To its patients, the Nurse Managed Primary Care Center is a doctor’s office like any other—they come in with their sore throats and high blood pressure and come out with antibiotics and dietary counseling.

But there are no doctors. As its name suggests, the University of Delaware clinic is led by advanced practice nurses. These are nurses who have obtained a master’s degree and chosen one of four specializations, most commonly nurse practitioner.

In Delaware, as elsewhere, these nurses can diagnose illness, prescribe medication and do most of what a family doctor can.

In recent years, as the demand for primary care doctors further outstripped their supply, nurses have steadily expanded their scope and can now prescribe medicine in all 50 states. Carolyn Haines, director of UD’s primary care practice, says nurses are well suited to the challenge of helping patients prevent illness and live healthier lives.

Then there are the economics. Advanced practice nurses are less expensive to hire than medical doctors. Payment from health insurance companies varies, but many pay the same for services whether they’re delivered by a nurse or doctor. The federal government, though, pays 85 cents on the dollar for care delivered by nurses.

The number of licensed nurse practitioners in Delaware jumped by 30 percent over the past year alone, to 1,372 as of February. National surveys show that about three-fourths of nurse practitioners work in primary care. Considering that about 800 doctors practice primary care in Delaware, it’s likely that nurse practitioners in that setting now outnumber doctors. As Delawareans become older, they’ll need the continuity of care—a team to look after all aspects of their health—that only primary care can provide.

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And, increasingly, they’ll be seeing nurses. Though nurses can practice independently, most still collaborate with physicians, who tend to treat patients with the more complicated illnesses.

Some doctors, however, question whether advanced practice nurses have the training to spot rare but serious illness. They wonder whether patients will suffer the trade-offs of this transition.

This reliance on advance practice nurses to do the work that doctors used to do raises a series of questions, both for the quality of care patients will receive and the compensation for the nurses themselves.

PRIMARY CARE, SECONDARY PAY

The growing complexity of medical billing and record keeping may discourage physicians from getting into family medicine, but the crux of the shortage comes down to economics.

Dr. Andrew Dahlke, president of the Medical Society of Delaware, says the average doctor graduates from medical school with debt of more than $300,000. Meanwhile, a doctor who chooses a specialty like cardiology or radiology can earn twice as much or more than they could earn in family medicine.

“If you’re making a primary care salary, you can’t pay your bills easily and that’s why there’s so few of them,” Dahlke says. Another key factor, he says, is the federal government’s decision to cap the number of physician residency slots at 1996 levels, part of a Clinton-era cost-cutting measure.

In Delaware, all of Kent and Sussex counties have a primary care shortage, according to the federal government, as does the New Castle area and much of downtown Wilmington. The areas with the biggest shortages are rural places where the population tends to be older and fewer physicians tend to live.

This translates into delays in making appointments and even finding a doctor.

“I have several friends who’re searching for an office that’s accepting new patients,” says Sarah Carmody, executive director of the Delaware Nurses Association.

As a result, there has been a huge growth in urgent care centers, where you can drop in without an appointment to see if your stubbed toe is broken or if your croaky throat is strep. Though hospitals often start these centers to funnel patients into their systems and reduce wait times at emergency rooms, they’re also a convenient outlet for people without a primary care doctor.

That said, urgent care is not supposed to be a replacement for the family doctor. “We strongly encourage patients to find a primary care doctor to treat their chronic issues,” says Leslie Verucci, a past president of the nurses association who works in urgent care.

Faced with a shortage of primary care doctors, the market has responded.

“It doesn’t take a rocket scientist to figure out that [advanced practice nurses] are adding another type of caregiver to help meet this demand,” says Gary Alderson, president of the association.

The nurses themselves say their training and prevention-focused ethos suit them well in a new frontier of medicine that’s as much about keeping people healthy as curing the ill.

PRIMARY CARE MAY BE MEDICINE’S FUTURE

Primary care is central to the future of medicine because it’s the best place to prevent illness and lower healthcare costs.

Dahlke says each dollar spent on primary care reduces costs elsewhere by between $5 to $13 because it prevents disease or slows its progress. Nurses say this is a role to which they are uniquely suited.

Nurses ask, “How do I prevent patients from getting to this disease state by getting my message across effectively and helping the family partner with me in achieving that goal?” says Keith Fishlock, an advanced practice nurse at Alfred I. duPont Hospital for Children.

Keith Fishlock is an advanced practice nurse at Alfred I. duPont Hospital for Children.//photo by Carlos alejandro

Susan Conaty-Buck, president of the Delaware Coalition of Nurse Practitioners, says healthcare spending has historically been tilted toward treating the sick rather than keeping people healthy enough to prevent illness.

As an example, consider a patient whose cholesterol is increasing but not yet high enough to be treated with medication. Such a patient could be referred to a nutritionist who can put together a healthy diet plan that works best for that person.

Clinics and hospitals that are paid based on how well they can prevent illness may see nutrition counseling as one way to keep a patient from getting diabetes, heart disease and other expensive-to-treat illnesses.

Dahlke agrees on the central role of prevention, but he thinks the better solution to the primary care gap is to incentivize doctors to fill it rather than hire more advanced practice nurses.

Without the broad, lengthy training of a medical doctor—family physicians typically train for seven years after their undergraduate degree, compared with a minimum of two or three years for advanced practice nurses—a nurse may lack the deep knowledge to spot unusual diseases, he says.

“Not everybody comes in and has a cold,” he says. “When you get something that’s more odd or esoteric, they’ll have difficulty coming up with an answer.”

One 2012 survey found that about a third of medical doctors believed the wider use of nurse practitioners would reduce the quality of care. Meanwhile, 57 percent of doctors worried that more nurse practitioners would reduce their own income and three-quarters worried they’d be replaced.

Dahlke also suggests that advanced practice nurses may be more likely to refer their patients to specialists than medical doctors are. Inevitably, he says, many of these patients will fall through the cracks, never see a specialist and end up in the emergency room.

“I think we have no choice but to use APRNs (advanced practice registered nurses), I just don’t think it’s a better solution than having doctors,” he says.

There has been plenty of debate over research on whether advanced practice nurses are as effective as doctors. Repeated studies have found the care they deliver is at least comparable if not equal in quality to the care provided by a doctor.

“In many cases, there are studies where we go head-to-head and have the same or better outcomes” than medical doctors, Conaty-Buck says, quickly adding that nurse practitioners aren’t competing with doctors.

Haines says patients themselves don’t mind being seen by a nurse practitioner rather than a doctor; she can’t remember a time when a patient said they were uncomfortable.

ARE PAY, BENEFITS KEEPING UP?

As more is asked of nurses, it seems reasonable to expect that more will be given, both in terms of pay and prestige. In Delaware, nurse practitioners earned an average salary of about $105,000 a year in 2017, roughly on par with the national average.

That’s about half of what family doctors make on average, though Haines says nurses expect to be paid less. She says there are other benefits besides salary to consider. As many employers do, hers paid for her master’s degree while she worked.

“I started working as a nurse practitioner with no graduate school loans and could work right away at a job I loved,” she says.

As it is for doctors, pay for advanced practice nurses tends to be higher in hospitals and specialty clinics and lower for primary care. One specialty in particularly high demand is mental health nurse practitioners, Conaty-Buck says. Such a nurse could have a job lined up a year before graduation.

Though they want competitive wages, advanced practice nurses prioritize the ability to work independently and not be held back by rules that limit what they can do.

Susan Conaty-Buck is president of the Delaware Coalition of Nurse Practitioners.//Photo by Carlos alejandro

As Fishlock, the pediatric advanced practice nurse, puts it, “It’s the ability to have autonomy and to do what I love, as well as being supported in personal and professional growth.”

For example, when he sought licensure from the Drug Enforcement Administration to prescribe narcotics, his employer paid the $800 fee.

The Delaware Nurse Practice Act, passed in 2015, largely gave advanced practice nurses this autonomy, though some nurses are looking for fewer rules about when they can practice on their own. To operate their own practice, a licensed nurse has to apply for a separate state independent practice license.

This is a hurdle no other licensed professional has to clear, says Carmody, the nursing association executive director. Advanced practice nurses must spend 4,000 hours and two years working in a collaborative agreement with a doctor before going out on their own.

“That is seen as a barrier,” Carmody says.

There are other nationwide regulatory hurdles holding nurse practitioners back from putting out their shingle, Conaty-Buck says. Medicare requires a doctor’s signature before it will pay for home medical equipment like special shoes for someone with diabetes.

And even if they pay full price, insurance companies can make it difficult for nurse practitioners in solo practice to get on a list of approved medical providers. The result is that only a handful of nurse practitioners in Delaware operate in private practice without a doctor, Conaty-Buck says.
Meanwhile, it seems clear that the need for nurse practitioners and other advanced practice nurses is only set to rise.

At the height of the baby boom, in 1957, 4.3 million babies were born in America. This year, they turn 62, and over the next decade they will ratchet up demand for primary care. One government projection shows a shortfall of 110 primary care physicians in Delaware alone by 2025.

“Nurse practitioners nationwide,” Carmody says, ”are rising to meet that challenge.”