The once identifiable hallmarks of the American entrepreneurial health-care systemaccess to care on demand, unrestricted provider choice, and a relatively stable delivery systemhave been supplanted by a process of health-care management commonly referred to as managed care. In the broadest sense, managed care can be defined as a variety of methods to finance and organize the delivery of comprehensive health care with attempts made to control costs by limiting the provision of services. This description of managed care characterizes the integration of financing, cost-containment strategies, and business principles with the delivery of health care. Or, as medical sociologist David Mechanic stated, managed care is moving health care from advocacy to allocation.
A Pew Health Professions Commission Report predicts that 80% to 90% of insured Americans will move under the umbrella of managed-care systems over the next decade. Recent statistics support these predictions. In 1996, Medicare enrollment into managed-care plans grew by 27% and Medicaid enrollment grew by 33%. The number of new health maintenance organization (HMO) enrollees doubled over the past 8 years to 64 million, with nearly three-quarters of American workers receiving their coverage from a variety of managed-care plans; also, 63 new HMOs were licensed, bringing the total number to 630.[4,5] The unpredictable managed-care market has been described by economists as a buyers market, producing not only underused hospitals but specialists who are forced to compete for the diminishing number of fee-for-service patients.
Intrinsic to specialty practice is the routine use of costly diagnostic tests and the need to acquire state-of-the-art technology so as to remain competitive. There is also a general sentiment that specialists are more expensive. Compared to the practice patterns of primary-care physicians, managed-care organizations (MCOs) view specialty practices as resource-intensive and specialists as cost centers. This has led to the implementation of strict gatekeeping practices, systematic utilization management reviews, and the implementation of practice guidelines by MCOs to decrease specialty referrals.
The oncology community has voiced its objections to these documented managed-care practices (eg, restricted access to specialty care, administrative challenges to professional autonomy and clinical decision-making, and reduced employment opportunities for specialists within MCOs.) In response to these market changes, some physicians have formed their own health provider groups and integrated health systems. Friedman defines an integrated delivery system as having a core of physicians on salary or exclusive contract, with a common culture and a consistent product. The system is run by a single board, and offers a full array of health care services provided through capitation for a defined set of populations.
Adapting to the managed-care market has also challenged another group of oncology care providers, advanced practice nurses (APNs), who are being markedly affected by the cost-containment and reengineering efforts hospitals are employing in attempts to remain competitive. In 1995, Milliman and Robertson speculated that in an optimally managed system, only 0.8 beds per 1,000 (assuming 85% occupancy) will be required as hospital occupancy levels continue to decline. This number suggests that about three out of every four hospital beds currently in use will not be needed to meet the inpatient needs of the US population.
Recently released statistics by the American Hospital Association show that, between 1991 and 1995, approximately 190 facilities stopped providing inpatient acute-care services and 335 community and noncommunity facilities closed. The unprecedented wave of hospital closures and the systematic increase in hospital/corporate mergers will cause the loss of 200,000 to 300,000 nursing positions. Furthermore, other industry statistics indicate that there are about 2.6 physicians (1.0 primary-care practitioners and 1.6 specialists) for every 1,000 people in the United States. In optimally managed systems, only 0.5 primary-care physicians and 0.8 specialists are really needed per 1,000 patients. These system changes have mobilized the nursing profession to assess and reexamine advanced practice nursing and, on an individual basis, are prompting APNs to remain marketable by acquiring new skills, additional administrative and professional degrees, such as mbas and jds, and advanced certifications.
Building on the preceding information, this paper will now identify who APNs are, how diverse APN roles are being implemented in oncology practice settings, the market influences affecting APN/physician relationships, and emerging roles and opportunities for APNs within oncology.
Nursing can trace the term specialist back to the turn of the century, when postgraduate courses were offered by hospitals. The first issue of the American Journal of Nursing, published in 1900, included an article entitled specialists in Nursing that addressed the development of specialized clinical practice. By 1980, the American Nurses Association affirmed that Specialization is a mark of the advancement of the nursing profession. Nevertheless, it is important to distinguish between specialization in nursing and advanced nursing practice. Specialization involves concentration in a selected clinical area within the field of nursing. Advancement, as described by Cronenwett, involves both specialization and expansion. Expansion refers to the acquisition of new practice, knowledge and skills, including the knowledge and skills that legitimize role autonomy within areas of practice that overlap the traditional boundaries of medical practice. The term expanded role has been used throughout the nurse practitioner literature.
Within the nursing community, there is no clear definition of advanced nursing practice. Calkin has proposed a conceptual definition, and other authors have defined advanced nursing practice in terms of particular roles. To offset this lack of consensus, specialty organizations, such as the Oncology Nursing Society (ONS), have developed a core definition of advanced practice for their specialties. In 1990, the ONS defined advanced nursing practice as expert competency and leadership in the provision of care to individuals with actual or potential diagnosis of cancer.
Advanced practice nurses generally function as licensed registered nurses who have met advanced educational and practice requirements and are prepared at the graduate level. The defining characteristics of advanced nursing practice, as described by Hamric et al, include three primary criteria and eight core competencies. The three primary criteria are graduate education, certification, and a practice focused on patient and family. The eight core competencies include clinical practice expertise, expert guidance and coaching, consultation, research skills, clinical professional leadership, collaboration, change agent skills, and ethical decision-making skills. These competencies encompass all roles and cross all practice settings.
Of the 2.2 million registered nurses in the United States, about 100,000 are APNs. There are four established advanced practice roles: nurse practitioners (NPs), nurse anesthetists (CRNAs), nurse midwives (CNMs), and clinical nurse specialists (CNSs). There are also many abbreviations used in state legislatures to describe APNs (see box on page 00). Of these four groups, approximately 25,000 are nurse practitioners; 40,000 are clinical nurse specialists; 5,000 are certified nurse midwives; and 20,000 are certified registered nurse anesthetists.
On a state-by-state basis, many legal and regulatory inconsistencies exist both between and within APN roles. Variations also exist among states regarding titles, scope of practice, collaborative protocols, practice agreements, and prescriptive authority. Advanced nursing practice varies among institutions and practice settings, but there are marketable leadership skills common to all APN roles. These include mastering change, systems thinking, shared vision, continuous quality improvement, redefining health care, and service to the community. These leadership qualities are incorporated into the oncology roles of the CNS and NP. The focus of this paper will be a discussion of these established functions and the emergence of case managers, acute care nurse practitioners (ACNPs), and blended CNS/NP roles.