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Health plan battle: Nurse practitioners vs. physician assistants

SHERRY MAYS

Nurses at Tahoe Forest Hospital will face changes with the implementation of the Tahoe Forest Hospital’s Community Health Plan, hospital officials say.

“With reduction in revenue, the market is going to be driven by patient demand,” Chris Spencer, TFH’s director of outpatient services said. “If patients want cheaper care, nurses and nurse practitioners are going to have to step in an perform more tasks.”

This is a trend that has been going on for more than two decades, Spencer said.

“The industry has seen nursing shortages and just the opposite,” she said. “When doctors and nurses decide to specialize their education or generalize the rollercoaster begins.”

Nurses are training in more specialized areas and are receiving more training. In a managed care environment this is important, but in the district it is causing controversy and anxiety within the ranks of nurses and mid-level practitioners.

Mid-level practitioner is a general term for a group of medical professionals that have advanced medical training above the nursing or paramedic level, but are below the physician level of training. Mid-level practitioners come in two categories, nurse practitioners and physician assistants. Although they are very similar, they are also very different.

The distinct difference between the two professions is THF hires nurse practitioners and not physician assistants, even though professionals on either side may have the exact same education.

The difference between the two classes of mid-level practitioners is the background from which the professional has come. Nurse practitioners come from registered nursing backgrounds and physician assistants come from a paramedic, emergency medical technician or other technical background.

“I don’t understand why the district won’t hire physician assistants,” said Shari Schmidt, physician assistant. “I was working at the Kings Beach clinic when the district decided to only hire nurse practitioners and now my good friend has my old job.

“At (U.C.) Davis, where I received my training, the nurse practitioners were trained in the same classrooms as the physician assistants. So why does the hospital see such a difference?”

Spencer said THF sees the two professions as completely different and it comes down to the different backgrounds that the practitioners have come from.

“The hospital sees nurse practitioners as being more convenient and more in-line with the internal credentials within the hospital,” she said.

The hospital recognizes that nurse practitioners have already been registered as nurses and have satisfied academic degrees at the master’s level.

“Some PAs come through with the minimal amount of academic experience and others have master’s degrees,” Spencer said. “At least with NPs we know where their education has taken them. I’m not saying that physician assistants are less educated, I’m only saying that from the hospital’s standpoint it is easier to hire nurse practitioners.”

Nurse practitioners and physician assistants were developed out of a need for more care in rural areas, where physicians were choosing not to practice. Just as public demand created the need for more mid-level practitioners, it will also determine the need for practitioners or physicians under the managed care plan, she said.

“That is why we hire nurse practitioners-they can practice on their own and deliver care without total supervision from doctors,” she said. “If a doctor charges $100 for a general exam and a nurse practitioner can do the same job for $65, they will probably chose the practitioner.”

Just like physicians, nurse practitioners must seek advice on cases, but not as much as the physician assistants require, Spencer said.

“Assistants can diagnose and treat patients, but require a case-by-case analysis right then and there,” she said. “Nurse practitioners will be reviewed, but probably on a weekly or monthly basis.”

In response to a June article in the Reno Gazette-Journal stating the discontent among nurses at Reno’s Washoe Medical Center, Spencer said conditions at THF will not get to that point.

“Things will change, but I don’t think for the worst,” she said.

The article’s author wrote about the problems with “team nursing” and the use of “less-skilled” nurses. She wrote about nurses facing less flex time and more “floating” among departments. The personnel who did not get laid-off under the financial squeeze caused by managed care now worked harder, with more hours and less trained support.

Kathlee Martin, a nurse practitioner at St. Mary’s Hospital in Reno, said many nurses and practitioners are concerned about the level of care given to patients under managed care.

“With cutbacks, comes less time available for patient care,” she said. “We can’t forget who the most important people are in this equation-the patients.

“If docs spend less time with patients and more of the responsibility falls on the shoulders of nurses and their aides, time is spread thinly and something must give.”

At peak times at Tahoe Forest Hospital this may have significant impacts on the staff. In Jan. and Feb. of 1997, the hospital was at 100 percent capacity, officials said.

For the 49 full-time and 90 part-time registered nurses at THF, time can be at a minimum for patient care.

Spencer sees registered nursing taking a different avenue in the future.

“Patients are looking for one-stop shopping and nurses and nurse practitioners are perfect for this,” she said. “It will all happen at a clinical level.

“Nurse practitioners will be able to handle almost any patient and any condition that happens into a clinic. This is where nurses will probably spend more time, rather than spending it in acute care in a hospital environment. There is going to be more flexibility needed.”

Hospital Administrator Larry Long said that streamlining to increase hospital efficiency will happen no matter what. Although he did not comment on possible staff cutbacks, he did say that the most skilled personnel would be maintained to increase efficiency.

Joseph Ferrera, THF community relations officer, agreed.

“There will be a definite need to streamline hospital costs, which will include personnel,” he said. “There won’t be massive layoffs, but there will be some rearranging. It’s all a matter of change and people will have to make the changes with us (the district).”

Schmidt does not agree.

“I think that physician assistants should be included in the picture,” she said. “There is no reason to exclude us.”

Spencer concluded that no matter who performs the tasks, early detection is the key to keeping a community healthy.

“If a patient feels more comfortable in a clinic or if they chose to want to pay less for medical treatment, it means the same thing,” she said. “As long as they can get the treatment they need then the plan is successful.”


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