Nurse practitioners push for more freedom

Back bill allowing them to forgo supervising doctor


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From sick babies to diabetic seniors, Mona Counts has treated thousands of patients, many of whom would travel an hour or more to visit her primary care health clinic in rural Greene County. She knows their family medical histories better than they do because she treated their parents and grandparents over the decades.

"Patients would describe me as an old-time family doc," she said last week.

But she's not a family doctor -- she's a nurse practitioner, and doesn't have an M.D. behind her name (though she does have a Ph.D.). So, despite her wealth of experience, state law says she's not allowed to operate a full medical practice without collaborating with two supervising physicians.

It's a requirement whose utility has come and gone, says Ms. Counts, now in her 70s and semi-retired. Back when nurse practitioners "were relatively new on the marketplace, [doctors] wanted to make sure they would be safe providers of health care," Ms. Counts said. But "the need for that collaborative agreement has just gone away."

That's why Pennsylvania's nurse practitioners are pushing for a change in state law, contained in Senate Bill 1063, that would allow them to practice as independent primary care providers without first signing collaborating agreements with supervising physicians. Eighteen other states, and Washington, D.C., have done the same, giving nurse practitioners "full practice authority."

Nurse practitioners who work in the primary care realm, which is most of them, are able to do many of the things that primary care doctors do -- evaluate patients, order and evaluate diagnostics tests, prescribe drugs, refer to specialists.

Allowing them to function independently could help relieve the oncoming shortage of primary care physicians, said Lorraine Reiser, a director with the American Association of Nurse Practitioners, and a nursing professor at Clarion University.

"When my previous collaborating physician left, I was forced to find another," said Ms. Reiser, who practices at the Hilltop Community Healthcare center in Pittsburgh's Beltzhoover neighborhood.

In Pennsylvania, a nurse practitioner who wants to prescribe drugs to patients must have partnerships in place with a primary physician collaborator, as well as a backup. If those partnerships aren't on file and renewed every two years, a nurse practitioner can't prescribe and, essentially, can't practice.

It may sounds like a mere administrative hurdle, but at times, the requirement acts as a barrier to care, said Kathy Magdic, an acute care cardiology nurse practitioner who practices at UPMC Presbyterian. If a practitioner is operating a clinic in a rural area where there aren't many primary care physicians nearby, it can be difficult to find new doctor collaborators.

If that happens, a nurse practitioner can be "forced to shut down her practice," Ms. Magdic said.

Physicians are also limited as to the number of collaborating agreements they can sign (a maximum of four), and in cases where a physician works for a large medical center, sometimes the center won't permit the doctor to sign a collaborating agreement with nurse practitioners who work outside the hospital network.

And some physicians charge nurse practitioners and their clinics for their collaboration services, adding to overhead expense.

Changing the law in Pennsylvania could take some time, though, if history is an indicator. Pennsylvania was one of the last states to allow nurse practitioners to prescribe drugs. That happened in 2000, and the campaign to give them that authority took more than a decade.

That was, in part, because of ongoing resistance from doctors' groups when it came to granting more autonomy to non-doctors who practice in the medical field. Now, as then, getting buy-in from physician groups will be a challenge.

The Pennsylvania Medical Society "is in favor of team-building," said Chuck Moran, spokesman for the group. "Collaborative agreements play an important role in building health care teams while providing a safety net for patients. We would hate to see health care become more fragmented."

Fragmentation might be a moot point, though, as the primary care physician shortage accelerates. Meanwhile, the number of nurse practitioners is growing fast -- there are 8,400 of them in Pennsylvania, and 171,000 nationwide, with more than three-quarters of them working in primary care fields like family medicine and pediatrics.

As the number of nurse practitioners grows, so will the number of those seeking a doctorate in nurse practice. There were 53 such doctorate programs in 2007, more than 90 in 2008, and there could be 200 doctorate programs in 2015, according to the American Association of Colleges of Nursing.

Physicians groups worry that patients might be confused by nurses with a "Dr." before their name.

They also worry that nurse practitioners with a doctorate will eventually push to broaden their scope of practice, eating away at what physicians do -- and at the money they make, since treating a patient at a nurse practitioner clinic is cheaper than being seen by a doctor in most cases.

Groups such as the American Academy of Family Physicians point to an article in the Jan. 16 edition of the Chronicle of Higher Education, in which Mary O'Neil Mundinger, dean of Columbia University School of Nursing in New York, was quoted as saying:

"If nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients."

That's a recipe for a bifurcated system of care, some doctors say.

"Saving money should not be the main factor for decisions that impact patient care and safety. Cutting costs by substituting nurses for physicians would lead the United States to two classes of care -- one run by physicians and a second by differently qualified health care professionals," wrote Reid Blackwelder, president of the American Academy of Family Physicians.

But in Pennsylvania, this isn't a scope-of-practice issue, at least not yet, Ms. Reiser said. It's about freeing up nurse practitioners to do what they're already trained, and permitted by law, to do.

Doing so would allow them to be more easily credentialed -- and paid -- by health insurers as primary care providers.

"How valid is it [when] you have a collaborating agreement with a physician that never sees your patients, doesn't know your patients? ... Is it just that the physicians feel as though they need to have that control over another profession?"

Ms. Counts -- whose Greene County clinic, Mount Morris Primary Care Center, was purchased a few years ago by Cornerstone Care, a small clinic chain -- now runs her own small practice. She says nurse practitioners have proven themselves over the years to be capable providers of care, at a reasonable cost, with patient population health outcomes that are comparable to those of primary care doctors.

"I think they've shown their abilities," she said.


Bill Toland: btoland@post-gazette.com or 412-263-2625.

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