Nurse Practitioners' Ongoing Struggle for Autonomy

From The Floor

Nurse Practitioners' Ongoing Struggle for Autonomy

The batle ahead to expand scope of practice in California

By Genevieve M. Clavreul, RN, Ph.D.
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It seems like every day, another expert points to nurse practitioners as the solution to our nation’s mounting provider shortages and spiraling healthcare costs. Unfortunately, the reality is that NPs’ struggle for autonomy still faces many obstacles and every attempt to remove those barriers seems to unleash the political dogs of war. As that battle heats up, let’s take a look at where nurse practitioners currently stand and talk to a few about the future of their practice.

A Patchwork of Laws
Since the education and training of nurse practitioners is guided by a common accreditation organization with a national certification exam, you might expect that the laws defining NPs’ scope of practice (SOP) would be reasonably consistent throughout the country.   

Sadly, that couldn’t be further from the truth: NP SOP is a confusing patchwork of rules that vary widely from state to state. The 2012 edition of the now-defunct Pearson Report, an annual overview published in the American Journal of Nurse Practitioners, included a summary of nurse practitioners’ SOP in each state and the District of Columbia, broken down into seven categories:

1. Autonomous practice: In most states, including California, nurse practitioners must be supervised by a physician or work under a collaborative practice agreement. However, the District of Columbia and a growing number of states (18 in 2012) now allow NPs to practice without physician supervision.

2. Primary care provider status: No state explicitly prohibits nurse practitioners from being recognized as primary care providers, but 10 states have either ambiguous laws or no laws regarding this point.

3.  Independent prescribing authority: California is one of the majority of states that permit nurse practitioners to prescribe medication only with the supervision or delegation of a physician. However, 18 states now authorize NPs to prescribe drugs independently.

4. Physical therapy referrals:
While California is one of the many states that either don’t require a physician referral for physical therapy or allow nurse practitioners to make those referrals, four states impose restrictions on NP referrals and four other states only allow physicians to refer patients for physical therapy.

5. Authority to sign death certificates: Only 22 states and the District of Columbia allow nurse practitioners to do this; two other states allow it under certain circumstances. In California, only licensed physicians have this authority.

6. Authority to sign handicapped parking permits:
California, like most states, does allow NPs to sign handicapped parking permit forms, but six states still don’t.

7. Authority to sign workers’ compensation claims: Thirteen states, including California, don’t allow nurse practitioners to do this.

Are you confused yet? To make this a little easier to understand, the locum tenens firm Barton Associates has created a color-coded interactive graphic based on the 2012 Pearson Report.

Physicians Push Back
Nurse practitioners have made great strides in many areas, but each gain has come only after a difficult struggle. In most states, it’s up to the legislature to decide whether and how the SOP for healthcare providers should be expanded and every new bill brings out each side’s lobbyists in force.

Inevitably, the fiercest battles are sparked by attempts to remove the physician supervision requirements for nurse practitioners. Proponents argue that allowing NPs to diagnose and treat patients independently is the best (if not the only) way to deal with the shortages of primary care providers in medically underserved areas. In many rural areas, physicians — particularly specialists — are already hard to come by and the few who are wiling to sign a collaborative practice agreement like those required in California or Kansas don’t come cheaply. According to the Kansas APRN Task Force, one psychiatrist in the western part of that state demanded the princely sum of $16,000 a year just to sign an agreement!

Any nurse can tell you how resistant doctors can be to any perceived threat to their authority. Therefore, it’s no surprise that state medical associations have mounted expensive campaigns to squelch measures aimed at giving NPs greater autonomy, claiming that removing physician supervision would put patients at risk.

Last summer, for example, the California Medical Association (CMA) used that argument to kill S.B. 491, a bill that would have ended California’s physician-supervision requirement for NPs. State Sen. Ed Hernandez (D-24), one of the bill’s original sponsors, has promised to introduce a similar measure in the next legislative session, but you can bet that one won’t get by without a fight, either.
Lower Reimbursement
Scope of practice is only one of the obstacles facing nurse practitioners. Despite recommendations from the Institute of Medicine, NPs still receive lower Medicare reimbursement rates than doctors — and often lower Medicaid rates as well. Worse, even if state laws recognize NPs as primary care providers, some insurance companies don’t.

Those issues complicate the idea of nurse practitioners as a cheaper alternative to physicians. Instead, some hospitals have become reluctant to hire NPs, who are more expensive than hospitalists, but don’t bring in as much revenue as doctors.

Nurse Practitioners Speak Out
With so many headaches, one might wonder why a nurse would go to the trouble of becoming a NP at all. I decided to put that question to a few NPs I know and ask for their thoughts on the state of their profession. Here’s what they said:

Susanne J. Phillips, MSN, FNP-BC, was actually headed to medical school when an appointment with a nurse practitioner led her to change her educational direction. Over the course of her career as an NP, she has worked at various federally qualified health centers and other community-based clinics, a faculty primary care practice, a physician’s office and her own NP-owned primary care practice. She is now an associate clinical professor at UC Irvine.

Susanne says what originally attracted her was the idea of being “present” with patients, something that as a patient, she had found sorely lacking in her interactions with doctors. Her favorite parts of her practice are still her interactions with patients and having the opportunity to promote better health practices. Her least-favorites aspects are battling with insurance companies and having to bill for her services under a physician’s name.

Although she would like to see NPs receive greater autonomy, Susanne says that overall, she’s had positive experiences with the physicians who have supervised her over the years. Nonetheless, she is frustrated with the Legislature for bowing to the CMA’s crusade against bills like S.B. 491. She feels that the current requirement for collaborative practice agreements forces NPs to focus too much on getting paid rather than on quality and safety.

Even so, Susanne is optimistic about the eventual expansion of NPs’ SOP. Her outlook on the future of the profession is generally positive and she encourages other RNs to pursue training as NPs.

Gigi Schlueter, RN, MSN, FNP, practices at a medical spa, a very different environment than many NPs. Like Susanne, Gigi enjoys her interactions with her patients and feels a sense of accomplishment when patients “parrot” back advice that she previously gave them.

Gigi also shares Susanne’s frustration with the apparently intractable resistance of California’s medical community to expanding the SOP for nurse practitioners. Both NPs anticipate that the enactment of the Affordable Care Act’s individual insurance mandate will force the issue and believe that as long as the Legislature refuses to expand the SOP for NPs, there won’t be enough providers to meet the needs of Californians.

Finding Allies
By now, California’s nurse practitioners understand how fiercely the medical community is prepared to fight any attempt to expand NPs’ scope of practice. Nonetheless, if California is to join the other states that have extended full autonomy to nurse practitioners, NPs must redouble their efforts and fight even harder.

NPs also need to gather additional allies. Nurse practitioner autonomy already has influential supporters like AARP, but NPs should also reach out to the rest of the nursing community, to other professional associations and even to those physicians who don’t view autonomous NPs as a threat. At the end of the day, this is a political struggle and will be won by the side that commands the most votes.

After all, if states like Arizona and Utah can give full autonomy to NPs, why should California lag behind?   

Geneviève M. Clavreul, RN, Ph.D., is a healthcare management consultant who has experience as a DON and as a lecturer on hospital and nursing management.

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