Expanded scope: Nurse practitioners making inroads

Gail Sadler, a nurse practitioner, provides a wide array of primary-care services at her private practice in Carrollwood, Fla., a community that has been buffeted for years by a physician shortage.

But she isn't allowed to write prescriptions for controlled substances—not even cough syrup with codeine. This leaves some of her patients in a difficult spot when they need immediate access to medication.

“Many physician practices are overcrowded as it is, so to have patients go to them just to get a prescription filled is an access-to-care issue,” Sadler said.

Florida, where some counties have a third less physicians per capita than the national average, is the only state in the U.S. that doesn't allow nurse practitioners, who hold at least a master's degree and must be nationally certified, to prescribe controlled substances, even if they have a collaborative agreement with a physician.

But nurse practitioners' struggle to practice to the full scope of their skills and knowledge isn't unique to Florida. For years, advanced nurse practitioners around the country have been fighting for the right to write prescriptions or to operate practices without the need of a collaborative agreement with a physician.

Advocates' efforts to expand nurse practitioners' duties have only intensified since insurance expansion under the Affordable Care Act began. Nearly 18 million Americans have gained coverage. Moreover, a 2015 Kaiser Family Foundation survey found that more than 58 million Americans reside in areas with primary-care physician shortages.

Having a wider scope of practice would also allow nurse practitioners to diagnose patients, order tests, complete death certificates and initiate involuntary psychiatric commitment for unstable patients without the need for a supervisory relationship with a provider.

A 2010 Institute of Medicine report titled “The Future of Nursing: Leading Change, Advancing Health” recommended that nurses be given the right to perform procedures, actions and processes based on their education and training. Restricting their practice, according to the report, undermines nurse practitioners' ability to provide much-needed primary care in areas where there are physician shortages, especially rural areas.

There has been some progress since the report. A December 2015 update from the IOM showed that Connecticut, Maryland, Minnesota, Nebraska, Nevada, North Dakota, Rhode Island and Vermont had changed their laws to give nurse practitioners full practice and prescriptive authority, bringing the total to 21. Another six—Arkansas, Kentucky, New York, Texas, Utah and Wisconsin—have expanded nurse practitioners' scope of practice.

States in the mid-Atlantic and Southeast continue to have the most restrictive practice laws. “We have a serious shortage of primary-care physicians in the U.S., and the shortage is only going to get worse as fewer and fewer go into primary care and we expand coverage,” said Stuart Altman, a professor of health policy at Brandeis University who served as chairman of the IOM committee that produced the follow-up report. “Nurse practitioners have the training to provide this care.”

Still, state and national medical societies continue to oppose nurse practitioners gaining broader practice authority. They argue that nurses don't have the training to practice without some form of physician supervision.

A family physician typically has as much as 11 years of school and 21,000 hours of post-graduate training. An advanced nurse practitioner has between five to seven years of education and only 5,300 hours of post-graduate training, according to an American Academy of Family Physicians analysis.

Physician groups say the lower level of training increases costs without alleviating shortages. Two recent studies, one performed by the Mayo Clinic, suggested that increased use of nurse practitioners led to increased use of diagnostic imaging services and referrals to specialists.

Physicians say advanced nurse practitioners can help alleviate the primary-care shortage, but only if they are a part of a coordinated team led by a doctor. “What we're for is team-based care where it's the right provider, the right care at the right time,” said Dr. Robert Wergin, the AAFP's board chairman. “Everyone contributes to the care, but we're not necessarily interchangeable.”

“Independent practice and team-based care take healthcare delivery in two very different directions,” an American Medical Association spokeswoman added. “One approach would further compartmentalize and fragment healthcare delivery, while team-based care fosters greater integration and coordination.”

Nurse practitioners support collaboration, but not if it's mandatory. “When it's mandated by the state, it can curtail access to care,” said Andrea Parsons Schram, a family nurse practitioner and assistant professor at Johns Hopkins School of Nursing. “If a nurse practitioner has to collaborate, and that collaborator leaves the state or retires, then she may have to stop seeing patients.”

Giving more autonomy to nurse practitioners is showing results in some areas. Since Nevada passed its scope-of-practice law in 2013, there's been a nearly 36% increase in the number of nurse practitioners registered in the state, said Scott Lamprecht, president of the Nevada Nurses Association.

The quality of care has also increased, Lamprecht said, because nurse practitioners can spend more time with patients than primary-care physicians, which allows them to provide more detailed instructions on how to address health issues.

Nevada's expanded scope-of-practice law also allows nurse practitioners to stop paying monthly fees to their collaborative physicians, which can range as high as $3,000. Also, they no longer have to compile case documents for their physician partners, said Sally Miller, a nurse practitioner in the state.

In states still holding out against broader nurse practitioner responsibilities, physicians have seized on the nation's opioid epidemic as a reason to avoid giving those care providers the right to prescribe controlled substances such as oxycodone. “What about the great strides Florida has made in recent years to combat the pill-mill epidemic?” Dr. Alan Harmon, Florida Medical Association president, asked in a letter posted on its site about a pending bill that would allow nurses to prescribe controlled substances. “This legislative proposal will not fix Florida's physician shortage. Rather, it will expand the problem and create greater issues elsewhere.”

Nurses dismiss these criticisms. “To insinuate that NPs will exacerbate the problem is a false ploy being used by organized medicine to keep NPs under physician supervision,” said Mary Chesney, clinical associate professor at the University of Minnesota School of Nursing. “To date, there isn't any study or evidence to support that nurse practitioners are any more likely than physicians to mis-prescribe narcotics.”

Despite recent progress, the slow pace of change frustrates nurse practitioners. “We're still battling with organized medicine, who has been spending a great deal of time and money raising questions about the qualifications and ability of advanced nurse practitioners with both policymakers and the public,” said Janet Haebler, senior associate director of state government affairs at the American Nurses Association.

Sadler, president of Florida's chapter of the Association of Nurse Practitioners in Business, is cautiously optimistic about the drug-prescribing legislation making its way through that state's Legislature. This is the most progress Sadler has seen on such legislation since she began fighting for it 15 years ago.

The reason for optimism? Both the House and Senate versions of the bill have made it through several committees for the first time, and are expected to be voted on by both lawmaking bodies this legislative cycle.

“If you're feeling bad, and you're 70 years old, you shouldn't have to drive 45 minutes to the next town or wait days for a doctor to come back to a local practice to get a prescription,” said state Sen. Denise Grimsley, a nurse, who crafted a compromise version of the bill.