March 30, 2015 -- Nebraska this month became the 20th state to approve a law allowing nurse practitioners to treat patients without the supervision of a doctor, a move that supporters say is gaining traction as state legislators work to find more providers to care for the newly insured under the Affordable Care Act.
Under the bill signed by Republican Gov. Pete Ricketts on March 5, nurse practitioners starting in September will not have to work with a physician to diagnose and treat patients. They currently are required to get a signature from a doctor before treating a patient.
Nurse practitioners are registered nurses who have completed a master's or doctoral degree program, and have advanced clinical training beyond their initial professional registered nurse preparation, according to the American Association of Nurse Practitioners, which represents 205,000 members nationwide. Under the guidance of a physician in most states, they can diagnose and write prescriptions for patients.
LaDonna Hart, president of the Nebraska Nurse Practitioners, said the state has been losing nurse practitioners to the 19 other states that do not have physician supervision requirements. She said it's difficult to find doctors to work with nurse practitioners.
"It's difficult to recruit physicians to rural communities and that's not just for Nebraska, that's throughout our most rural states in the nation," Hart said. "It's difficult to retain physicians in rural communities. We see physicians come to practice for loan repayment then leave rural communities."
Hart said the law would help nurse practitioners who want to start their own practice or be in rural areas where primary care is needed most.
Even in states that don't require physician supervision, there are often supervisory requirements for newer nurse practitioners. In Nebraska, new nurse practitioner graduates will be required to have one year of supervision by a doctor or nurse practitioner with five years or more of experience before they can practice medicine on their own.
Lawmakers in California, Illinois, Kansas, Maryland, Pennsylvania, South Carolina, and Texas are considering similar bills easing supervision requirements for nurse practitioners.
Taynin Kopanos, vice president for state government affairs for the American Association of Nurse Practitioners (AANP), said nurse practitioner laws are getting support in state legislatures as more patient advocacy groups and long term care groups are lobbying alongside AANP to pass the laws.
She also said lawmakers are moving beyond the alarm of a physician shortage to how to maximize their health care workforce related to nursing, pharmacy, mental, dental and other specialties. The increased need for primary care providers as more patients gain insurance under the health law has also helped.
"We'd have a much more effective health system if every health care professional were able to practice to the fullest extent of their education," she said.
The American Medical Association has been working to stop such legislation.
The influential doctors lobby wrote in a Jan. 15 letter to Kathy Campbell, Nebraska's Health and Human Services chairwoman, that allowing nurse practitioners to practice without physician supervision would "further compartmentalize and fragment health care delivery."
"Increased use of physician-led teams of multidisciplinary health care professionals will have a positive impact on the nation's primary care needs," according to the group's letter. "This team-based approach includes physicians and other clinicians working together, sharing decisions and information, to achieve improved care, improved patient health and reduced costs."
Kansas nurse practitioners have been pushing for an independent practice law for the past three years. A bill that would remove mandated collaborative agreement requirements for nurse practitioners but would require them to have board certification and malpractice insurance coverage hasn't been taken up by the House or Senate health committees this session. The measure would also allow nurse practitioners to serve as a primary care provider and lead health care teams and patient-centered medical homes.
Rachelle Colombo, director of government affairs for Kansas Medical Society, said physicians have the largest breadth and depth in training and are more equipped to take care of patients than a nurse practitioner, making the physician supervision necessary.
"It still provides patients with a measure of oversight and protection because there's a physician involved with delivery of care even if it's done remotely," she said.
Colombo also said that nurse practitioner laws don't give enough distinction between physicians and nurse practitioners "despite significant training differences" and the thousands more hours of supervision doctors must have before treating patients on their own.
Linda Burnes Bolton, vice president for nursing and chief nursing officer at Cedars-Sinai Hospital in Los Angeles, said nurse practitioners have enough education and training to practice on their own to provide primary care. However, she says, like doctors who must have more training and education to become heart or brain surgeons, nurse practitioners also need more training to specialize in areas beyond primary care.
"Nurse practitioners were never meant to replace doctors, and none of these professional organizations have ever touted 'let's get rid of physicians and use nurse practitioners'," she said. "It's about sharing the load."