare practice and also put physicians
at the point where they give the best cost-effective health care practice because of the supposed
competition they have assumed Nurse practitioners and physician assistants would introduce.
Likewise, nurse practitioners are also the symbol of retail clinics to provide and improve patient
access to health care by providing affordable quality care. Ultimately, the ‘inclusion policy’
would expand the pool of available health care providers by empowering advance nurse
practitioners and physician assistants to practice to the full extent of their training. Enacting this
bill will not create any financial obligation to the government but will reduce their financial
obligations in the long run.
The criterion to meet the bill objective of this interpretation is that the bill may not be
construed to expand the scope of practice of an advanced practice nurse or PA. The option
provided for the criteria is valid because it will prevent practitioners from carrying out tasks that
is not within their scope of training which provide a safety net for patients to ensure that the care

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that they receive is within the scope of the practitioner’s expertise and is legitimate. To promote a
more equitable pattern and safe service to needy populations, Bangley, Chan-tack & Hicks,
2013, recommends an “ongoing active commitment by policy makers, educational institutions,
and the professions to a mission of public service and to incentives that support and promote
authorized care to the underserved” (para. 6).
The solution to this policy is to allow the bill to pass to enable trained health care
practitioners practice to the full extent of their training and education, to prevent any form of
primary care provider shortage which may result from increase in the demand for primary health
care provider. Huang & Finegold, 2013, added that expansion of insurance coverage is expected
to increase demand for primary care services, “findings that justifies the need to promote policies
that encourage more primary care providers and community health centers to practice in areas
with the greatest expected need for services” (para. 2). This bill had lots of potentials; however, it
was withdrawn and did not have enough votes to go through. Recommendation is made for
future re-introduction of the bill for further evaluation.

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Bagley, Chan-Tack., & Hicks. (2000). Health outcomes among patients treated by nurse
practitioners or physicians. Journal of American Medical Association; 283: 2521-2524
Carter, J., & Chochinov, M. (2007). A systematic review of the impact of nurse practitioners on
cost, quality of care, satisfaction and wait times in the emergency department
CJEM ; 9(4):286-295
Cooper, Getzen., & Laud. (2008). Economic expansion is a major determinant of physician
supply and utilization. Journal of Health Services; 38: 675-696
Green, L., Savin, S., & Lu, Y. (2013). Primary care physician shortages could be eliminated
through use of teams, non-physicians, and electronic communication. Journal of Health
affairs. 32:111-19. doi: 10.1377/hlthaff.2012.1086
Grumbach, K., Hart, G., Mertz, E., Coffman, J., Palazzo, L. (2003). Who is caring for the
underserved? A comparison of primary care physicians and nonphysician clinicians in
California and Washington. Annals of Family Medicine. (1) 2 97-104
doi: 10.1370/afm.49 Ann Fam Med
Hooker, J & McCaig, L. (2003). Use of physician assistants and nurse practitioners in primary
Care. Journal of Health Affairs; 20: 231-238.
Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse
practitioners working in primary care can provide equivalent care to doctors. Journal of
American Board of Family Medicine, 23 (5), 25-43.

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Huang, E., Finegold, K. (2013). Seven million Americans live in areas where demand
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Wing, P., Langelier, M., Continelli, K. (2004). The changing scope of practice. Non-physician
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