Add able hands to medical system

Over the next few years, millions of uninsured Americans will sign up for new coverage, but that step alone doesn't guarantee that they will have access to medical care.

Even before the federal health reform law passed in March, the Association of American Medical Colleges predicted a national shortage of physicians of roughly 124,400 by 2025. The baby boom generation grows older, and that means doctors and nurses are retiring at the same time that their patients' medical needs are increasing.

Those trends, combined with expanded availability of insurance, will require changes in how health care is delivered, and the rules providers must follow.

Nurse practitioners are a logical starting point. The title refers to registered nurses who have received additional training and passed national certification exams. Most have a master's degree, and some hold a doctorate.

Virginia formally recognized nurse practitioners in 1973 amid a provider shortage in rural communities and inner cities. More than 5,000 nurse practitioners now work in the commonwealth. State regulations require that they be under the direct supervision of a physician. A nurse practitioner with the authority to prescribe medications must work in an office where the supervisory physician regularly practices, and that doctor can oversee no more than four nurses.

Only 12 states have such strict supervisory rules. Most others permit more flexible partnerships in which a doctor periodically reviews patient records at a medical office manned by nurses. Fourteen states allow nurse practitioners to establish independent practices. Several are considering relaxing rules so that nurse practitioners are better able to help with growing patient loads. Maryland this year freed them to practice as long as they have a written agreement with a physician.

Even in Virginia, some exceptions to state regulations already exist. Nurse practitioners serving at military facilities aren't covered by state supervisory rules. At federally-funded health centers in rural areas, they may prescribe medications as long as a doctor makes periodic site visits.

If nurse practitioners are trained to examine patients, make routine diagnoses, prescribe medications, order tests and handle referrals, prohibitive state licensing rules should not bar them from doing so. But some physicians view them as a threat.

Doctors argue that there is a risk in handing over too much responsibility to a provider with roughly half the years of education and far less clinical training than a family physician. But there is no evidence that patients are less safe in the states that give nurse practitioners greater autonomy. Indeed, safety can be improved if doctors are free to concentrate on the sickest patients.

Dr. Bill Hazel, the state's secretary of health and human resources and an orthopedic surgeon, has recognized the need and coaxed doctors and nurses to begin discussions about changing the regulations.

The Medical Society of Virginia may be determined to retain the supervisory rules, but Hazel's leadership has kept doctors at the table in search of a compromise. That's a good sign. A turf war is in no one's interest. However, the inevitable calls for a study of the issue should be recognized as an effort to delay progress that needs to begin immediately.

Team-based care models in which nurse practitioners play a greater role in rural health centers need to be expanded through regulatory reform and pilot projects throughout the state. Licensing rules should ensure quality of care and improve access; relaxing Virginia's regulations governing nurse practitioners will do both.