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HMO NURSES AS GATEKEEPERS

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NEW YORK-An innovative health care program that plans to use nurse practitioners as primary health care providers could lead to significantly lower health care costs, but the concept also may face several roadblocks.

Those roadblocks might include employees' possible reluctance to see a nurse instead of a doctor and potential liability issues. The program also could lead to heavier use of expensive specialists, observers say.

Even if it is successful, the program is unlikely to become widespread quickly, because relatively few of the approximately 100,000 nurse practitioners have the experience to step in as primary health care providers. More typically, nurse practitioners, who have two years of advanced study beyond their four-year baccalaureate degrees, work directly under physicians' supervision in doctors' offices, hospital clinics or for health maintenance organizations.

Under an agreement between Norwalk, Conn.-based Oxford Health Plans Inc. and medical providers at Columbia Presbyterian Medical Center in New York, starting by early April members of certain health plans will have the option of seeing up to 20 nurse practitioners affiliated with Columbia Presbyterian instead of physicians as their primary care providers.

While they will refer patients who need specialists or emergency care to doctors, the nurse practitioners will have broad authority, including the ability to admit patients to Columbia Presbyterian under their own care and to prescribe drugs.

While rates to be paid for the primary care services will be the same whether the employee sees a doctor or nurse, the program eventually could lead to lower health care costs because of nurses' focus on health education and prevention, says program designer Mary Mundinger, dean of the Columbia University School of Nursing, which is affiliated with Columbia Presbyterian.

Studies indicate nurse practitioners save money because they are more likely to use health care education instead of medication or other expensive interventions to treat patients, said Ms. Mundinger.

Furthermore, she said, nurse practitioners are "more likely to recommend and prescribe preventive care, and they're much more likely to engage the patient in developing some health promotion activities."

A public relations campaign targeted at employers and employees will be introduced in conjunction with the program, she said.

Dr. Ben Safirstein, vp-medical affairs at Oxford, said in a statement that the agreement is for a clinical study that is a "first step in the research and study of the health care benefits nurse practitioners may be able to provide our members. The pilot program is a breakthrough for nurses looking to utilize their special skills. It will create a dialogue to discuss new ways for nurses and doctors to work together to improve the quality of health care to patients."

In the past few years, in a trend the reimbursement system has reinforced, doctors have spent less time with patients but authorized more procedures, said Dr. Stephen Rosenberg, director of clinical services at Coopers & Lybrand in New York and a professor at Columbia College of Physicians and Surgeons, which also is affiliated with Columbia Presbyterian.

Physicians may be inclined to immediately order $800 in tests to rule out the possibility of a rare disease. A nurse is more likely to encourage a patient to change his diet and wait to see how that works out before turning to an expensive test, said Dr. Rosenberg, who added programs such as these also could help meet the increasing need for primary care professionals.

According to the American Medical Assn., for instance, the percentage of general practice physicians dropped 70.9% between 1970 and 1995, although the the number of specialists in family practice has increased.

Some benefit managers also view the program positively.

If this approach means delivering quality care while managing cost, it could be an option, said Bernard Knobbe, manager-employee benefits for Morton International Inc. in Chicago. "It doesn't surprise me health plans are starting to consider another alternative to meet the needs of their employees or patients."

"We support the use of allied health professionals," said Suzanne Mercure, manager of benefits administration for Southern California Edison Co. in Rosemead, Calif.

"In our concept of a patient care team there should be many options, and a nurse practitioner can easily be one," Ms. Mercure said of the program. She added, " I really do believe in the future we will use many more allied health professionals. It won't be such an aberration."

However, Helen Darling, manager of health care strategy at Stamford, Conn.-based Xerox Corp., questioned how receptive employees would be to the program. "I don't think that consumers, at least the consumers I know, are going to be happy with any sort of diminution in the level of expertise that they're able to have available to them on a routine basis," she said.

"I actually think the average employee and their family would be concerned if there was any perception there was anyone coming between them and their doctor," she said.

While the program could be cost-effective and increase focus on preventive care, "I think this concept creates a plethora of questions and concerns that will need to be addressed before it has any chance of success," said Brian Humphrey, vp and managing executive at Sedgwick Noble Lowndes in St. Louis.

"For example, who is ultimately responsible for the decisions made, the nurse or the doctor or the health plan? Secondly, I would expect an increase in liability and ultimately an increase in costs as a result."

Also of concern, he said, is the difference between nurse practitioners and primary care physicians in technical knowledge, diagnostic skill and triage skills. In addition, this approach could create a lack of credibility with patients and lead to more use of specialists, said Mr. Humphrey.

Katherine Chavigny, a registered nurse and director in Chicago of the AMA's office of health-related professions and nursing affairs, said: "I don't think that the public knows the limitations of the nurse practitioner or physicians assistant. I think the most cost-effective care is when the nurses and the physicians assistants and the physicians work together."

Dr. Robert Scully, an internist and associate medical director at the Urbana, Ill.-based Health Alliance Medical Plan, said his plan also favors a team approach. "We think the nurse practitioner and physicians assistant works better in collaboration with a physician," with the physician ultimately responsible for the decisions made, he said.