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Nurse Practitioners: Challenges and Opportunities 2015 and Beyond

Primary health care is on the agenda with the release today by the Government of an options discussion paper ‘Better outcomes for people living Chronic and Complex Health Conditions through Primary Health Care’.  The paper was developed by the Primary Health Care Advisory Group, led by former AMA President Dr Steve Hambleton.  While the paper does mention nurse practitioners (twice in fact!) it disappointingly short on any new options for better utilizing this important group of health professionals in the primary health sector.

With the paper now out for consultation, Dr Hambleton and his colleagues might be interested in the following piece by Mack Madahar, a primary health care and mental health nurse practitioner.  In it he identifies a number of current barriers and opportunities to increasing the role of nurse practitioners in the primary health care sector in order to improve both the quality and efficiency of care provided.

Mack Madahar writes:

Nurse Practitioners (NPs) were provided access to the MBS in November 2010. Besides limited access to pathology/radiology, NPs were provided with 4 time-tiered MBS item numbers for professional attendances. While most NPs have established themselves in public hospitals, primarily because of the relative financial certainty it provides, there are handful of NPs trying to establish a niche in primary care (PC).

There is a tremendous amount of debate in PC about burgeoning Medicare costs and the ability to offer fully subsidised PC. Whilst GPs are well placed in PC, Primary Health Care (PHC) NPs have demonstrated to be an excellent resource in providing care that is safe, effective and affordable.

Besides improving patient satisfaction, PHC-NPs facilitate a focus on complex and chronic care needs, which may increase patient throughput and productivity. Such services provide excellent examples of NPs offering value-added service at little cost. Nevertheless, PHC-NPs face daily challenges, some of which are worth mentioning. This in order to gain better understanding of these problem/s and convert such challenges into possibilities for change into the future.

 Challenges

Access to only 4 time-tired MBS item numbers is limiting growth of NPs in PC at a time when there is an increase in ageing, chronic disease and mental health populations. Limited ability to earn a living is turning NPs away from collaborating with GPs in the provision of PC.

  • PHC-NPs are unable to make MBS-reimbursable referrals to allied health professionals and have limited access to MBS diagnostic imaging items.  This contributes to duplication of care and practice inefficiencies.
  • There are no after-hour MBS item numbers for NPs working in PC. This means that running such services from an administrative standpoint make it financially unviable.
  • Lack of incentive payments for bulk-billing children, elderly and health care cardholders prevents PHC-NPs from focusing on the marginalized populations they were designed to serve.
  • PHC-NPs can independently perform simple procedures such as insertion of contraceptive implants, as well as Spirometry and ECG interpretation. Unlike GPs, PHC-NPs have no access to procedural MBS item numbers.  This means the full costs of performing such procedures are passed on to patients and/or GP practices, which provides a financial barrier to essential screening and diagnostic services. This also means that GPs have to foot the bill for consumables when NPs have performed such services. The cost must not be passed on to practices as part of a collaborative.
  • There is a lack of knowledge of the PHC-NP role.  The AMA (to their credit) has done an excellent job in muddying the waters by confusing the NP role with that of the practice nurse (PN). NPs are independent practitioners who work beyond the contemporary RN scope of practice.  They are able to prescribe medicines, order and interpret diagnostic tests, and make referrals to medical specialists.  They perform their functions above and beyond the PN role.

Opportunities

Minister of Health Hon Sussan Ley recently announced a new payment model that encourages General Practices to provide after-hours services. Though specific eligibility around the PIP has not been announced, it is hoped that NPs working in collaboration with GP are included in this arrangement.

At the same time an MBS Review Task Force has been announced. This taskforce will examine the relevancy of 5500 MBS item numbers and align them with clinical evidence. While this is encouraging there are no NPs on the review panel. This presents a missed opportunity to provide informed financial consideration of the NP role in general practice.

The Primary Health Care Advisory Group (PHCAG) is another excellent announcement and shows the Minister’s commitment to support patients with chronic and complex health conditions. Except for the inclusion of the chair from the Australian Practice Nurse’s Association, NPs are missing from the advisory group. Perhaps it is time for a change of heart.

NPs are underutilized in PC due to financial constraints. This missed opportunity places added burden on GPs, and contributes to strain on the public health system. Small increases in government spending to improve access to existing MBS item numbers (at a reduced rate, e.g. 85%) will encourage NPs numbers in PC and provide an impetus for PNs to enroll in NP programs. While PNs work tirelessly, NPs provide an advanced level of expertise that can support general practices in a greater cost-effective manner.

Conclusion

The current government is committed to cost savings in health and PC is proving to be one of their toughest challenges.  PHC-NPs working together with GPs offer a real solution to support all aspects of chronic and complex health problems, with the potential to contribute to real health systems savings. New payment initiatives and advisory committees demonstrate the government’s commitment to cost savings and evidenced-based care.  Greater consideration of the PHC-NPs role can help support this Government’s aspirations.  This valuable resource should be allowed to work to its full potential to demonstrate the potential of a cost saving alternative in the long term.

Mack Madahar is a PHC and MH nurse practitioner. He acknowledges the valuable input of Chris Helms, RN, NP, MSN, ANP-BC, FACNP, in writing this paper.