[Congressional Record Volume 144, Number 105 (Thursday, July 30, 1998)]
[Senate]
[Pages S9485-S9487]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




            NURSING SCHOOL ADMINISTERED PRIMARY CARE CLINICS

 Mr. INOUYE. Mr. President, I rise today to speak on an health 
issue of great importance now and in future years. As our population 
continues to increase, our elderly live longer, and healthcare 
technology advances, the need for access to care will undoubtedly also 
increase.
  Because of these monumental increases in the need for healthcare 
access for many Americans, I wish to take a few minutes to discuss the 
need for support of nursing school administered primary care centers.
  Nursing centers are university or nonprofit entity primary care 
centers developed (primarily) in collaboration with university schools 
of nursing and the communities they serve. These centers are staffed by 
faculty and staff who are public health nurses and nurse practitioners. 
Students supplement patient care while receiving preceptorships 
provided by colleges of nursing faculty and primary care physicians, 
often associated with academic institutions, who serve as collaborators 
with nurse practitioners.
  Nurse practitioners, and public health nurses, in particular, are 
educated through programs which offer advanced academic and clinical 
experiences, with a strong emphasis on primary and preventive health 
care. In fact, schools of nursing that have established these primary 
health care centers blend service and education goals, resulting in 
considerable benefit to the community at large.
  Nursing centers are rooted in health care models established in the 
early part of the 20th century. Lillian Wald in the Henry Street 
Settlement and Margaret Sanger, who opened the first birth control 
clinic, provided the earliest models of service.
  Since the late 1970's, in conjunction with the development of 
educational programs for nurse practitioners, college of nursing 
faculties have established nursing centers. There are currently 250 
centers nationwide, affiliated with universities and colleges of 
nursing in Arizona, Utah, Pennsylvania, South Carolina, Tennessee, 
Texas, Hawaii, Virginia, and New York. The Regional Nursing Centers 
Consortium, an association of eighteen nursing centers in New Jersey, 
Pennsylvania and Delaware, was established in 1996 to foster greater 
recognition of, and support for, nursing centers in their pursuit of 
providing quality care to underserved populations.
  Nursing centers tend to be located in or near areas with a shortage 
of health professionals or areas that are medically underserved. The 
beneficiaries of their services have traditionally been the underserved 
and those least likely to engage in ongoing health care services for 
themselves or their family members. In the 1970's, I sponsored 
legislation that would give nurses the right to reimbursement for 
independent nursing services, under various federal healthcare 
programs. At the same time, one of the first academic nursing centers 
was delivering primary care services in Arizona.
  As the Vice Chairman of the Committee on Indian Affairs, I am pleased 
to note that the University of South Carolina College of Nursing has 
established a Primary Care Tribal Practice Clinic, under contract with 
the Catawba Indian nation, which provides primary and preventive 
services to those populations. The University also has a Women's Health 
Clinic and Student Health Clinic, which are both managed by nurse 
practitioners.
  Another prime example of services provided by nurse practitioners is 
the Utah Wendover Clinic. This clinic, in existence since 1994, 
provides interdisciplinary rural primary health services to more than 
10,000 patients annually. The clinic now has telehealth capabilities 
that provide interactive links from the clinic to the university 
hospital, 120 miles away. This technology allows practitioners direct 
access to medical support for primary care, pediatrics, mental health, 
potential abuse, and emergency trauma treatment.
  To date, nursing centers have demonstrated quality outcomes which, 
when compared to conventional primary health care, indicate that their 
comprehensive models of care have resulted in significantly fewer 
emergency room visits, fewer hospital inpatient days, and less use of 
specialists. The Lasalle Neighborhood Nursing Center, for example, 
reported for 1997 that fewer than 0.02 percent of their primary care 
clients reported hospitalization for asthma; fewer than 4 percent of 
expectant mothers who enrolled delivered low birth rate infants; 90 
percent of infants and young children were immunized on time; 50 
percent fewer emergency room visits; and the clinic achieved a 97 
percent patient satisfaction rate.
  What makes the concept of nurse managed practices exciting and 
promising for the 21st century is their ability to provide care in a 
``spirit of serving'' to underserved people in desperate need of health 
care services. Interestingly, nurse practitioners have consistently 
provided Medicaid sponsored primary care in urban and rural communities 
for a number of years, and have consistently demonstrated their 
commitment to these underserved areas.
  The 1997 Balanced Budget Act (P.L. 105-33) included a provision that 
for the first time ever allowed for direct Medicare reimbursement of 
all nurse practitioners and clinical nurse specialists, regardless of 
the setting in which services were performed. This provision built upon 
previous legislation that allowed direct reimbursement to individual 
nurse practitioners for services provided in rural health clinics 
throughout America. The law effectively paved the way for an array of 
clinical practice arrangements for these providers; however, per visit 
payments to nurse run centers, as opposed to individual practitioners, 
was not formally included in the law.
  Federal law now also mandates independent reimbursement for nurse 
practitioners under the Civilian Health and Medical Programs of 
Uniformed Services (CHAMPUS), the Federal Employee Health Benefits Plan 
(FEHBP) and in Department of Defense Medical Treatment Facilities.
  As the Ranking Member of the Defense Appropriations Subcommittee, my 
distinguished colleagues and I have listened to the testimonies of the 
three Service Chief Nurses each year, during the Defense Medical 
hearings. I am proud to report that the military services have taken 
the lead in ensuring the advancement of the profession of nursing. 
Military advanced practice nurses provide care to service members and 
their families at all of the treatment facilities. The Graduate School 
of Nursing at the Uniformed University of the Health Sciences (USUHS), 
which has a very successful nurse practitioner program, was recently 
recognized in the top 100 graduate schools in the United States. The 
Commanding General at Tripler Army Medical Center, a two star position, 
is a nurse. This

[[Page S9486]]

is a first ever accomplishment for nurses in the military. I hope to 
see more nurse officers in these leadership roles, even at the three 
star level.
  At the beginning of this session of Congress, I proposed legislation 
to amend Title XIX of the Social Security Act to expressly provide for 
coverage of services by nursing school administered centers under state 
Medicaid programs, similiar to payments provided to rural health 
clinics. Today, as we debate a number of health care issues, I urge us 
to consider creative avenues for expanding health care access for all 
Americans, particularly the poor and underserved. Nursing centers, as 
new models of health care providers, offer quality services for lower 
payments.
  In closing, I would like to reiterate that nurse practitioners 
provide cost effective, preventive care in underserved areas across 
America. Their educational programs emphasize the provision of care to 
patients with limited resources, financial and otherwise. A recent 
article in U.S. News and World Report showcased the successful Columbia 
Advanced Practice Nurse Associates (CAPNA), a nurse run primary care 
clinic in New York City. Dr. Mary Mundinger, the Dean of the Columbia 
School of Nursing and a Robert Wood Johnson Health Policy Fellow in 
1984, was the catalyst for the center, which she envisions as a 
``prototype of a new branch of primary care.''
  Nurse practitioners have proven themselves to be well trained 
providers of high quality, cost effective care.
  Nursing school administered centers offer viable alternatives to 
health care access for the poor and underserved, and allow Americans 
more choices in their selection of cost effective, quality care 
services. The issues surrounding quality, access and the provision of 
patient care services are, Mr. President, at the crux of our current 
debates over health care reform. We owe it to each and every American 
to provide the very best options for quality health care available.
  Mr. President, I thank you for the opportunity to address my 
colleagues on this most important topic. I ask that an article on this 
subject be printed in the Record.
  The article follows:

           [From the U.S. News & World Report, July 27, 1998]

  For nurses, a barrier broken--It's a test insurers are backing: Can 
                   primary care work without doctors?

                           (By James Lardner)

       Seems like everybody's been trying to take a bite out of 
     doctors' paychecks lately--the federal government, employers, 
     insurers, and now, of all people, nurses. In New York City, 
     Medicare and eight private health plans have given their 
     enrollees permission to get primary care from a group of 
     nurse practitioners or NPs, who diagnose, treat, prescribe, 
     refer, and bill very much as if they were M.D.'s.
       About 250 New Yorkers have signed up with the 10-month-old 
     practice, known as CAPNA (for Columbia Advanced Practice 
     Nurse Associates), and though it's still a tiny operation--
     just four NPs--business is growing by six or seven new 
     patients a week. Supporters think the idea of a nurse-run 
     form of primary care has a lot of potential. Many doctors are 
     dubious.
       The New York State Medical Society's chief lobbyist, 
     Anthony Santomauro, sees a threat to the well-being of 
     physicians as well as of patients. ``Your action,'' 
     Santomauro warned his colleagues recently, ``could decide 
     whether nurse practitioners . . . continue to serve under 
     your direction and supervision or . . . become independent 
     practitioners in direct competition.'' To Robert Graham, 
     executive vice president of the American Academy of Family 
     Physicians, what the nurses are doing ``comes very close to 
     practicing medicine, which of course, requires a medical 
     degree and a license.''
       The law aside, critics argue that primary care entails 
     subtle diagnostic decisions that physicians are uniquely 
     qualified to make. ``The four years in medical school and 
     three years in residency training and many hours of 
     continuing education that physicians receive are very 
     different from the 500 to 700 hours of training that most 
     nurse-practitioner programs call for,'' says Nancy Dickey, a 
     Texas physician who recently became president of the American 
     Medical Association. (There are roughly 140,000 nurses with 
     advanced degrees in the United States; as a rule, NPs have 
     master's degrees that entail two years of classroom and 
     clinical training.)
       While physicians stress the possibility of confusion about 
     who is or isn't an M.D., they may be up against a bigger 
     problem: a widespread longing for a slower-paced, more 
     personal form of health care than many people feel they can 
     get from physicians these days. ``If you spend 10 minutes 
     with a doctor in New York City, you're doing well,'' says 
     Doris Ward, a 77-year-old former nonprofit executive. Ward 
     came to CAPNA's offices on East 60th Street seeking treatment 
     for high cholesterol and anxious to find ``someone who would 
     sit down and talk to me for a little while.'' Her NP, Marlene 
     McHugh, devoted an hour to the initial appointment and 
     recommended a dietary rather than a medical approach to her 
     problem.
       Thomas Becker, a 36-year-old marketing manager, was 
     confused about whom he was seeing. He didn't know that 
     Edwidge Thomas was not a doctor when he picked her from a 
     list supplied by his health plan; in fact, he didn't realize 
     his mistake until his first visit. But Thomas asked such 
     insightful questions that ``it didn't really matter to 
     me,'' Becker says. After three appointments, two for 
     sports-related injuries and one for flu, he rates CAPNA 
     ``absolutely excellent.''
       Bedside manner. Mary O'Neil Mundinger, dean of the Columbia 
     University School of Nursing and the driving force behind 
     CAPNA, sees it as the prototype of a new branch of primary 
     care. She spent 17 years as a bedside nurse before getting a 
     doctorate in public health, and she dismisses the suggestion 
     that nurses are likely to overlook symptoms or botch 
     diagnoses (``We don't miss things,'' she says crisply). But 
     physicians, she argues, overemphasize diagnosing and 
     prescribing, and tend to consider their work over once they 
     have recommended a program of treatment; nurses, she says, 
     are better at getting patients to follow the program.
       Two studies seem to bolster her case. Nurse practitioners 
     have long provided primary care to those who might otherwise 
     have gone unserved, such as residents of rural areas, and a 
     1986 study by the Office of Technology Assessment concluded 
     that the care they provided was equivalent to that offered by 
     physicians. When it came to communication and prevention, the 
     OTA found NPs more adept.
       In addition, a 1993 analysis of studies comparing care 
     offered by physicians with that provided by NPs found that 
     nurses spent about 25 minutes with a patient; doctors spent 
     17. The two groups were about equal in their rates of 
     prescribing drugs, but the nurses provided more patient 
     education and stressed exercise more often than the doctors.
       While the debate may seem to pit nurses against doctors, 
     the more important division exposed by CAPNA may be between 
     two types of physician, primary-care providers and 
     specialists. Critics of the CAPNA model fear that NPs, 
     because they have less training than physicians, will rely 
     too much on specialists. Many specialists respond that in the 
     age of managed care, overreferral by nurses is far less of a 
     danger than underreferral by doctors, who are torn between 
     the interests of patients and, as Eric Rose, the chief of 
     surgery at Columbia-Presbyterian Medical Center, puts it, 
     ``the care of their bankbooks and the HMOs' bankbooks.'' 
     (CAPNA has been referring surgery cases to Columbia-
     Presbyterian.)
       CAPNA's acceptance by insurers as a legitimate primary-care 
     alternative to a practice run by physicians is clearly a 
     breakthrough for nurses, who were long defined as hospital 
     workers who existed to do the bidding of physicians. As 
     recently as the 1970s, nursing-school curricula included 
     elaborate protocols of respect (surrendering one's chair, for 
     example) that a nurse was supposed to follow when a physician 
     entered a room.
       The power of physicians is also under attack from market-
     oriented critics, who see them as attempting to carve out a 
     monopoly at the consumer's expense. In the past, physicians' 
     organizations have used their clout to beat back proposals to 
     give quasi-medical powers to nonphysicians. But CAPNA was 
     created with no change in the law; Mundinger reasoned that 
     the kind of health care she hoped to offer affluent patients 
     in midtown Manhattan was already the norm in much of rural 
     and inner-city America. New York itself allowed NPs to write 
     prescriptions--otherwise, health care in many areas of the 
     state would have ground to a halt. ``As long as it was just 
     poor folks, nobody was paying any attention,'' Mundinger 
     says.
       The groundwork was laid in 1993, when Columbia-Presbyterian 
     sought the nursing school's help in expanding health care 
     services in two poor, upper-Manhattan neighborhoods. Spotting 
     an opportunity, Mundinger asked in return for something that 
     earlier partnerships of nurse practitioners had lacked: 
     hospital admitting privileges--the ability to get patients 
     into Columbia-Presbyterian and supervise their care there. 
     Two new primary-care practices were created, one with doctors 
     and nurse practitioners working as equals, the other run 
     entirely by NPs.
       Mundinger's next brainstorm was to see if the concept would 
     work in an affluent neighborhood. This time, in a move with 
     widespread implications for health care, she went after 
     managed-care plans for the right of reimbursement.
       Equal treatment. For the HMOs--under constant pressure from 
     employers to cut costs--a nurse-run practice had obvious 
     appeal if it meant lower payments for the same services. But 
     Mundinger rejected support that was conditioned on reduced 
     reimbursement, insisting that would open the HMOs to the 
     charge of chiseling and cast her practice as a cheap 
     substitute for real medicine. After months of discussions, 
     Oxford Health Plans agreed to go along. Seven more health 
     plans followed suit, all giving the nurses the same fee-for-
     service rates as doctors.
       Mundinger's admirers say she has not only created a 
     significant new model of health

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     care but, in doing so, has called the medical profession's 
     bluff. Say Uwe Reinhardt, a health economist who teaches at 
     Princeton University, ``Doctors always say the are rugged 
     individualists, for free enterprise and such, and now at the 
     first sight of a nurse they run to the government and say, 
     `Please use your coercive powers to protect us!' ''
       Even some supporters, however, fear that Mundinger's model, 
     for all its noble objectives, will appeal to the basest 
     motives of insurers and employers, leaving patients, in the 
     end, with less-trained people who are in just as much of a 
     hurry. There is some reason for doubting this: A study in the 
     April Nurse Practitioner, for example, found NPs more 
     consistent than gynecologists in adhering to medical 
     standards in evaluating cervical dysplasia, a precursor to 
     cervical cancer. And as Robert Brook, a Rand analyst who is 
     conducting an internal assessment for CAPNA, puts it: ``It's 
     not like we started out with a perfect system.''

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