To the editor: Several comments made in the Feb. 17 story, "HMO Nurses As Gatekeepers," call for the perspective of members of the Iowa Nurses' Assn.

For example, the story indicated that "relatively few of the 100,000 nurse practitioners have the experience to step in as primary health care providers." Pediatric nurse practitioners have been providing primary care services in Iowa since the 1970s.

We have a number of maternal and child health clinics providing health care. We have several family nurse practitioners setting up their own clinics in rural Iowa, establishing a collaborative practice with physicians and providing access to health care.

There are areas of the state where, even after 10 years of state investment in attracting physicians, there are still no physicians. Iowa has one of the lower ratios of patient care physicians per 100,000 population in the nation. Nationally, there are 203.7 patient care physicians per 100,000 population, while in Iowa that figure was only 138.8. Our advanced practice nurses have lots of opportunities to step in as primary care providers. Or are your comments only directly at urban HMOs?

The story also states that nurse practitioners "work directly under physicians' supervision." Iowa is one of 26 states where there is no requirement for collaboration or supervision of advanced practice nurses by physicians.

Helen Darling, manager of health care strategy at Stamford, Conn.-based Xerox Corp., was quoted as saying: "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. I actually think the average employee would be concerned if there was any perception there was anyone coming between them and their doctor."

From a state with a higher concentration of physicians than other states, it's an easy statement to make. Our state residents would just like access to care. Also, if the HMO or company has employees who desire fixing or curing after the fact, rather than preventing illness, Ms. Darling's statement makes sense. Advanced practice nurses focus their practice on health rather than the physician focus on disease. This comment also misses the choice of some individuals not to bother the doctor with simple questions on their health.

Brian Humphrey, vp and managing executive at Sedgwick Noble Lowndes in St. Louis, was quoted as saying he expected "an increase in liability and ultimately an increase in costs." The article also states his view that the use of nurse practitioners could create a lack of credibility with patients and lead to more use of specialists.

This statement lacks an understanding of using a triage approach to individuals presented with routine health needs, such as earaches, upper respiratory conditions and minor injuries. In Iowa, there are not enough physicians to see patients needing care. With use of advanced practice nurses, they can handle the routine and refer to physicians those patients who need physician expertise. The tone of articles like yours toward advanced practice nursing further encourages comments like Mr. Humphrey's to continue.

While your story tries to be balanced, my perception is that you favor only the physician providing care and cast skepticism about the Oxford plan. Nursing advocates had hoped that HMOs would welcome an increased focus on preventive care.

We hope insurance people like the agent working with our association won't be discouraged. We hope he will continue working with our association in promoting the choice of advanced practice nursing care for primary care services. We also hope that stories won't misinform as to the legal authority of advanced practice nurses throughout the United States.

Linda Goeldner

Executive Director

Iowa Nurses' Assn.

West Des Moines, Iowa