Why nurse practitioners train on the backs of physicians

“Nurse practitioner (NP) education is seriously underfunded. The profession is attempting to saddle private physicians with this cost.”

That is how “Dr. X” replied to my email asking whether he would be willing to precept a nurse practitioner student for her clinical rotation. I read through his clearly disgruntled letter and wanted to explain to him why NPs have to train “on the backs” of physicians and why funding for nursing education needs to change.

I couldn’t argue with a lot of what Dr. X said in his email though. Yes, helping train a novice clinician, whether a medical student or a nurse practitioner, takes up time and that can equal money. And I will not argue with him that “NP education is seriously underfunded.” I definitely won’t argue that this is a serious problem for the NP profession. But what I will debate are his comments that “medical school provides medical training at huge costs, and that NP programs are attempting to train with the goodwill of physicians.” This subject is far more complicated than he implies.

Graduate medical education (GME) is partially funded through federal tax dollars. Yes, we all contribute to the cost of training physicians. The federal government contributes about $9.5 billion in Medicare funds and Medicaid kicks in about $2 billion to help pay for GME at teaching hospitals. GME covers all physician specialties, not just primary care. Additionally, Veterans Administration Hospitals provide funding in their hospitals, and many private insurers support GME. Of course, medical schools also contribute to the cost of medical education for physicians. Through various funding sources, medicine receives financial incentives to train their students. However, nurse practitioner education does not have the same kind of endowment — financial responsibility rests solely with the students or schools.

First, a little background on advanced practice registered nurses (APRNs): APRNs are masters- or doctorate-level registered nurses who have advanced training. APRNs include nurse practitioners, clinical nurse specialists, certified nurse midwives and nurse anesthetists. They can diagnose illnesses, treat medical conditions and provide education to patients. Multiple studies show APRNs provide safe, affordable care and improve access, especially in primary care — an area in significant need. Research shows that the United States will need an additional 23,640 primary care providers by the year 2025. And fewer med students are choosing primary care. But APRNs — NPs in particular — can help with the growing shortage in primary care. But we need to train our APRNs first, so we need preceptors (medical mentors) to help with this training. Unfortunately, there is a preceptor crisis for APRNs. Due to changes in medicine and the influx of medical providers needing training, there are just not enough willing preceptors. How will we get enough well-trained APRNs if there are not enough willing preceptors to train them?

One answer is to financially incentive APRN preceptors. After all, it works for medicine. Why isn’t NP education covered under Medicare and other federal funding? The fact is, NPs did not exist when Medicare was implemented, so their clinical training doesn’t generally qualify for Medicare funding. However, in 2012, the Centers for Medicare and Medicaid Services (CMS) undertook a study called the graduate nursing education demonstration (GNE) to see if Medicare reimbursements given to practicing clinicians who supervised (precepted) the training of APRNs would increase the number of APRNs. In other words, will paying preceptors incentivize more medical providers to precept resulting in more APRNs? In September of this year, a report to Congress demonstrated that it does. It was both feasible and affordable for Medicare to pay hospitals to help increase clinical training opportunities for APRNs in community and hospital settings. The demonstration is in its sixth year, and an independent CMS evaluation showed a significant increase in APRN primary care providers.

Funding GME makes sense because we need a knowledgeable and well-trained physician workforce. But funding medical education for APRNs also makes sense! It’s time to change antiquated policies in funding, policies that have barely evolved since Medicare’s inception in 1965. The responsibility of training APRNs should be shared by the student, the nursing programs, and government agencies. Policy changes must be made to Medicare to support and compensate for APRN clinical training. APRNs can be part of the solution for the primary care shortage. However, many changes must be made in funding the current training process to succeed. But in the meantime, Dr. X., can you please help precept an NP student?

Lynn McComas is a nurse practitioner.

Image credit: Shutterstock.com

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