The Nurse Practitioner Is In

The Nurse Practitioner Is In

No, she's not a doctor. She just does a lot of the same things doctors do.

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On a Tuesday morning in July, Dan Hellie woke up with excruciating lower back pain. The timing was terrible for the WRC-TV sports reporter and anchor since he was due in Richmond to cover the Washington Redskins training camp and the highly anticipated return of quarterback Robert Griffin III. Moreover, the next two days were to be Hellie’s last at the station and he didn’t want to call in sick.

Fortunately, Hellie, 38, had a physical scheduled that morning with Kelly Goodman, a Bethesda nurse practitioner. The exam was required for the new job he was starting in August at the NFL Network in Culver City, Calif. Hellie, who would be moving from Bethesda to Los Angeles with his family in the coming weeks, had put off scheduling a physical with his doctor. Now, he figured he’d have to wait a month for an appointment.

His wife, Anne, saw Goodman for primary care and adored her empathetic approach. She had suggested he call to see if the nurse practitioner might be able to fit him in. That Monday, he was told there was an opening the next morning.

By Tuesday afternoon, Goodman had completed Hellie’s physical, given him medicine for his back, and referred him to a colleague who was both a doctor and a chiropractor. By evening, Hellie was en route to Richmond for his farewell assignment.

“It made all the difference in the world getting in to see her as quickly as I could,” Hellie says.

The ease with which Hellie was able to see Goodman underscores why some people are choosing nurse practitioners over doctors for their primary health care.

Nurse practitioners say they’re a cost-effective solution to the rising demand for primary care providers, performing many of the same tasks handled by family physicians: routine physicals, referrals to specialists, surgery preparation, chronic disease management, and preliminary diagnostic work. Offering an alternative to time-pressed doctors, nurse practitioners are gaining a reputation for prompt appointments, longer visits and a focus on prevention.

“In this day and age, doctors don’t really have a lot of time for teaching and explaining, for putting a pathway in place to live a healthier life,” says Goodman, one of the few nurse practitioners in Montgomery County who practice independently.

According to the Kaiser Family Foundation, 180,233 nurse practitioners were licensed in the U.S. and 3,493 in Maryland in 2011. Nationwide enrollment in nurse-practitioner programs increased by 60 percent from 2006 to 2010, says the American Association of Nurse Practitioners (AANP). Meanwhile fewer medical students were pursuing family and internal medicine due to the lower salaries and quality of life issues associated with these specialties, according to Kaiser.

Due to insurance requirements of the Affordable Care Act, 30 million people are expected to enter the health care system in January. Nurse practitioners will likely play a role in meeting their primary care needs, says Dr. Kenneth Miller, AANP co-president and associate dean for academic administration at The Catholic University of America’s School of Nursing.

Though primary care doctors and nurse practitioners often work in tandem, organizations representing both groups are debating how independent nurse practitioners should be. The American Academy of Family Physicians (AAFP) envisions nurse practitioners playing a vital but ultimately supportive role to doctors in a team approach to health care, according to a recent AAFP study. Nurse practitioners, meanwhile, continue to lobby for greater autonomy.  

From Monday through Friday, Goodman, 42, sees patients at her clinic in a shopping mall off Sangamore Road. She says her practice has grown steadily since it initially opened in Northwest Washington, D.C., in 2009.

In July, she hired a nurse practitioner who specializes in family medicine, and she plans to hire another soon so the practice can treat children. The clinic serves roughly 1,500 patients.  

By contrast, the average patient load of a primary care physician is 2,300, according to a 2012 study in Annals of Family Medicine. Having little control over insurance reimbursement rates, doctors are forced to see a high volume of patients to stay in business, says Michael Faulkender, associate professor of finance and director of the master’s program in finance at the Robert H. Smith School of Business at the University of Maryland.

With higher malpractice insurance premiums, bigger salaries, larger staffs and greater student loan debt, doctors are shouldering increased costs, Faulkender says. “They’re going to have to generate more revenue to cover those higher-level costs.”    

The cost pressures can translate to less time with patients. Several of Goodman’s patients say they’ve come to her out of frustration over the lack of personal interaction with their primary care doctors; they praise her listening skills and timeliness when responding to emails and returning test results. Goodman spends 20 to 40 minutes with each patient, never double-books, and tries not to see more than 20 to 25 patients per day.

“I feel like I can be really open and honest” with her, says Chevy Chase, D.C., resident Will Caggiano, 40, an executive recruiter who says his appendicitis was caught by Goodman in 2011 after emergency room doctors misdiagnosed it as a heart problem. “She’s not going through the motions, unlike what I’ve experienced before.”

Caggiano’s enthusiasm is reflected in studies that show nurse practitioners outranking physicians in patient satisfaction. A 2010 Veterans Health Administration survey of 1.6 million veterans found that patient satisfaction scores increased by 5 percent when more nurse practitioners were hired at VHA facilities, compared with a 1.8 percent increase when more physicians were hired.

Economics are also driving patients to Goodman, particularly those whose physicians have exited insurance-based practices for concierge medicine, charging retainers of $980 to $2,000 annually for 24-hour access.

These patients have either been dropped by doctors who no longer accept insurance or Medicare, or have left because they can’t afford or don’t want to pay a retainer.

Goodman says that absorbing patients who were priced out of concierge practices was central to her business plan. She encountered them while working as an emergency room nurse at Sibley Memorial Hospital in Northwest D.C. before opening her practice.

“People don’t want to doctor-hop,” Goodman says. “I tell them, ‘I want to be the last provider you’ll see in your lifetime.’ ”

Although not all nurse practitioners accept private insurance, Goodman does and also accepts Medicare. Co-pays and premiums for nurse practitioners’ services aren’t necessarily cheaper than those for doctors because insurance companies don’t always reimburse nurse practitioners at the same rate as they do physicians, says Taynin Kopanos, AANP’s vice president for government affairs. Medicare, for example, reimburses nurse practitioners 85 percent of what it reimburses doctors for the same procedures, but Medicare copays remain constant regardless of the provider.

“Where consumers may see the cost benefit is in their health outcomes,” Kopanos says. “Studies have shown [that] patients treated by [nurse practitioners] stick to their medication and treatment plans with more success,” which could lead to savings resulting from fewer hospitalizations and disease flare-ups.

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