Stiff resistance

The campaign to give more primary-care duties to nurse practitioners faces headwinds across the country. Physician groups continue to resist sweeping measures that would expand the allowed scope of practice for licensed nurses with advanced medical training.

Last year, Virginia passed a significantly scaled back measure that still requires physicians to supervise nurse practitioners, who usually have two years of post-graduate education. A 2010 version of the bill, which drew the ire of the Medical Society of Virginia, would have eliminated mandatory physician supervision for nurse practitioners.

“It's a matter of education for our physician colleagues over the long haul,” said Mark Coles, government relations chair for the Virginia Council of Nurse Practitioners. “What we have now are incremental changes.”

The stakes are huge for a broad cross-section of healthcare providers looking to expand the role of these highly trained professionals in the delivery of primary and supportive care.

They include the burgeoning number of retail clinics popping up across the country, hospital groups seeking to maximize the use of licensed professionals on staff and the nascent accountable care organizations, which will require trained professionals to coordinate care for individual patients across multiple settings. With a looming shortage of primary-care physicians, those tasks could easily be performed by nurse practitioners.

There are implications for costs even when nurse practitioners are paid as much as primary-care physicians. Research has shown they tend to order fewer tests and diagnostic procedures.

But laws limiting the scope of practice for nonphysician medical professionals stand in the way of an expanded role for nurse practitioners in many states. State legislators, responding to the need and pressure from nurse practitioner professional societies, have introduced 1,795 scope-of-practice-related bills since 2011.

But only about 1 in 5 have passed, according to the National Conference of State Legislatures. Nurse practitioner-related bills account for only 90 of the total.

Nationally, most of the legislation aims to expand the roles of the midlevel providers, said Rachel Morgan, the health community director for the National Conference of State Legislatures.

For instance, this month Indiana Gov. Mike Pence signed a law that allows military training to count toward an emergency medical technician license. Military medics are qualified to deliver care, but don't have the licensing to practice when they return home as a civilian.

But the stiffest opposition comes when expanded scope-of-practice laws encroach on turf traditionally reserved for physicians. In Virginia, the state medical society raised safety concerns about the original 2010 proposal by citing nurse practitioners' lack of training and coursework. They urged greater focus on nurse education and clinical preparation rather than expanding nurse practitioners' scope of practice.

“Virginia must take all steps necessary to not only ensure access to care, but to ensure the delivery of quality care,” a 2009 Medical Society letter to the Joint Commission read.

After 2010, the failure to pass legislation led supporters to scale back their ambitions. Rather than fighting physician groups, the two sides collaborated on a limited bill, which emphasized physician-led, team-based care.

It required nurse practitioners to continue practicing under a physician's supervision, although the physician-nurse practitioner supervision ratio was increased to 1-to-6 from 1-to-4.

The bills went into effect in January.

Still, there is some movement on other fronts. Virginia has introduced 46 scope-of-practice bills since 2011 and adopted 33, which slightly expand the authority of nurse practitioners, physician assistants and other providers.

For example, a law passed last year allows Virginia nurse practitioners to perform some surgeries with proper physician supervision.

“The underlying impetus has always been the increasing shortage of providers,” Coles said.

Follow Ashok Selvam on Twitter: @MH_aselvam