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9 Challenges to the Medical Monopoly Nurses’ Gains in Direct Payment, Hospital Privileges, Prescriptive Authority, and Expanded Practice Laws By the 1980s it was possible for nurses to attack the medical monopoly directly. Following the U.S. Federal Trade Commission’s ruling in 1975 that antitrust laws also applied to professional workers in the health-care system, unfair laws and practices affecting nurses could now be legally challenged. In this chapter we consider the monopolistic medical practices that limit nurses’ access to facilities, exclude them from direct or third-party reimbursements, force them to use backup physicians, deny them hospital affiliations, and limit their prescriptive authority. Clearly, physicians had been engaging in group boycott, tying, and bottleneck agreements, all of which were now subject to attack under the new antitrust ruling. Efforts by nurses and others to weaken these monopolistic practices were countered by physicians with a quality-of-care defense; thus, proof of the equal or superior patient care provided by nurses compared to physicians was imperative. Fortunately, the strategy of shifting nursing education to colleges and universities had paid off as more nurse researchers were capable of and involved in investigating the comparative outcomes of patient care and providing proof of nurses’ competence, particularly in primary care. Increasingly, economic competition between nurses and physicians was openly discussed, but the future of advanced practice nurses (APNs)* and, of course, physician’s assistants (PAs) was still tied to the profits they provided physicians, who, given the projected physician surplus, had few incentives to give nurses greater autonomy. Studies of the cost-effectiveness of APNs proved that their contributions were substantial, although varying according to different work situations. In aggregate, the nurses’ positive economic impact on the nation’s health-care system was or could be considerable. Although physicians continued to stress any weaknesses in the research studies, there were numerous reports by the early 1980s on the comparative costs and productivity of APNs that provided evidence that they could successfully substitute for physicians in primary care. Despite these findings, federal education funds for APNs began to dry up *In the early 1990s, the term “advanced nurse practitioner” (ANP) was replaced by the term “advanced practice nurse” (APN or APRN) to describe those nurses with advanced and/or master’s level preparation in a variety of clinical specializations. The more generic term “nurse practitioner ” (NP) continues to be used widely by many authors and is used in most legislative titles, e.g., state nurse practice acts. 324 AN OUTDATED, BURDENSOME MODEL under the Reagan administration in the 1980s, and evidence began to accumulate proving that institutions, not consumers, had profited from the services of the APNs. Indeed, as we see in this chapter, some researchers were asking whether the nurses were floundering without a constituency. Given the backlash against feminism in the 1980s, it is hardly surprising that a predominantly female group of professional workers would be under attack, particularly given research evidence that APNs infrequently needed to consult with physicians. In contrast, the physicians were more satisfied as their control over nurse practitioners increased, and thus they were still more inclined to accept PAs, over whom they had complete control. Physicians asserted that a stalemate on APNs had been reached; they accused nurses of being more concerned with power than patient care and claimed that “gender politics” obscured rather than clarified problems. All these accusations are very similar to those expressed by physicians in the early twentieth century, but by the end of the century, such assertions were substantially weakened by the research on nurses’ cost-effectiveness and on their quality of care, evidence too often missing in physicians’ pronouncements. Despite the dismissal of “gender politics,” some physicians admitted that they would accept only those APNs who were sexually and politically “nonthreatening.” Thus, in the 1980s and into the 1990s gender remained a central problem despite shifts in the gender mix within professional groups. Research on the practice characteristics of male and female PAs revealed significant gender differences: More male PAs were in surgical and family specialties and more females in internal, pediatric, obstetric, and gynecologic specialties . Furthermore, the women were more likely to be in clinics than in physicians’ offices and to work in urban areas. Additional research on malefemale differences in descriptions of the self and of the ideal of PAs produced results that were very similar to those found in earlier research on male...

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