- Email: [email protected]
Meeting Australia’s Emerging Primary Care Needs by Nurse Practitioners
Meeting Australia’s Emerging Primary Care Needs by Nurse Practitioners Michael A. Carter, DNSc, DNP, Eileen Owen-Williams, DNP, PhD, and Phillip Della, PhD, RN ABSTRACT
Australia is experiencing challenges in developing the workforce to meet emerging primary care needs and has attempted to address these challenges by producing more physicians. However, new medical graduates are selecting specialty practices rather than primary care. Nurse practitioners (NPs) provide primary care in other countries, whereas Australia’s nurse NPs are primarily in hospital-based, specialty practices. Lessons learned from the United States’ experience can position NPs as a solution to the emerging Australian primary care shortage. Keywords: Australia, Medicare Benefits Schedule, nurse practitioners, Pharmacy Benefits Scheme, primary care Ó 2015 Elsevier, Inc. All rights reserved.
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ustralia has a keen interest in assuring the best health care possible. The National Healthcare Agreement in 2012 states that the Australian health system should “provide all Australians with timely access to quality health services based on their needs, not ability to pay, regardless of where they live in the country.”1(pA-2) The basis for the delivery of this broad approach to care is a robust primary care delivery system. The Australian Medical Association says that primary care providers are expected to diagnose and treat a wide variety of acute and chronic health conditions as well as serve as the referral source for specialty care.2 Australia reports problems with an unequal distribution of primary care doctors, with the majority located in urban, affluent areas and lower numbers and poorer doctor/patient ratios in rural, poor areas.3 The challenge is meeting the increased need for primary care services in the setting of a coexisting decrease in traditional primary care providers’ availability. There are a number of factors that have led to the increased need for primary care providers, including higher rates of chronic disease in an aging population of Australians.4 There have been increases in type 2 diabetes, dementia, and arthritis in Australia.4 Recent Australian initiatives, including patient-centered care, www.npjournal.org
increased demand for after-hours care, inclusion of the social determinants of health, and increased demand for health promotion and disease prevention, act to increase the need for primary care provision.4 These health care needs are paired with a shortfall in the number of general practice doctors due to aging and retirement and a marked decrease in the proportion of medical school graduates who elect primary care practice after completing medical school.5 PROBLEMS WITH THE OLD MODEL OF CARE DELIVERY
Primary care in Australia is commonly provided by a general practitioner (GP) in private practice, and payment is usually made by the patient, with a portion reimbursed to the patient by the Medicare Benefit Schedule (MBS). Some patients have additional private insurance to help offset the difference between the GP charges and the Medicare payment. The Australian Medicare payment structure is based primarily on the time the GP spends with the patient. A challenge with this model care is the increased complexity of the conditions being treated in primary care, leading to an increase in the number of patient encounters for chronic illness and comorbid conditions.5 The time-based model of care payment is most cost effective for the GP when the health The Journal for Nurse Practitioners - JNP
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condition is a self-limiting acute illness. Chronic illnesses require that the patient self-manage the condition with the consultation of the primary care provider. This means that sufficient time must be allocated during the visit to evaluate the problems and select the best treatment from a range of treatments for the specific patient—with the consideration of individual preference, culture, health literacy, available resources, and other patientcentered care characteristics. These visits must be scheduled at regular, frequent intervals. Substantial patient education is required and the coordination of the care provided by a number of other providers is critical to high-quality outcomes. All of these issues act to increase the time needed for each visit and the frequency of visits. Chronic illness management requires that each primary care provider cares for fewer patients, further increasing the need for additional primary care providers. Australia’s Health Workforce Series5 provides useful information concerning primary care physicians in the country. Over the past 20 years, there has been a substantial decrease in the proportion of Australian medical school graduates selecting primary care. This decrease has been coupled with other changes in primary care practices. Australian doctors are working fewer hours than in the past and the range of services that they provide has decreased, with many primary care physicians no longer providing surgical or obstetrical services to their patients.5 Nearly 25% of the physicians in Australia are over age 55, and a substantial number will be retiring in the next decade.5 Australia has increased the number of medical schools and class sizes but has not been successful in meeting the primary care demands of the country. There has been about a 25% increase in the number of primary care physicians in Australia over the past 10 years as compared with the 47% increase in all clinical physicians.5 One of the approaches that Australia has used to make up for the shortfall in doctors is to import doctors who have obtained their medical education in another country. Clearly, there is the draw of a substantially different economic picture for many doctors from low-resource countries. Yet, is this the best policy for sustaining a health care system for the 648
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future? This policy is short-sighted and immoral, often leaving the developing countries with an increased medical workforce shortage.6,7 Currently, 26% of all doctors in Australia have received their primary medical education in another country,5 compared with 25% of all doctors in the US.8 Almost 40% of Australian visas are granted to doctors from lower resource countries. About one third of the GPs in Australia were trained overseas.5 The World Health Organization has developed a global code of practice regarding the international recruitment of health personnel.9 Both Australia and the US have signed this agreement. One of the key areas of this agreement is that resource-rich countries should educate and retain their own workforces. Rich countries become a substantial drain on lowresource countries when they become destination countries. There are substantial moral and ethical questions that arise when resource-rich countries develop health workforce plans that rely on the recruitment of health personnel from other countries as compared with domestic training. Yet, this is exactly what the Health Workforce Australia plan has done.5 Australia has an alternative in place using existing, educated health workforce personnel who are citizens of the country, are culturally similar, speak local dialects, understand the health system, and are distributed throughout the country. The full deployment of nurse practitioners (NPs) can help Australia to meet the looming primary care shortage. THE CASE OF US NPS
The case of NPs in the US is proposed for consideration to influence Australian policy. The role of NPs was begun in the US by Loretta Ford and Henry Silver in 1965 to provide primary care to children.10 Children were not receiving the care needed and these 2 pioneers believed there was a better way than to rely only on physicians. The early NP programs taught diagnostic skills, including history-taking, physical examination, differential diagnosis, laboratory testing, and radiography. These skills were combined with medical diagnosis and referral systems. Studies showed that these new NPs were well prepared to provide primary care.11 Volume 11, Issue 6, June 2015
In the late 1970s and early 1980s, the US saw a rapid proliferation of NP programs at the master’s level and the various state laws regulating nursing practice changed quite rapidly. Initially, no state had legislation that allowed for NPs to diagnose or prescribe drugs, but states began to allow for both. Federal laws also evolved and, for the first time, NPs began to participate in federal health insurance payments. In the early 2000s, US NP master’s programs evolved into the doctor of nurse practice (DNP). In 2004, the American Association of Colleges of Nursing issued their position paper in which the DNP was recognized as the single degree for advanced practice nursing beginning in 2015.12 Today, there are over 200 programs offering the DNP that enroll almost 12,000 students annually. This evolution to the practice doctorate has been controversial. Some in nursing were concerned that existing master’s prepared NPs would be devalued. Organized medicine was concerned that patients would mistakenly believe the NP to be the physician. Neither of these has proven to be the case. One of the rather unique issues in the development of American NPs is that they were broadly prepared as generalists to provide primary care. Most of the early patients treated by NPs were poor, rural, or otherwise underserved by the US health care system. This meant that NPs were required to have substantial knowledge to manage the complex health problems experienced by these patients. More recently, NP preparation has expanded to include acute care NPs, who work mostly in medical specialty practices or hospital emergency departments, intensive care units, and other acute care settings. The US health system’s organizational and financial structure is quite different from that of Australia and almost all care in the US is provided by private rather than public providers. Care is paid by a mixture of private and government insurance plans and NPs are usually included in these payment systems. Inclusion in payment systems did not occur initially for NPs in the US, but, over the past 5 decades, the public has insisted that their NPs be paid, instigating changes in health care reimbursement. The American Association of NPs reports that there are about 181,000 NPs in the US, most of www.npjournal.org
whom (88%) have been prepared in primary care. The vast majority (96%) are female, an average of 48 years of age, and have been practicing as a NP for 13 years.13 The US currently prepares 6 family NPs for every family physician trained.14 The primary care system of the US could not function without the services of NPs. QUESTIONS OF QUALITY, SAFETY, AND EFFECTIVENESS OF NP PRACTICE
Throughout the history of NPs in the US, there have been questions concerning the quality of the care they provide, the safety of the care, and ultimately the effectiveness of the care. These same questions will likely be asked of Australian NPs. Thousands of studies have been conducted on NP care with similar findings. Recently, a study reviewed 27,993 articles published between 1990 and 2009, of which 37 met the rigorous requirements for inclusion. This study revealed that NP practice is equivalent or better than that of physicians on all measures of quality, safety, and effectiveness.11 This rich history of research regarding the quality, safety, and effectiveness of NP care in the US will not likely put to rest the issue of equivalency of NP practice to that of physicians. The 2 professions use different models of education and have different underlying epistemologies upon which their education is built. Differences should be expected but have not yet been reported. THE AUSTRALIAN PICTURE OF NPS
NPs in Australia are more recent than in the US. The Australian health care system is designed and funded in very different ways than the US health care system and has had a substantial effect on how NPs have evolved. Planning to introduce NPs in Australia began in the early 1990s and the first NPs were recognized in December 2000. By December 2013, 1,000 NPs had been endorsed.15 Currently, registered nurses who seek endorsement as NPs in Australia must complete a master’s course at one of the universities preparing NPs. The core curriculum must include pharmacology, advanced physical assessment, and differential diagnosis, including the use of laboratory and radiographic testing. Students applying to the master’s courses that prepare NPs must also have had at least 3 The Journal for Nurse Practitioners - JNP
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years of full-time practice in advanced practice in the area in which the NP intends to practice. The term “advanced practice” has different meanings in the US and Australia. Advanced practice in the US means the nurse is prepared to practice in 1 of 4 roles: NP; nurse midwife; nurse anesthetist; or clinical nurse specialist. The title “advanced practice nurse” and the titles for the 4 roles are protected by boards of nursing in most states. The Nursing and Midwifery Board of Australia defines advanced practice nursing as “a level of nursing practice that uses comprehensive skills, experience and knowledge in nursing care.”16(pX) Six domains have been identified for advanced practice nursing in Australia and include: direct and comprehensive care; support of systems; education; research; publication; and professional leadership.17 Advanced practice nursing is not a protected title in Australia and may include institutionally determined titles, such as clinical nurse specialist and clinical nurse consultant. This has resulted in confusion when attempting to compare NPs in the US with those in Australia. Australian NPs have not trained as generalists in primary care as was the case in the US. Australian NPs have traditionally practiced in public hospital systems in specialty practice. Two previous elements that restricted the growth of NP practice in Australia were the lack of access to the MBS and lack of authority to prescribe through the Pharmaceutical Benefits Scheme (PBS). Prohibition against billing for service, inability to refer for other services covered by Medicare, and lack of prescription payment meant that NPs did not work much differently from registered nurses. This situation changed in 2010 when the Australian Senate passed legislation to provide access to the MBS and the PBS for NPs in private practice.18 Historically, Australia has had very limited experience with NPs in primary care.19 This means that questions could be raised as to whether Australians would accept NPs as their primary care providers. Parker and colleagues posed this question to 7 focus groups of consumers in 5 Australian states.20 Few of the consumers had any experience or knowledge about NPs. But the groups were very positive about NPs when told that NPs were registered nurses who 650
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could prescribe drugs and order laboratory and radiologic tests. The respondents indicated that they would find NPs very acceptable for their primary health care. Yet, challenges remain in Australia. Only NPs in private practice can obtain MBS or PBS numbers.21 Few NPs are eligible for these numbers because most are employed in the public health system. Prescribing also requires a collaborative agreement with a physician even if that physician is not associated with the NP practice. There are only 4 MBS codes that can be claimed by the NP for rebate. To further complicate the issue, the NP rebate is a reduced rate of that for the general practitioner for the same service, and referrals to allied health professionals by NPs will not receive a Medicare rebate.21 RECOMMENDATIONS FOR THE FUTURE
Australia is experiencing a primary care shortfall that will become substantially greater in the next decade. The current medical model of primary care that relies solely on GPs to deliver care will not meet Australia’s needs, and Australia continues to rely on importing doctors to meet this shortfall. A better solution is to expand the use of NPs. Australian NPs are well positioned to meet the emerging increased demand for primary care. Australia will need to adopt the following policy changes if NPs are to be successful primary care providers. COMMIT TO THE PREPARATION OF NPS FOR PRIMARY CARE PRACTICE
The Nursing and Midwifery Board of Australia currently requires registered nurses to have at least 3 years of full-time experience over the previous 6 years in advanced practice nursing to be endorsed as an NP.16 This particular requirement creates a barrier to preparing NPs for primary care. Most of the advanced practice roles are in hospital or specialty practice, which do not appropriately provide nurses with the experiential knowledge for subsequent practice in primary care. The US has demonstrated that nurses with little or no hospital experience can be well prepared to assume independent practice as primary care providers. In addition to the experience requirement, there is a requirement that NPs complete a master’s Volume 11, Issue 6, June 2015
course.16 These courses have been designed for clinical nurse consultants or clinical nurse specialists to further expand their role. The current NP educational courses should be modified to include a generalist focus in primary care. The current programs do not provide the broad comprehensive care focus that is required by future NPs if they are to become primary care providers. This broad base as a generalist will also serve as strong preparation for those NPs who subsequently work in specialty care. This base would include diagnosis and treatment of a broad range of acute and chronic health problems seen across the lifespan and settings with a focus on patient problems that present in ambulatory care settings. These new NPs will need additional knowledge of health promotion and disease prevention across the lifespan to meet Australia’s goals, as these are not a part of the current NP courses. CHANGE POLICY TO ELIMINATE COLLABORATIVE REQUIREMENTS WITH PHYSICIANS
The current requirement for a collaborative agreement with a physician must be eliminated. There is no evidence from any of the many US studies concerning NP practice that supports this very restrictive policy.11 The mandate of this collaborative practice agreement implies that, somehow, NPs must subvert their knowledge and ability to another profession. This policy promotes one health care profession’s control over another profession. Clearly, such an agreement does nothing to improve care of patients—acting instead to increase health care costs and decrease patients’ access to primary care. PROVISION OF MBS PROVIDER NUMBERS TO ALL NPS
Currently, Australian Medicare Benefit Schedule policy requires that NPs must be in private practice to obtain a provider number. The MBS number allows for billing and reimbursement of primary care services, triggers payment for prescription drugs ordered by NPs, and is required to refer patients to specific specialists and request pathology and diagnostic services. The goal of this policy is understandable, as NPs who are employed in the public sector are paid by public funds. Billing Medicare for care by these NPs could represent double billing. However, there is a way to work around this potential problem, to allow the NP to refer to specialists, and request www.npjournal.org
pathology and diagnostic items. Australian doctors do not have their practice limited in this way and neither should NPs. EQUITY OF MBS REBATES
The limitation of the MBS to only 4 items for NPs is difficult to understand.21 The MBS is designed to pay for multiple aspects of care not just the 4 time-related items; further, much of what NPs do to care for their patients does not fit into these 4 items. Medicare benefits are designed to pay for clinically relevant services; however, this limitation in billing restricts NPs from being paid for all their clinically relevant services. The current MBS rebate to NPs is only 85% of the payment level for physicians for identical care.21 The MBS rebates to NPs should be equal to that paid to physicians. The purpose of the rebate is to pay for care provided—specifically, the diagnosis, treatment, and referral of health problems, which are the same services whether provided by the NP or the physician. There is no justification for the inequity of reimbursement other than professional hubris. Regulations should be changed so that referrals to allied health professionals merit Medicare rebates as well. CONCLUSION
Great strides have been made by the pioneer Australian NPs. There is still much work to be done to assure that Australia’s people are able to receive the care to which they are entitled. Making the proposed policy changes will act to allow existing and emerging NPs to effectively provide quality care and receive reimbursement within the Australian health care system. Australia may or may not be willing to make the recommended changes proposed. Registered nurses currently work in primary care throughout the country so moving this work force to the NP level would represent advanced practice for them similar to what has been seen in hospital nursing practice. The Australian medical community would likely be mixed in their support for this move, as has been the US medical community. There may be other potential solutions for the primary care shortage in Australia, such as expanding The Journal for Nurse Practitioners - JNP
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the roles of pharmacists, physiotherapists, and osteopaths. These practitioners have different preparation than in the US, so lessons from the US are difficult to use for comparison. Work Force Australia5 did not recommend the use of these practitioners to decrease the physician shortage in primary care. The authors of this study are advocates for developing NPs in Australia to address the primary care shortage and believe this to be the best solution. References 1. Council of Australian Governments. National healthcare agreement. 2012. http://www.federalfinancialregulations.gov.au/content/npa/healthcare /national-agreement.pdf/. Accessed December 18, 2014. 2. Australian Medical Association. Statement on primary health care. 2010. https://ama.com.au/position-statement/primary-health-care-2010/. Accessed December 18, 2014. 3. Kamalakanthan A, Jackson S. The supply of doctors in Australia: is there a shortage? Discussion Paper No. 341. 2006. School of Economics, University of Queensland, Queensland, Australia. 4. Australian Institute of Health and Welfare. Key indicators for chronic disease and associated determinants. http://www.aihw.gov.au./chronic-disease/key -indicators/. Accessed December 18, 2014. 5. Health Workforce Australia. Australia’s Health Workforce Series Doctors in Focus. 2012. http://www.hwa.gov.au/sites/uploads/australias_health _workforce_series_doctors_in_focus_20120322.pdf/. Accessed December 18, 2014. 6. Hagoplian A. Recruiting primary care physicians from abroad: is poaching from low resource countries morally defensible? Ann Fam Med. 2007;5(6):483-485. 7. Starfield B, Fryer GE Jr. The primary care physician workforce: ethical and policy implications. Ann Fam Med. 2007;5(6):486-491. 8. American Medical Association. International medical graduates in the United States. http://www.ama-assn.org/ama/pub/about-ama/our-people/member -groups-sections/international-medical-graduates/imgs-in-united-states.page/. Accessed December 18, 2014. 9. World Health Organization. WHO global code of practice on the international recruitment of health personnel. WHA 63:10. 2010. http://www.who.int/hrh /migration/code/code_en.pdf/. Accessed December 18, 2014. 10. Ford L, Silver H. The expanded role of the nurse in child care. Nurs Outlook. 1967;15:43-45. 11. Stanik-Hutt J, Newhouse R, White K, Johantgen M, Bass E, Zangaro G, et al. The quality and effectiveness of care provided by nurse practitioners. J Nurse Pract. 2013;9:492-500. 12. American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing. 2004. http://www.aacn.nche.edu /publications/position/DNPpositionstatement.pdf/. Accessed December 18, 2014.
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13. American Association of Nurse Practitioners. Nursing practice facts. 2013. http://www.aanp.org/images/documents/about-nps/npfacts.pdf/. Accessed December 18, 2014 14. American Academy of Family Physicians. NRMP family medicine data. 2014. http://www.aafp.org/medical-school-residency/residency/match/nrmp/family -medicine.html/. Accessed December 18, 2014. 15. Australian College of Nurse Practitioners. Australian College of nurse practitioners history. http://acnp.org.au/history/. Accessed December 18, 2014. 16. Nursing and Midwifery Board of Australia. Endorsement as a nurse practitioner registration standard. http://www.nursingmidwiferyboard.gov.au/Registration -and-Endorsement/Endorsements-Notations/Endorsement-as-a-nurse -practitioner-registration-standard.aspx/. Accessed December 18, 2014. 17. Nursing and Midwifery Board of Australia. Fact sheet: advanced practice nursing. December 2013. http://www.nursingmidwiferyboard.gov.au/Codes -Guidelines-Statements/FAQ/fact-sheet-advanced-practice-nursing.aspx/. Accessed December 18, 2014. 18. Australian Government Department of Health. Eligible nurse practitioners questions and answers. 2014. http://www.health.gov.au/internet/main /publishing.nsf/Content/midwives-nurse-pract-qanda-nursepract#5_2/. Accessed December 18, 2014. 19. Gardner G, Gardner A, Middleton S, Della P, Kain V, Doubrovsky A. The work of nurse practitioners. J Adv Nurs. 2010;66(10):2160-2169. 20. Parker R, Forrest L, Ward N, McCracken J, Cox D, Derrett J. How acceptable are primary health care nurse practitioners to Australian consumers? Collegian. 2012:35-41. 21. Australian Government Department of Health. Medicare: nurse practitioners and midwives. May 2014. http://www.medicareaustralia.gov.au/provider /other-healthcare/nurse-midwives.jsp/. Accessed December 18, 2014.
Michael Carter, DNSc, DNP, FAAN, FNP-BC, is a university distinguished professor at the University of Tennessee Health Science Center in Memphis. He can be reached at [email protected]. Eileen Owen-Williams, DNP, PhD, CNM, FNP-BC, is a clinical assistant professor of nursing at the University of Arizona College of Nursing in Phoenix. Phillip Della, PhD, RN, FACN, is the head of school in the School of Nursing and Midwifery at Curtin University in Perth, WA, Australia. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.02.011
Volume 11, Issue 6, June 2015
Australia is experiencing challenges in developing the workforce to meet emerging primary care needs and has attempted to address these challenges by producing more physicians. However, new medical graduates are selecting specialty practices rather than primary care. Nurse practitioners (NPs) provide primary care in other countries, whereas Australia’s nurse NPs are primarily in hospital-based, specialty practices. Lessons learned from the United States’ experience can position NPs as a solution to the emerging Australian primary care shortage. Keywords: Australia, Medicare Benefits Schedule, nurse practitioners, Pharmacy Benefits Scheme, primary care Ó 2015 Elsevier, Inc. All rights reserved.
A
ustralia has a keen interest in assuring the best health care possible. The National Healthcare Agreement in 2012 states that the Australian health system should “provide all Australians with timely access to quality health services based on their needs, not ability to pay, regardless of where they live in the country.”1(pA-2) The basis for the delivery of this broad approach to care is a robust primary care delivery system. The Australian Medical Association says that primary care providers are expected to diagnose and treat a wide variety of acute and chronic health conditions as well as serve as the referral source for specialty care.2 Australia reports problems with an unequal distribution of primary care doctors, with the majority located in urban, affluent areas and lower numbers and poorer doctor/patient ratios in rural, poor areas.3 The challenge is meeting the increased need for primary care services in the setting of a coexisting decrease in traditional primary care providers’ availability. There are a number of factors that have led to the increased need for primary care providers, including higher rates of chronic disease in an aging population of Australians.4 There have been increases in type 2 diabetes, dementia, and arthritis in Australia.4 Recent Australian initiatives, including patient-centered care, www.npjournal.org
increased demand for after-hours care, inclusion of the social determinants of health, and increased demand for health promotion and disease prevention, act to increase the need for primary care provision.4 These health care needs are paired with a shortfall in the number of general practice doctors due to aging and retirement and a marked decrease in the proportion of medical school graduates who elect primary care practice after completing medical school.5 PROBLEMS WITH THE OLD MODEL OF CARE DELIVERY
Primary care in Australia is commonly provided by a general practitioner (GP) in private practice, and payment is usually made by the patient, with a portion reimbursed to the patient by the Medicare Benefit Schedule (MBS). Some patients have additional private insurance to help offset the difference between the GP charges and the Medicare payment. The Australian Medicare payment structure is based primarily on the time the GP spends with the patient. A challenge with this model care is the increased complexity of the conditions being treated in primary care, leading to an increase in the number of patient encounters for chronic illness and comorbid conditions.5 The time-based model of care payment is most cost effective for the GP when the health The Journal for Nurse Practitioners - JNP
647
condition is a self-limiting acute illness. Chronic illnesses require that the patient self-manage the condition with the consultation of the primary care provider. This means that sufficient time must be allocated during the visit to evaluate the problems and select the best treatment from a range of treatments for the specific patient—with the consideration of individual preference, culture, health literacy, available resources, and other patientcentered care characteristics. These visits must be scheduled at regular, frequent intervals. Substantial patient education is required and the coordination of the care provided by a number of other providers is critical to high-quality outcomes. All of these issues act to increase the time needed for each visit and the frequency of visits. Chronic illness management requires that each primary care provider cares for fewer patients, further increasing the need for additional primary care providers. Australia’s Health Workforce Series5 provides useful information concerning primary care physicians in the country. Over the past 20 years, there has been a substantial decrease in the proportion of Australian medical school graduates selecting primary care. This decrease has been coupled with other changes in primary care practices. Australian doctors are working fewer hours than in the past and the range of services that they provide has decreased, with many primary care physicians no longer providing surgical or obstetrical services to their patients.5 Nearly 25% of the physicians in Australia are over age 55, and a substantial number will be retiring in the next decade.5 Australia has increased the number of medical schools and class sizes but has not been successful in meeting the primary care demands of the country. There has been about a 25% increase in the number of primary care physicians in Australia over the past 10 years as compared with the 47% increase in all clinical physicians.5 One of the approaches that Australia has used to make up for the shortfall in doctors is to import doctors who have obtained their medical education in another country. Clearly, there is the draw of a substantially different economic picture for many doctors from low-resource countries. Yet, is this the best policy for sustaining a health care system for the 648
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future? This policy is short-sighted and immoral, often leaving the developing countries with an increased medical workforce shortage.6,7 Currently, 26% of all doctors in Australia have received their primary medical education in another country,5 compared with 25% of all doctors in the US.8 Almost 40% of Australian visas are granted to doctors from lower resource countries. About one third of the GPs in Australia were trained overseas.5 The World Health Organization has developed a global code of practice regarding the international recruitment of health personnel.9 Both Australia and the US have signed this agreement. One of the key areas of this agreement is that resource-rich countries should educate and retain their own workforces. Rich countries become a substantial drain on lowresource countries when they become destination countries. There are substantial moral and ethical questions that arise when resource-rich countries develop health workforce plans that rely on the recruitment of health personnel from other countries as compared with domestic training. Yet, this is exactly what the Health Workforce Australia plan has done.5 Australia has an alternative in place using existing, educated health workforce personnel who are citizens of the country, are culturally similar, speak local dialects, understand the health system, and are distributed throughout the country. The full deployment of nurse practitioners (NPs) can help Australia to meet the looming primary care shortage. THE CASE OF US NPS
The case of NPs in the US is proposed for consideration to influence Australian policy. The role of NPs was begun in the US by Loretta Ford and Henry Silver in 1965 to provide primary care to children.10 Children were not receiving the care needed and these 2 pioneers believed there was a better way than to rely only on physicians. The early NP programs taught diagnostic skills, including history-taking, physical examination, differential diagnosis, laboratory testing, and radiography. These skills were combined with medical diagnosis and referral systems. Studies showed that these new NPs were well prepared to provide primary care.11 Volume 11, Issue 6, June 2015
In the late 1970s and early 1980s, the US saw a rapid proliferation of NP programs at the master’s level and the various state laws regulating nursing practice changed quite rapidly. Initially, no state had legislation that allowed for NPs to diagnose or prescribe drugs, but states began to allow for both. Federal laws also evolved and, for the first time, NPs began to participate in federal health insurance payments. In the early 2000s, US NP master’s programs evolved into the doctor of nurse practice (DNP). In 2004, the American Association of Colleges of Nursing issued their position paper in which the DNP was recognized as the single degree for advanced practice nursing beginning in 2015.12 Today, there are over 200 programs offering the DNP that enroll almost 12,000 students annually. This evolution to the practice doctorate has been controversial. Some in nursing were concerned that existing master’s prepared NPs would be devalued. Organized medicine was concerned that patients would mistakenly believe the NP to be the physician. Neither of these has proven to be the case. One of the rather unique issues in the development of American NPs is that they were broadly prepared as generalists to provide primary care. Most of the early patients treated by NPs were poor, rural, or otherwise underserved by the US health care system. This meant that NPs were required to have substantial knowledge to manage the complex health problems experienced by these patients. More recently, NP preparation has expanded to include acute care NPs, who work mostly in medical specialty practices or hospital emergency departments, intensive care units, and other acute care settings. The US health system’s organizational and financial structure is quite different from that of Australia and almost all care in the US is provided by private rather than public providers. Care is paid by a mixture of private and government insurance plans and NPs are usually included in these payment systems. Inclusion in payment systems did not occur initially for NPs in the US, but, over the past 5 decades, the public has insisted that their NPs be paid, instigating changes in health care reimbursement. The American Association of NPs reports that there are about 181,000 NPs in the US, most of www.npjournal.org
whom (88%) have been prepared in primary care. The vast majority (96%) are female, an average of 48 years of age, and have been practicing as a NP for 13 years.13 The US currently prepares 6 family NPs for every family physician trained.14 The primary care system of the US could not function without the services of NPs. QUESTIONS OF QUALITY, SAFETY, AND EFFECTIVENESS OF NP PRACTICE
Throughout the history of NPs in the US, there have been questions concerning the quality of the care they provide, the safety of the care, and ultimately the effectiveness of the care. These same questions will likely be asked of Australian NPs. Thousands of studies have been conducted on NP care with similar findings. Recently, a study reviewed 27,993 articles published between 1990 and 2009, of which 37 met the rigorous requirements for inclusion. This study revealed that NP practice is equivalent or better than that of physicians on all measures of quality, safety, and effectiveness.11 This rich history of research regarding the quality, safety, and effectiveness of NP care in the US will not likely put to rest the issue of equivalency of NP practice to that of physicians. The 2 professions use different models of education and have different underlying epistemologies upon which their education is built. Differences should be expected but have not yet been reported. THE AUSTRALIAN PICTURE OF NPS
NPs in Australia are more recent than in the US. The Australian health care system is designed and funded in very different ways than the US health care system and has had a substantial effect on how NPs have evolved. Planning to introduce NPs in Australia began in the early 1990s and the first NPs were recognized in December 2000. By December 2013, 1,000 NPs had been endorsed.15 Currently, registered nurses who seek endorsement as NPs in Australia must complete a master’s course at one of the universities preparing NPs. The core curriculum must include pharmacology, advanced physical assessment, and differential diagnosis, including the use of laboratory and radiographic testing. Students applying to the master’s courses that prepare NPs must also have had at least 3 The Journal for Nurse Practitioners - JNP
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years of full-time practice in advanced practice in the area in which the NP intends to practice. The term “advanced practice” has different meanings in the US and Australia. Advanced practice in the US means the nurse is prepared to practice in 1 of 4 roles: NP; nurse midwife; nurse anesthetist; or clinical nurse specialist. The title “advanced practice nurse” and the titles for the 4 roles are protected by boards of nursing in most states. The Nursing and Midwifery Board of Australia defines advanced practice nursing as “a level of nursing practice that uses comprehensive skills, experience and knowledge in nursing care.”16(pX) Six domains have been identified for advanced practice nursing in Australia and include: direct and comprehensive care; support of systems; education; research; publication; and professional leadership.17 Advanced practice nursing is not a protected title in Australia and may include institutionally determined titles, such as clinical nurse specialist and clinical nurse consultant. This has resulted in confusion when attempting to compare NPs in the US with those in Australia. Australian NPs have not trained as generalists in primary care as was the case in the US. Australian NPs have traditionally practiced in public hospital systems in specialty practice. Two previous elements that restricted the growth of NP practice in Australia were the lack of access to the MBS and lack of authority to prescribe through the Pharmaceutical Benefits Scheme (PBS). Prohibition against billing for service, inability to refer for other services covered by Medicare, and lack of prescription payment meant that NPs did not work much differently from registered nurses. This situation changed in 2010 when the Australian Senate passed legislation to provide access to the MBS and the PBS for NPs in private practice.18 Historically, Australia has had very limited experience with NPs in primary care.19 This means that questions could be raised as to whether Australians would accept NPs as their primary care providers. Parker and colleagues posed this question to 7 focus groups of consumers in 5 Australian states.20 Few of the consumers had any experience or knowledge about NPs. But the groups were very positive about NPs when told that NPs were registered nurses who 650
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could prescribe drugs and order laboratory and radiologic tests. The respondents indicated that they would find NPs very acceptable for their primary health care. Yet, challenges remain in Australia. Only NPs in private practice can obtain MBS or PBS numbers.21 Few NPs are eligible for these numbers because most are employed in the public health system. Prescribing also requires a collaborative agreement with a physician even if that physician is not associated with the NP practice. There are only 4 MBS codes that can be claimed by the NP for rebate. To further complicate the issue, the NP rebate is a reduced rate of that for the general practitioner for the same service, and referrals to allied health professionals by NPs will not receive a Medicare rebate.21 RECOMMENDATIONS FOR THE FUTURE
Australia is experiencing a primary care shortfall that will become substantially greater in the next decade. The current medical model of primary care that relies solely on GPs to deliver care will not meet Australia’s needs, and Australia continues to rely on importing doctors to meet this shortfall. A better solution is to expand the use of NPs. Australian NPs are well positioned to meet the emerging increased demand for primary care. Australia will need to adopt the following policy changes if NPs are to be successful primary care providers. COMMIT TO THE PREPARATION OF NPS FOR PRIMARY CARE PRACTICE
The Nursing and Midwifery Board of Australia currently requires registered nurses to have at least 3 years of full-time experience over the previous 6 years in advanced practice nursing to be endorsed as an NP.16 This particular requirement creates a barrier to preparing NPs for primary care. Most of the advanced practice roles are in hospital or specialty practice, which do not appropriately provide nurses with the experiential knowledge for subsequent practice in primary care. The US has demonstrated that nurses with little or no hospital experience can be well prepared to assume independent practice as primary care providers. In addition to the experience requirement, there is a requirement that NPs complete a master’s Volume 11, Issue 6, June 2015
course.16 These courses have been designed for clinical nurse consultants or clinical nurse specialists to further expand their role. The current NP educational courses should be modified to include a generalist focus in primary care. The current programs do not provide the broad comprehensive care focus that is required by future NPs if they are to become primary care providers. This broad base as a generalist will also serve as strong preparation for those NPs who subsequently work in specialty care. This base would include diagnosis and treatment of a broad range of acute and chronic health problems seen across the lifespan and settings with a focus on patient problems that present in ambulatory care settings. These new NPs will need additional knowledge of health promotion and disease prevention across the lifespan to meet Australia’s goals, as these are not a part of the current NP courses. CHANGE POLICY TO ELIMINATE COLLABORATIVE REQUIREMENTS WITH PHYSICIANS
The current requirement for a collaborative agreement with a physician must be eliminated. There is no evidence from any of the many US studies concerning NP practice that supports this very restrictive policy.11 The mandate of this collaborative practice agreement implies that, somehow, NPs must subvert their knowledge and ability to another profession. This policy promotes one health care profession’s control over another profession. Clearly, such an agreement does nothing to improve care of patients—acting instead to increase health care costs and decrease patients’ access to primary care. PROVISION OF MBS PROVIDER NUMBERS TO ALL NPS
Currently, Australian Medicare Benefit Schedule policy requires that NPs must be in private practice to obtain a provider number. The MBS number allows for billing and reimbursement of primary care services, triggers payment for prescription drugs ordered by NPs, and is required to refer patients to specific specialists and request pathology and diagnostic services. The goal of this policy is understandable, as NPs who are employed in the public sector are paid by public funds. Billing Medicare for care by these NPs could represent double billing. However, there is a way to work around this potential problem, to allow the NP to refer to specialists, and request www.npjournal.org
pathology and diagnostic items. Australian doctors do not have their practice limited in this way and neither should NPs. EQUITY OF MBS REBATES
The limitation of the MBS to only 4 items for NPs is difficult to understand.21 The MBS is designed to pay for multiple aspects of care not just the 4 time-related items; further, much of what NPs do to care for their patients does not fit into these 4 items. Medicare benefits are designed to pay for clinically relevant services; however, this limitation in billing restricts NPs from being paid for all their clinically relevant services. The current MBS rebate to NPs is only 85% of the payment level for physicians for identical care.21 The MBS rebates to NPs should be equal to that paid to physicians. The purpose of the rebate is to pay for care provided—specifically, the diagnosis, treatment, and referral of health problems, which are the same services whether provided by the NP or the physician. There is no justification for the inequity of reimbursement other than professional hubris. Regulations should be changed so that referrals to allied health professionals merit Medicare rebates as well. CONCLUSION
Great strides have been made by the pioneer Australian NPs. There is still much work to be done to assure that Australia’s people are able to receive the care to which they are entitled. Making the proposed policy changes will act to allow existing and emerging NPs to effectively provide quality care and receive reimbursement within the Australian health care system. Australia may or may not be willing to make the recommended changes proposed. Registered nurses currently work in primary care throughout the country so moving this work force to the NP level would represent advanced practice for them similar to what has been seen in hospital nursing practice. The Australian medical community would likely be mixed in their support for this move, as has been the US medical community. There may be other potential solutions for the primary care shortage in Australia, such as expanding The Journal for Nurse Practitioners - JNP
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the roles of pharmacists, physiotherapists, and osteopaths. These practitioners have different preparation than in the US, so lessons from the US are difficult to use for comparison. Work Force Australia5 did not recommend the use of these practitioners to decrease the physician shortage in primary care. The authors of this study are advocates for developing NPs in Australia to address the primary care shortage and believe this to be the best solution. References 1. Council of Australian Governments. National healthcare agreement. 2012. http://www.federalfinancialregulations.gov.au/content/npa/healthcare /national-agreement.pdf/. Accessed December 18, 2014. 2. Australian Medical Association. Statement on primary health care. 2010. https://ama.com.au/position-statement/primary-health-care-2010/. Accessed December 18, 2014. 3. Kamalakanthan A, Jackson S. The supply of doctors in Australia: is there a shortage? Discussion Paper No. 341. 2006. School of Economics, University of Queensland, Queensland, Australia. 4. Australian Institute of Health and Welfare. Key indicators for chronic disease and associated determinants. http://www.aihw.gov.au./chronic-disease/key -indicators/. Accessed December 18, 2014. 5. Health Workforce Australia. Australia’s Health Workforce Series Doctors in Focus. 2012. http://www.hwa.gov.au/sites/uploads/australias_health _workforce_series_doctors_in_focus_20120322.pdf/. Accessed December 18, 2014. 6. Hagoplian A. Recruiting primary care physicians from abroad: is poaching from low resource countries morally defensible? Ann Fam Med. 2007;5(6):483-485. 7. Starfield B, Fryer GE Jr. The primary care physician workforce: ethical and policy implications. Ann Fam Med. 2007;5(6):486-491. 8. American Medical Association. International medical graduates in the United States. http://www.ama-assn.org/ama/pub/about-ama/our-people/member -groups-sections/international-medical-graduates/imgs-in-united-states.page/. Accessed December 18, 2014. 9. World Health Organization. WHO global code of practice on the international recruitment of health personnel. WHA 63:10. 2010. http://www.who.int/hrh /migration/code/code_en.pdf/. Accessed December 18, 2014. 10. Ford L, Silver H. The expanded role of the nurse in child care. Nurs Outlook. 1967;15:43-45. 11. Stanik-Hutt J, Newhouse R, White K, Johantgen M, Bass E, Zangaro G, et al. The quality and effectiveness of care provided by nurse practitioners. J Nurse Pract. 2013;9:492-500. 12. American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing. 2004. http://www.aacn.nche.edu /publications/position/DNPpositionstatement.pdf/. Accessed December 18, 2014.
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13. American Association of Nurse Practitioners. Nursing practice facts. 2013. http://www.aanp.org/images/documents/about-nps/npfacts.pdf/. Accessed December 18, 2014 14. American Academy of Family Physicians. NRMP family medicine data. 2014. http://www.aafp.org/medical-school-residency/residency/match/nrmp/family -medicine.html/. Accessed December 18, 2014. 15. Australian College of Nurse Practitioners. Australian College of nurse practitioners history. http://acnp.org.au/history/. Accessed December 18, 2014. 16. Nursing and Midwifery Board of Australia. Endorsement as a nurse practitioner registration standard. http://www.nursingmidwiferyboard.gov.au/Registration -and-Endorsement/Endorsements-Notations/Endorsement-as-a-nurse -practitioner-registration-standard.aspx/. Accessed December 18, 2014. 17. Nursing and Midwifery Board of Australia. Fact sheet: advanced practice nursing. December 2013. http://www.nursingmidwiferyboard.gov.au/Codes -Guidelines-Statements/FAQ/fact-sheet-advanced-practice-nursing.aspx/. Accessed December 18, 2014. 18. Australian Government Department of Health. Eligible nurse practitioners questions and answers. 2014. http://www.health.gov.au/internet/main /publishing.nsf/Content/midwives-nurse-pract-qanda-nursepract#5_2/. Accessed December 18, 2014. 19. Gardner G, Gardner A, Middleton S, Della P, Kain V, Doubrovsky A. The work of nurse practitioners. J Adv Nurs. 2010;66(10):2160-2169. 20. Parker R, Forrest L, Ward N, McCracken J, Cox D, Derrett J. How acceptable are primary health care nurse practitioners to Australian consumers? Collegian. 2012:35-41. 21. Australian Government Department of Health. Medicare: nurse practitioners and midwives. May 2014. http://www.medicareaustralia.gov.au/provider /other-healthcare/nurse-midwives.jsp/. Accessed December 18, 2014.
Michael Carter, DNSc, DNP, FAAN, FNP-BC, is a university distinguished professor at the University of Tennessee Health Science Center in Memphis. He can be reached at [email protected]. Eileen Owen-Williams, DNP, PhD, CNM, FNP-BC, is a clinical assistant professor of nursing at the University of Arizona College of Nursing in Phoenix. Phillip Della, PhD, RN, FACN, is the head of school in the School of Nursing and Midwifery at Curtin University in Perth, WA, Australia. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.02.011
Volume 11, Issue 6, June 2015