Most Virginia nurse practitioners could gain the autonomy to practice without a physician's oversight if Gov. Ralph Northam signs a bill the General Assembly passed with near-unanimous support.
The measure would allow most types of nurse practitioners with five years of full-time clinical experience to earn approval to practice without maintaining a contract with a physician who oversees them. Northam, who must act by April 9, is evaluating the bill, according to his office.
Nurse practitioners have specialized training to write prescriptions, make diagnoses and perform other tasks that go beyond traditional nursing duties. Virginia is currently among 12 states , mainly in the South, with the most restrictive supervision requirements for nurse practitioners, according to the American Association of Nurse Practitioners.
"Nurse practitioners do not want to be MDs, but they do want to practice to their full scope of training. They have been providing competent, safe healthcare to patients for years, often in settings where the collaborating doctors are many miles away or even in another state," the bill's sponsor, Republican Del. Roxann Robinson, said during a subcommittee hearing.
Supporters of the bill say current collaborative practice agreements, the contracts nurse practitioners must have their whole careers, are an unnecessary and sometimes costly burden. Doing away with them could expand access to healthcare in areas of the state that sorely need it, they say.
While the bill passed with broad support, including from outside groups, the measure also sparked intense debate and drew opposition from doctors.
The Medical Society of Virginia, the state's largest association of physicians, has raised concerns about patient safety and quality of care. The group has lobbied the governor for a significant amendment to the version of the bill that passed.
"Every pilot is trained to fly a plane. But do you really want someone who's been trained to fly a two-person Cessna landing your 747? It's about having the right person in the right role," one medical student said while speaking against the bill in a subcommittee hearing.
But some nurse practitioners say doctors are more concerned about protecting their income — and their turf.
"They're worried about a nurse practitioner opening a clinic next door," said Paula Hill, a nurse practitioner and clinical director of the Health Wagon, which provides free healthcare in underserved areas of Appalachia.
Physicians in Virginia can't currently supervise more than six nurse practitioners at a time, so finding an available doctor has been a challenge for some.
"I delayed starting my business for having trouble finding a collaborating doctor," said Kristin Andrs, a nurse practitioner who runs her own practice in Petersburg.
As an herbalist trained in integrative medicine, Andrs said she thinks she had an especially hard time because of her specialty.
If her supervising doctor should retire or his health gets bad and he has to quit, Andrs said she would be in a bind.
Andrs said she pays her collaborating doctor under $1,000 a year. She said that they meet quarterly to go over charts so he can sign off on them and that she will occasionally call or text him with a question, but she's just as likely to reach out to another contact in the medical field.
Peter Buerhaus, a nurse, healthcare economist and professor at Montana State University, said the debate over the role of nurse practitioners has been going on since the 1970s but really heated up after the passage of former President Barack Obama's healthcare overhaul.
"People began to go, 'Hmm, how are we going to provide care for all of these individuals who are now going to have insurance?'" he said.
Buerhaus said the quality of care provided by nurse practitioners has compared favorably to doctors in hundreds of studies.
"The vast majority of this evidence shows that nurse practitioners provided comparable and oftentimes better care than physicians," he said.
The Medical Society of Virginia has asked Northam, himself a doctor, to amend the bill to include a provision requiring nurse practitioners to meet their five-year requirement while collaborating with a physician in the same type of practice area, according to Ralston King, the group's assistant vice president of government affairs.
"If that provision is included, we can drop our opposition to the bill," he said.
The Virginia Council of Nurse Practitioners, meanwhile, wants the bill enacted as-is and sees the proposed amendment as a step backward, said Cindy Fagan, the council's government relations chair. The requirement would further limit the physicians available to collaborate with, said Fagan, who added that there's other language in the proposed amendment the council sees as onerous.
If Northam amends the measure, the General Assembly will need to vote on it again when they reconvene in April.
If the bill takes effect as passed, 62% of affected nurse practitioners would have already met the five-year experience requirement, according to data from the Virginia Department of Health Professions.