Bill to empower nurse practitioners divides professional organizations

California legislators look to nonphysicians to address primary care gaps in the state, but physician organizations and others oppose the proposed solution.

By — Posted Aug. 26, 2013

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A bill moving through the California Legislature that aims to boost the primary care work force by allowing some nurse practitioners to practice independently has run into resistance from physician and nursing organizations alike, who oppose the current measure for opposite reasons.

Despite some recent revisions to narrow the circumstances in which nurse practitioners could set up shop on their own, the physician organizations insisted that the bill doesn’t go far enough to protect patient safety or encourage needed collaboration with doctors. Other key groups in the state withdrew their support on the basis that the newly amended version would heighten the liability risk for nurse practitioners.

Earlier in 2013, state Sen. Ed Hernandez, OD, drafted several scope-of-practice bills to empower more primary care professionals in light of the Affordable Care Act’s coverage expansions in 2014. “What good is a health insurance card if you can’t get into see a health care provider when you need one?” Hernandez asked in March, when he introduced the legislation. According to a statement on his website, California already faces a primary care shortage, a problem that will escalate when 7 million more individuals seek new coverage under the ACA starting in 2014.

The trio of bills he introduced would allow nurse practitioners, pharmacists and licensed optometrists to expand their practices in some capacities to help close the primary care gap in the state. All three professions have set high bars on training standards and quality of care, said Hernandez, an optometrist by training.

Among the three bills, the nurse practitioner legislation has drawn the most attention and concern from physicians in the state. Organizations such as the California Medical Assn. oppose the idea of such practitioners operating independently without physician supervision.

The legislation has advanced in the California State Assembly. After voting down the original measure, the Assembly’s Business, Professions and Consumer Protection Committee on Aug. 13 moved a revised bill that included amendments designed to narrow its scope. Under the revised legislation, nurse practitioners that have logged at least 4,160 hours of practice under a doctor’s supervision can practice independently, but only in certain health care settings, such as health facilities, clinics, county medical facilities, accountable care organizations or group practices. Provisions that would have allowed full independence in other settings were eliminated.

If legislators give final approval to the bill, then nurse practitioners “can’t hang up their own shingle and do it in their own practice — they have to be associated with a broader entity,” said Carmela Castellano-Garcia, president and CEO of the California Primary Care Assn., which represents health centers and community clinics.

At this article’s deadline, the bill was scheduled to move to the Assembly’s appropriations panel and then on to the full Assembly floor for consideration.

Castellano-Garcia said her organization continues to support the bill, even with the changes. “The work force shortage is a serious concern for community clinics and health centers. Our interest as primary care providers is to look at ways in which we could reduce this shortage by allowing our practitioners to practice at the highest level allowable within their licensure, and nurse practitioners are very critical members of the team in community health centers. We would certainly support the ability to have them operate with independence within the clinic context,” she said.

Other organizations don’t feel the same way. The American Assn. of Nurse Practitioners and AARP withdrew their support for the legislation after it was amended, saying the changes would undermine the bill’s original intent.

In a statement, AANP co-presidents Angela Golden and Kenneth Miller said the revised bill “would make it a crime for nurse practitioners to ‘supplant’ physicians and continue to require unnecessary oversight, negating work force gains contained in the prior bill.” The state would remain one of the most restrictive in the nation for nurse practitioners, according to AANP.

17 states and the District of Columbia allow nurse practitioners to practice independently.

AARP California State Director Katie Hirning voiced similar concerns about the amended bill, including the language that would prohibit nurse practitioners from setting up a private practice. “These changes are unacceptable,” she said in a statement.

Physicians want collaboration

Limiting the extent to which nurse practitioners’ scope of practice would be expanded also failed to appease physician organizations that opposed the original California legislation. “While many legislators voted for the bill with assurances that amendments would be taken to require some level of physician involvement, the current language is too general and does not ensure physician collaboration,” said Mark Dressner, MD, president of the California Academy of Family Physicians.

Participation in an ACO under the Affordable Care Act, for example, is defined rather broadly and represents more of a financial arrangement than a practice arrangement, he said. This is a situation that might allow a group of nurse practitioners to practice autonomously without any physician collaboration.

Another concern is that the legislation still would enable nurse practitioners to treat and diagnose patients without any physician supervision, despite significant differences in training and education between the two professions, CMA President Paul R. Phinney, MD, said in a statement.

In introducing the scope-of-practice bills, Hernandez said the three professions he chose would be regulated by independent boards to ensure that patient safety wasn’t compromised. But Dr. Phinney said the nurse practitioner legislation would grant these professionals authority to prescribe opioids such as oxycodone without physician supervision.

“The Board of Registered Nursing in California simply does not have the oversight capabilities to oversee something like that, and with overdose deaths on the rise, we can’t take that risk,” Dr. Phinney said. He spoke on behalf of CMA and the Coalition for Patient Access and Quality Care, which represents about 20 organizations.

Other states have similar laws

California hasn’t been the only state to take this approach: 17 states and the District of Columbia allow nurse practitioners to practice independently. But according to Dr. Dressner, this has not led to improved access in underserved areas in these states.

Although it aims to fill gaps in primary care, the Hernandez legislation provides no incentives for nurse practitioners to train in primary care, nor does it direct them toward practicing in physician shortage areas, Dr. Dressner said. He added that there are other ways to expand access to primary care, such as creating physician-led medical homes that include nurse practitioners.

The American Medical Association has supported the use of team-based, patient-centered care as long as physicians are at the helm. “The increased use of physician-led teams, comprised of a variety of health care professionals, is a practical approach to meet the demand caused by our aging population and newly insured Americans. In this approach to care, physicians, nurse practitioners, physician assistants, nurses and other professionals work together, sharing decisions and information for the benefit of the patient,” said AMA President Ardis Dee Hoven, MD.

The Hernandez bill, however, could end up producing a two-tiered system in the state, under which some patients would be treated by doctors and nurse practitioners working in teams, as other patients receive care from nurses without supervisory support from physicians, Dr. Dressner said.

Supporters of the legislation contend that the bill would not create patient safety or quality-of-care issues. “The increased access to care enabled by autonomous nurse practitioners, is, in fact, a greater driver of improved patient outcomes,” said William Barcellona, senior vice president for government affairs with the California Assn. of Physician Groups, in early August. CAPG represents physician groups that practice in the managed care model.

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California’s primary care problem

A 2009 report by the California HealthCare Foundation described a growing primary care physician shortage in the state. In 2014, 7 million more Californians are expected to seek health coverage under the Affordable Care Act, exacerbating the shortage situation, said state Sen. Ed Hernandez, OD, who has been pushing legislation aimed at bolstering the primary care work force using nonphysicians. The 2009 report found that:

  • Among California’s 58 counties, only 16 were estimated to have enough primary care physicians.
  • The state had 63 actively practicing primary care doctors per 100,000 people, at the lower end of the estimated need range.
  • Only 34% of actively practicing physicians said they were in primary care.
  • Rural counties in particular were experiencing a dwindling supply of primary care doctors and low physician practice rates.

Source: “Fewer and More Specialized: A New Assessment of Physician Supply in California,” California HealthCare Foundation, June 2009 (link)

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