Franz Kafka, a talented if universally depressing author, tells a story about a man from the country who wants to study law. In Before the Law, a parable in Kafka’s novel The Trial, the man wishes to gain entry to the law through a doorway. The doorkeeper says he can’t go through at the current time. When the man asks if he can ever go through, the doorkeeper responds, “It is possible but not now.” Waiting by the door for years, the man bribes the doorkeeper with everything he has. Although the doorkeeper takes the bribes, he says he accepted them only “to keep you from thinking you have omitted anything.” The man waits at the door until he’s about to die. Just before his death, he asks the doorkeeper why no one else has come in all these years, even though everyone seeks the law. The doorkeeper replies, “Here no one else can gain entry, since this entrance was assigned only for you. I am now going to shut it.”
Here’s my point: The man asked and begged and bribed for the opportunity to enter the doorway, but never had the courage to just walk through the door. So his dream went unrealized.
Contrast this with what nurses have done. We never asked, “Are we there yet?” We walked through the door—in this case, the door of advanced practice—despite obstacles and threats. We didn’t request permission to enter, didn’t beg or offer bribes. And now it looks like the dream may be more fully realized than we ever thought possible.
The New York Times reports, “In many states, nurse practitioners perform medical services once provided only by primary care doctors.” The author suggests, “If the healthcare system is overhauled, patients and practitioners are likely to face a primary care bottleneck [when] an estimated 30 million newly insured people will begin making appointments for check-ups and other routine care with physicians who are already stretched thin. …The increase in demand may well put an end to a simmering policy dispute over the circumscribed role of nurse practitioners in medical care. If tens of millions of new patients enter the healthcare system, it seems clear that nurse practitioners will be needed to perform many of the tasks now performed by physicians.”
Nurse practitioners (NPs) number roughly 125,000 nationwide. More than three-quarters of them work in primary care, making them the largest group of non-physician primary care providers, according to a study by the American College of Physicians. (Physician assistants generally work for specialists rather than in primary care.) Twenty-two states allow NPs to practice independently, without physician involvement. In other states, they work with varying degrees of oversight and input from physicians. NPs provide care that is comparable to that of primary care physicians, but at a lower cost. A RAND Corporation study that examined ways to control healthcare spending in Massachusetts found that increasing the use of NPs and physician assistants for certain types of office visits could save up to $8.4 billion by 2020.
Unlike physicians, whose residencies are funded almost entirely by Medicare, most nurses pay for their own education. Yet in 2006, nursing education received a little more than $300 million in federal funds. Half that amount was restricted to hospital diploma programs, which graduate only about 25% of nurses today.
The Senate Finance Committee healthcare reform bill (if it isn’t changed) would provide $50 million annually from 2012 through 2015 to fund a Medicare demonstration program for graduate nurse education. Participating hospitals would receive Medicare reimbursement for their educational and clinical instruction costs. Meanwhile, the House healthcare reform bill unveiled in November 2009 would authorize an additional $638 million to support nurse training from 2011 to 2015, including training for advanced practice nurses. With or without a public option, these monies are likely to stay.
We’re almost there!
Leah Curtin, RN, ScD(h), FAAN
Executive Editor, Professional Outreach
American Nurse Today
Dr. Leah Curtin, RN, ScD (h), FAAN, is Executive Editor, Professional Outreach, American Nurse Today. An internationally recognized nurse leader, ethicist, speaker, and consultant, she is a strong advocate for both the nursing profession and high-quality patient care. Currently she is Clinical Professor of Nursing at the University of Cincinnati College of Nursing and Health. For over 20 years, she was the Editor-in-Chief of Nursing Management. In 2007, she was appointed to the Standards and Appeals Board of DNV Healthcare, a new Medicare accrediting authority. Dr. Curtin can be reached at LCurtin@healthcommedia.com.
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