Mack Madahar. Nurse Practitioners: Challenges and Opportunities.

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

There is tremendous amount of debate in primary care about burgeoning Medicare costs and the ability to offer fully subsidised primary care. Whilst GPs are well placed in primary care, primary health care nurse practitioners have demonstrated to be an excellent resource in providing care that is safe, effective and affordable. Besides improving patient satisfaction, primary health care nurse practitioners facilitate a focus on complex and chronic care needs, which may increase patient throughput and productivity. Such services provide excellent examples of nurse practitioners offering value-added service at little cost. Nevertheless, primary health care nurse practitioners 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 four MBS item numbers out of 5,500 items is limiting growth of nurse practitioners in primary care at a time when there is an increase in ageing, chronic disease and mental health populations. Limited ability to earn a living is turning nurse practitioners away from collaborating with GPs in the provision of primary care.
  • Primary health care nurse practitioners 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 nurse practitioners working in primary care. 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 primary health care nurse practitioners from focusing on the marginalized populations they were designed to serve.
  • Primary health care nurse practitioners can independently perform simple procedures such as insertion of contraceptive implants, as well as spirometry and ECG interpretation. Unlike GPs, primary health care nurse practitioners 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 nurse practitioners have performed such services. The cost must not be passed on to practices as part of a collaborative system.
  • There is a lack of knowledge of the primary health care nurse practitioner role. The AMA has done an excellent job in muddying the waters by confusing the nurse practitioner role with that of the practice nurse. Nurse practitioners are independent practitioners who work beyond the contemporary registered nurse 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 practice nurse 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 has not been announced, it is hoped that nurse practitioners working in collaboration with GPs 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 nurse practitioners on the review panel. This presents a missed opportunity to provide informed financial consideration of the nurse practitioner 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, nurse practitioners are missing from the advisory group. Perhaps it is time for a change of heart.

Nurse practitioners are underutilized in primary care 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 nurse practitioner numbers in primary care and provide an impetus for practice nurses to enroll in nurse practitioner programs. While practice nurses work tirelessly, nurse practitioners 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 primary care is proving to be one of their toughest challenges. Primary health care nurse practitioners working together with GPs offer real support to 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 primary health care nurse practitioners 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.

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