Point-Counterpoint: Should Pa. let nurse-practitioners do more?

Earlier this summer, the Pennsylvania Senate passed a bill that would allow nurse practitioners to practice to the full extent of their license, removing a requirement that they have "collaborative agreements" with physicians - a form of oversight.

Supporters say that the measure, which next goes to the House, would improve access to cost-effective care by allowing nurse-practitioners independently to take on more tasks, including prescription-writing. Opponents maintain that physicians, who undergo more training, should keep providing supervision.

"Full practice authority" for nurse practitioners is allowed in 21 states and Washington. The Veterans Administration is considering a similar move. Nine area schools have graduated more than 2,000 nurse practitioners in the last three years. But a fifth of those students left for areas that allow full scope.

To get both sides, we spoke with Antonia Villarruel, dean of the University of Pennsylvania School of Nursing, and with Scott E. Shapiro, a cardiovascular disease specialist and president of the Pennsylvania Medical Society.

What do nurse-practitioners typically do, and how would this change if the legislation is approved?

By far, the main work of nurse-practitioners is primary care, completing physical assessments, diagnosing and treating acute and chronic conditions. If someone has a chronic condition - such as diabetes or hypertension - they work to make sure they can function day to day by working on diet, medication and exercise, making sure their symptoms are under control. Research shows that nurse-practitioners can manage 80 to 90 percent of patients' primary-care issues.

Most nurse-practitioners already work in a collaborative practice with physicians. They work within health systems, in federally qualified health centers or retail clinics. Nurse-practitioners are more likely than physicians to work in rural areas, provide care in a wider range of community settings, and serve a high proportion of uninsured patients and vulnerable populations. Nurse-practitioners who work in rural areas of Pennsylvania are often the only provider for newly insured patients. If a collaborating physician retires or moves from the area, it can unnecessarily disrupt care to all these clients. It may mean there is no one to provide health care to that community.

But right now, in Pennsylvania, nurses can't assess and treat or prescribe medications for patients without a formal collaborative agreement. The agreement may mean a physician needs to authorize a treatment plan a nurse-practitioner has determined necessary. There is much variation in the collaborative agreements.

In New Jersey, nurse-practitioners don't need a collaborative agreement to assess and treat a patient. But they can't prescribe medications without one. Collaborative agreements restrict practice, result in unproductive time for physicians and add a whole level of unnecessary bureaucracy.

What would be the benefits of removing these restrictions?

First, study after study demonstrates that removing this barrier to full scope of practice will increase access to primary care. With Medicare expansion and the Affordable Care Act, there is an unprecedented opportunity for people to access primary care. But there is a shortage of primary-care providers, especially in rural areas.

Second, full scope of practice for nurse-practitioners will decrease costs. Studies show that prices for office visits are lower in areas where nurse-practitioners are employed, but only when they have full scope of practice. Some offices may charge less for a visit with a nurse-practitioner than with a physician. Most physicians want nurse-practitioners to work within their scope of practice - so they can more effectively do their jobs.

Who else supports this?

The largest consumer group in the nation, AARP, is actively working to advance legislation for full scope of practice. The Federal Trade Commission also does. The Governor's Association and Hospital Association of Pennsylvania also support it.

The Medical Society of Pennsylvania says it is a safety issue. But studies show that nurse-practitioners can provide primary care and manage a majority of chronic illness management and have similar patient outcomes to those treated by physicians. The Medical Society also expresses a concern that team-based health care will be negatively affected. Just as physicians reach out to their colleagues who are experts in a particular specialty beyond their own, nurse-practitioners reach out, as well. The proposed legislation will not diminish collaboration.

Is there a concern that nurse-practitioners do not have enough training for the expanded role?

Nurse-practitioners are registered nurses. All have either a master's degree or a doctorate of nursing practice. They have to be certified by a nationally accredited professional body. A compromise of this Senate bill was a provision that nurse-practitioners would need to work at least three years or 3,600 hours with physician collaboration requirements before being granted full scope of practice authority. This provision makes the law one of the most restrictive in the U.S. But advanced practice nurses were willing to compromise if it meant getting full scope of practice in the state.

Overall, how can this legislation help fill gaps in the medical system?

Many of our physician colleagues are not going into primary care. They're going into specialties. That's fine. But we need providers at the primary-care level. We need professionals who can effectively manage chronic conditions and who can take care of less complex issues: routine physicals, common infections, immunizations. There is enough work for everyone.

From your perspective, how do doctors and nurse-practitioners work together now?

Health care in Pennsylvania and across the country is made up of many different, crucial players working together as a team. In my cardiology practice, we have multiple nurse-practitioners and physician assistants that are a very valuable part of our team. They have outstanding clinical skills, and they work together with the 17 cardiologists in my practice in a pre-established way, with a game plan that's well planned out, and with a series of checks and balances that allows them to practice right up to the level that they're comfortable with. But they're not pressured to go past that, which might be the case if they didn't have that safety net of a collaborative agreement.

Why do you oppose removing the collaborative agreement requirement?

The objections are many. From a broader view, the entire American health-care system, everything about the way we'll practice medicine in the years to come - both for legislative reasons and for clinical reasons - is pushing us to population-based health- and team-based medicine. We're focusing on making sure that we improve the patient experience, both the quality and the value of the health care they receive, their health-care outcomes, and patient safety. And physicians, like never before, are working as the heads of much larger teams to advance medicine across the country.

The proposed legislation flies in the face of everything that everyone is pushing us toward by fracturing that team. If nurses are always going to be seeking collaboration without the agreement, why are we having this conversation? If we have an agreement in place to use when we need it, but not when we don't need it, that's the definition of collaboration.

Right now, nurse-practitioners have the freedom under Pennsylvania law to do everything within their comfort zone, so long as they have established, through interactions with the physicians, that that's within that individual's skill set. That is the perfect system for American health care.

Advocates of the change point out that there aren't enough primary-care physicians, and that nurse-practitioners could fill the gap. Do you agree?

The Pennsylvania Medical Society looked at a study that evaluated the availability of primary-care physicians across the state. In virtually every part of the state, a patient is within 30 minutes of a primary-care physician that can see them within a reasonable amount of time. And that's including the rural parts of the state. In more populated parts, that distance is much shorter.

We could always use more physicians, but a shortage of primary care is not something that is going to be addressed by allowing nurse-practitioners to practice without a collaborative agreement. It's a solution that doesn't work for a problem we don't have.

Does the current bill's compromise - more clinical hours for nurse-practitioners - solve anything for you?

There are a lot of problems with that. I didn't see any details on what constitutes meaningful education. There's no specific curriculum, no formalized plan for how a nurse-practitioner would be evaluated afterward. For physicians, the way we're evaluated, the curriculum we use, the hours of training, that's standardized across the country. A primary-care physician has to complete 16,000 hours, on average, before they see a patient. For my specialty, I did three more years of training after that. A nurse-practitioner, on average, is completing between 500 and 750 hours.

Nurse-practitioners are wonderful, and they do great work. But the enormous difference in the time, the scope and the breadth of a nurse's training and a physician's training really pan out.

If you were to change the current system in any way, what would it be?

The current system really works. It allows us to take all of the nurse-practitioners in Pennsylvania and allow them to practice completely up to the scope of their abilities, with the checks and balances we need for patient safety. To start taking away patient safety measures, we're not solving problems with that. We're creating problems.

In my office, nurse-practitioners have immediate access to a physician. There's no chance of a delay, and that's critical. It can't be more efficient than what we currently have. In my opinion, if you are told you should be practicing independently, you are much less likely to seek help. A collaborative agreement makes it much easier, both logistically and professionally, to seek that help.

For doctors as well as nurses, the more experience you have, the less likely you are to shotgun-order tests. You have experience and knowledge to know what the patient in front of you could have, and what they could not have. It saves money. It saves time. And in critical instances, it could save lives. You can't legislate knowledge. You can't legislate experience.