This summer the American Association of Nurse Practitioners, which represents nearly 250,000 nurse practitioners in the United States, announced a $2 million advocacy campaign to push for independent practice rights.
Meanwhile, the American Academy of Physician Assistants is calling for the elimination of any legal requirements for PAs to maintain a collaborative relationship with a physician in order to practice.
The trend has the potential to create a two-tiered health care system in which those who can afford it get to see doctors and those who can’t are limited to getting care from unsupervised nurse practitioners and physician assistants, said William S. Mayo, DO, president of the American Osteopathic Association.
“Often we find that patients are unaware of their health care provider’s credentials and there is a clear need for transparency, particularly when it comes to the management of complex patients in the primary care setting,” Dr. Mayo added. “It’s important for legislators to understand the difference in qualifications and why those differences matter.”
Advocating for physicians and patients
Studies have shown that less qualified professionals cost the system more. Specifically, researchers found that nurse practitioners make poorer quality referrals to specialists, expose patients to increased radiation by ordering more diagnostic imaging and prescribe more drugs than physicians.
Currently, 22 states and the District of Columbia allow nurse practitioners to diagnose patients, order and interpret diagnostic tests, and prescribe medication, including controlled substances like opioids, without any physician involvement or oversight. Additional legislation seeking to expand the independent practice rights of non-physician clinicians is expected to be introduced in several states this year.
“It’s extremely clear that these groups of non-physicians are using the physician shortage as a lever to push states into letting them independently practice medicine without attending medical school. While physicians highly value the care they provide, and the system clearly needs them, it is dangerous to substitute nurses and PAs for doctors,” Dr. Mayo said.
Working with state affiliates, AOA has defeated several bills that would have cut physicians out of the health care equation.
In 2018, Oklahoma Senate Bill 570 aimed to greatly expand the scope of practice for Advanced Practice Registered Nurses (APRNs), allowing them to perform a wide range of primary care services, such as prescribing medication without any physician involvement. The bill would have also allowed APRNs to replace physicians as a patient’s primary care provider of record.
In Wisconsin, House Bill 568 sought to repeal requirements that nurse-midwives must practice with an obstetrician and maintain malpractice insurance, and in Kentucky, House Bill 445 would have allowed APRNs to prescribe controlled substances independently after four years prescribing under a collaborative agreement, which could have been made with another APRN.
Although it professes to improve patient access to care, the APRN Compact usurps state law regarding APRN scope of practice by eliminating physician involvement requirements for APRNs who practice under a multistate license, regardless of state law to the contrary, according to David Pugach, JD, AOA senior vice president of public policy.
So far, Idaho, North Dakota and Wyoming have enacted the compact, which becomes effective if 10 states approve the legislation.
Responsibility without accountability
Some independent practice states allow nurses who have passed a single licensure exam at the end of a two-year master’s program to perform many of the same duties of a primary care physician. Classes may be online, with minimal hands-on experience and no supervised postgraduate training.
Despite their lower training, in some states independent practice nurses are not required to maintain a physician’s level of malpractice insurance to compensate patients in the event of an adverse outcome.
Pugach noted that when such events occur, physicians must step in to fix a problem that could have been minimized or prevented if the patient’s care had been properly supervised from the outset. Such avoidable adverse outcomes not only harm patients but unnecessarily drive up the costs of health care for everyone.
“The AOA’s position is clear,” said Pugach. “Team-based health care is a winning model and nurses and physician assistants play vital roles. We will partner with our state affiliates to protect patients by ensuring that physicians are leading those teams.”