Nurse Practitioners Protest State-Governed Limits on Practice

A doctor is a doctor is a doctor. But nurse practitioners are not equal across the US.

Frank Garber, a Louisiana nurse practitioner, works as an independent contractor for emergency departments. He believes advanced practice registered nurses are "the answer to many of today's health problems."

Yet one of the greatest obstacles, Garber thinks, is the high degree of control state boards exercise over nurse practitioners' scope of practice. Nurse practitioners in states such as Alaska and Idaho practice with a high standard of autonomy, while nurse practitioners in Hawaii and Kansas, among other states, must include a collaborating physician's name and phone number on prescriptions. Some NPs have no choice but to refer patients to expensive specialists or to the emergency room even when their training has prepared them to provide treatment.

"Here in Louisiana, we must practice with a collaborative practice agreement under a physician," Garber says. "I believe this is good, allowing for physician involvement in maintaining a standard of care, but for those who choose to open clinics this comes at a cost, where the physician wants a stipend."

The financial cost of the physician stipend is holding Garber back from opening his own clinic. "If the health care reform passes, for nurse practitioners to step up as primary care resources for the communities, the playing field needs to be leveled," he says. "At least by allowing for equal reimbursement as our physician counterparts. I would love to open a primary care practice, but do not see myself doing so with the present arrangement."

Many states have some sort of collaborative practice agreement, but Louisiana's is more restrictive than others. The Louisiana NP's authority to prescribe controlled substances may include Schedule II only if relevant to practice, and the authority does not extend to prescriptions for managing weight management or chronic pain. Contrast this with Iowa and New Mexico, where an nurse practitioner under a collaborative practice agreement may prescribe controlled substances including Schedule II-V with fewer restrictions.

Florida and Alabama, however, win the prize for the most restrictive policies regarding nurse practitioner scope of practice. These are now the only two remaining states in the US where nurse practitioners are legally prohibited from prescribing controlled substances.

In late 2008, the Florida Senate published a study examining available evidence on all sides of the issue. Some of the more interesting points the study points out include:

• In December 1986, research conducted by the US Congress Office of Technology Assessment found that advanced practice nurses prescribed less frequently than physicians. They also tended to limit their prescribing to well-known and “relatively simple drugs.”
 
• As of mid-2008, the US Bureau of Health Professions, Health Resources, and Services Administration identified nearly 6000 areas nationwide as "health professional shortage areas" (HPSAs) for primary care. At that time, 63 million people lived in these HPSAs.
 
• According to the federal government, it would take over 16 thousand health professionals to meet the need for primary care providers in HPSAs. Yet a recent survey of medical school graduates showed that only 2 percent chose to practice primary care, leaving a huge gap.

The Florida Senate study concludes by stating, "Advanced practice nurses do not appear to be any more susceptible to diversion or inappropriate prescribing than any other prescribing practitioners....Senate professional staff recommends that the Legislature consider extending authority to Florida-licensed ARNPs who have attained certification in a nursing specialty from a nationally recognized certifying entity to prescribe controlled substances under protocols and within the scope of practice for their specialty."

Yet Florida law has not changed.

The restrictions on nurse practitioners have a powerful effect on individuals and communities. Jeffrey P. Hazzard, an nurse practitioner in a Florida occupational health clinic, says that a substantial number of his patients earn about $12 per hour and are uninsured. "The three physician groups in my town charge over $100 for a new patient to be seen in their clinics," Hazzard says. "The local hospital will not see non-emergent cases in the ER without a $150 deposit. The health department shut its primary care clinic. There simply is no option for care."

Because of the overwhelming patient need, Hazzard prices his office visits at only $35. Patients pay his cost plus 10% for laboratory tests. He draws blood for free.

He knows it's not a sustainable business model. But making a profit, Hazzard says, is not what he needs most: "What I really need are the silly restrictions on my practice lifted. I need to be able to prescribe controlled medications so I treat anxiety more effectively. I need to be able to treat coughs and pain. I need to be able to order physical therapy and durable medical equipment for these patients. I need to be listed on private insurance panels so that my patients don't have to leave me when they finally get insurance. I need to have my hands untied so I can do the job I'm educated for."

If the state board regulations were backed up by federal law, nurse practitioners might not experience such frustration. But nurse practitioners with identical training to Garber and Hazzard are autonomously prescribing controlled substances in Wyoming and Washington.

"The irony is that nurse practitioners with the exact same education and certification and licensed to practice in other states have had all this red tape cut," Hazzard says.

As I recently pointed out in Family Practice Docs Upset That Some Nurses Earn More, only 2% of fourth-year medical students plan to work in primary care after graduation (according to a survey published in JAMA in September 2008), so isn't it high time the AMA stopped it's lobbying efforts to hold Nurse Practitioners down and put the interests of patient's first?.

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