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Bob Hobbs, 48, is a nurse-practitioner who almost had to close his doors before a Kentucky law went into effect last month. Now he doesn't need a collaborative arrangement with a physician in order to prescribe medications or offer basic treatment to his patients. / Nina N. Greipel for USA TODAY

LOUISVILLE, Ky. -- Nurse practitioner Bob Hobbs once came within days of closing his doors to patients because a doctor who gave him permission to write scripts was leaving the state and he couldn't find another one quickly enough.

But a just-enacted Kentucky law ensures that won't happen again.

The measure gives nurse practitioners the right to prescribe common drugs, such as blood pressure and diabetes medicines, without having an agreement with a doctor. Laws granting more independence to nurse practitioners also passed this year in Connecticut, New York and Minnesota, and the U.S. Department of Veterans Affairs is considering a similar proposal.

"It's great. It's been a long time coming," said Hobbs, who runs his own practice in Louisville. "With a physician agreement, there's always a risk: What if they move, or have a car wreck tomorrow? What do you do?"

Nurse practitioners have been pushing for more independence for decades and started making real headway in the run-up to the Affordable Care Act, which is increasing the ranks of insured patients and threatening to worsen doctor shortages.

According to the American Association of Nurse Practitioners, 19 states and the District of Columbia now allow them to treat patients and prescribe drugs independently. Another 19 allow nurses to practice semi-independently, requiring a physician agreement for some piece of patient care, such as prescribing potent painkillers. Proposals to give nurses more autonomy have also been floated in some of the 12 states the association still considers restrictive.

"States that continue to wait will be behind the game in meeting access-to-care needs and providing for their residents," said Tay Kopanos, vice president for state government affairs for the group. "Nurse practitioners have been providing care for our country for a half a century?.We need to make sure we're practicing at the top of our education and skill set."

But such efforts face powerful opposition, with many doctors arguing patients get the best care when doctors stay involved. The American Medical Association contends that allowing nurse practitioners to practice independently hasn't so far solved access problems, improved health or lowered costs.

"The (AMA) encourages physician-led health care teams that ensure health care professionals work together as the ideal way to provide high quality and efficient care," officials said in a statement to USA TODAY. "Patients win when each member of their health care team plays the role they are educated and trained to play."

Nurse practitioners counter that there simply aren't enough doctors to go around. The federal government says there are 6,100 primary care shortage areas across the U.S., with more than 3,500 people per primary care doctor. And experts expect shortages to worsen as the population ages and the burden of chronic illness grows.

The quest for more independence "is much less about turf wars than it is about patients that need to be seen," said Elizabeth Visone, president of the Connecticut Advanced Practice Registered Nurse Society. "As the Affordable Care Act goes along and more people have insurance, there have to be people to see them."

Different providers

Across the nation, there are more than 192,000 practicing nurse practitioners, who are advanced-practiced registered nurses.

They generally have up to seven years of schooling, including post-graduate study, compared with 11 years of schooling, including required residencies, for family doctors, according to the American Academy of Family Physicians. But nurse practitioners said the two types of training are very different and not really comparable.

Hoping to find out whether nurse practitioners could help fill doctor shortages, the National Governor's Association examined several studies for a 2012 report that said they provide "at least equal quality of care to patients as compared to physicians."

Some patients say nurse practitioners are better at certain aspects of care.

Margo Grace, 53, sees Hobbs for arthritis in her knee and to get guidance on nutrition and exercise. She said he's "very accessible," easy to talk to, and spends 30-45 minutes with her during visits. On a recent morning, Hobbs listened to her heart and discussed test results before giving her a knee injection.

"Typically, a visit with Bob will last two to three times longer than one with any of my other physicians," she said. "And I never feel awkward asking him questions, and he's always willing to take the time to answer them for me ? I found that the care that I get here is as good or better than a physician's office."

Kirk Haynes, 43, said much the same about Jessica Estes, a psychiatric nurse practitioner with an independent practice in Hawesville, Ky. who treats him for bipolar disorder. "I feel real comfortable with the nurse practitioners because they tend to be more cautious, and at the same time, they take the time to listen," he said.

Still, he said he'd rather see a doctor for his severe heart disease, since that care is so specialized and complicated.

Restrictions and problems

While experts have never suggested nurse practitioners replace doctors, a 2010 report by the Institute of Medicine recommended they be allowed to practice to the full extent of their training -- and said most states have long lagged behind.

Before passing its law, New York didn't allow nurse practitioners to treat patients or write scripts without a physician agreement. Kentucky allowed them to set up their own practices but not to prescribe drugs without an agreement.

While doctors said the agreements helped keep patients safe, nurse practitioners said such restrictions ?? which still exist in several states ?? have caused no end of trouble for them.

Stephen Ferrara, executive director of The Nurse Practitioner Association New York State, said several practices run by nurse practitioners have had to temporarily close because they couldn't find collaborating physicians. Syracuse nurse practitioner Patricia Donnelly and her co-owner spent two years searching for one physician before being able to open a practice, he said, then nearly had to shutter it eight years later when the doctor retired.

Visone said psychiatric nurse practitioners in Connecticut also had to close practices after collaborating physicians left the state or retired ?? creating particular hardships for patients because mental health providers are in such short supply.

Many times, doctors charged nurse practitioners for signing collaborative agreements ?? sometimes $1,000 a month ?? even in states where they didn't need to review patient charts or provide supervision. Estes, who said she was lucky not to have to pay for her agreement, called it "a piece of paper that sits in a file. No one looks at it."

Nonetheless, she said she always feared what would happen if she lost it. She's the only psychiatric provider in her rural county, and closing down would leave 2,500 patients with nowhere to go.

Opposition remains

Nurse practitioners said they're optimistic about the new laws, even though they contain caveats. Kentucky's, for instance, requires them to have had a collaborative agreement for four years before being able to prescribe without one, and it doesn't allow them to prescribe "scheduled drugs" such as opioid painkillers. Connecticut's law requires them to have practiced three years under a physician agreement before being able to practice on their own. And Minnesota's law exempts nurse anesthetists.

None of the laws passed easily. Minnesota State Sen. Kathy Sheran, a Democrat and former nurse practitioner, said this is the sixth year she has been working on legislation and "the opposition was significant all along."

Critics in Kentucky also fought proposals for years, arguing doctors needed to remain in the equation because of their higher level of expertise.

"From the physician's side of things, there was concern about the difference in education," said Ron Waldridge II, a family physician in Shelbyville, Ky. "This bill wasn't exactly what the doctors wanted and it wasn't exactly what the nurse practitioners wanted, but it was a good compromise" as the ACA expands the need for providers.

But as nurses push for more laws, national doctor groups don't appear ready to make such compromises. The American Academy of Family Physicians' position on the matter says nurse practitioners shouldn't practice independently; they should be "under the direction and responsible supervision of a practicing, licensed physician."

"Granting independent practice to nurse practitioners would be creating two classes of care: one run by a physician-led team and one run by less-qualified health professionals," said a 2012 academy report. "Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor."

Nurse practitioners said they realize the value of physicians, frequently reach out to them for guidance, and don't see that changing under the new laws.

"We collaborate all the time," said Visone, who works in an office with physicians. "None of us works in a vacuum."

Grace, like several other patients, said she trusts nurse practitioners to seek help when necessary and has no problem with them practicing on their own.

"With our aging population, I think we need more people out helping ...And with all that's going on with health care, I think it's a great thing to have options."

Laura Ungar also reports for The (Louisville, Ky.) Courier-Journal.



Copyright 2014USAToday

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