Advanced practice nurses spar with doctors who oppose granting more autonomy

Advanced practice nurses spar with doctors who oppose granting more autonomy

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By Rose Hoban

Stephenie Brinson is fed up with having to pay a doctor every month to periodically examine her patients’ charts and paperwork twice a year — just so she can run a private nursing practice in Garner.

A primary care provider and board-certified family nurse practitioner, Brinson she started a primary care business 10 years ago that has grown to employ more nurse practitioners and serve a large population of un- and underinsured patients. She had worked as a nurse in other health care settings for a decade before deciding to strike out on her own.

Making that happen was complicated.

To meet legal requirements in North Carolina, Brinson had to find a physician to act as her supervisor. That doesn’t mean that a doctor would be constantly looking over her shoulder. Instead, under a scope of practice law that many advanced nurse practitioners have spent a decade lobbying the General Assembly to change, a physician gives a nurse practitioner permission to practice with the understanding that there will be a semiannual review of charts and other paperwork.

“Getting a supervising physician was a real challenge,” Brinson said. “I reached out to an M.D. friend of mine and asked if he could provide collaboration for a period of time. And he said yes. And then, after several months, he said no.”

When that happens, nurse practitioners like Brinson have only 30 days to find another physician to provide that oversight. She found someone, but the reality of how tangentially that doctor was involved in Brinson’s practice was eye-opening.

“She was charging me $500 a month to be able to provide supervision,” Brinson said. “She lived in Durham, and I had a practice in Garner. She never came to my practice.”

Now, three supervising physicians later, Brinson has a pretty steady agreement. After expanding her clinic, with another four nurse practitioners, her physician supervisor charges $500 every month for each nurse practitioner on staff. Plus, Brinson is paying half of the malpractice insurance premiums for that physician and giving him a small share of her clinic’s profits.

When asked how much time that doctor spends each month fulfilling the legal requirements for physician supervision, Brinson had a quick answer: “Oh, a good, solid 10 minutes.” 

Perennially undeterred

The physician oversight regulation that Brinson finds so mind-boggling, especially after seeing how it works firsthand, is at the root of a decades-long rally for change.

Nurses gather in force in the legislative halls of power at least once a year, hoping that lawmakers will hear them and make changes that they say could make health care more accessible and affordable.

In 2022, the state Senate added language to legislation that would have given advanced practice nurses more autonomy as part of a long-awaited willingness to expand Medicaid. After it passed the Senate, the proposal stalled in the state House, which left North Carolina on the roster of 11 states that have yet to expand the Medicaid program to cover more low-income beneficiaries — as the Affordable Care Act allows. 

Failure of that bill also left the nurses under the physician supervision they find so frustrating. 

On March 2, 2023, state Senate leader Phil Berger (R-Eden) and House speaker Tim Moore (R-Kings Mountain) announced they had finally reached a negotiated agreement that will allow Medicaid expansion with the passing of the state’s next biennial budget. 

But there was no provision for the changes that nurses passionately want. 

“I continue to be supportive of the SAVE Act,” Berger said. “We will continue to work to address the issue of supply, particularly supply for primary care needs.”

The nurses aren’t taking their exclusion from the bill sitting down, and they’ve mustered their forces behind a separate bill to give them the autonomy that exists in dozens of other states: the SAVE Act, a perennial proposal for more autonomy for advanced nurse practitioners. It was introduced again this year in the House and Senate.

But physician organizations are pushing back. For as long as the nurses have sought autonomy from them, doctors have fought against granting it, arguing that they are not trained to practice individually but rather as part of a coordinated care system in which doctors have the education, training and experience to lead these teams.  

Advocates for advanced nurse practitioners argue that such statements ignore the education and training that nurses need for advanced certification, and that doctors ignore the reality: Advanced practice nurses collaborate with physicians all the time. 

“Let’s stop pretending that physician supervision in a law written 50 years ago is real. It is not,” said Sen. Gale Adcock, a nurse practitioner for three decades who has been trying to change the law since arriving at the General Assembly in 2015.

Adcock (D-Cary) was speaking at a news conference that is part of a multi-pronged effort to build momentum for repeal of the supervision rules. 

As in years past, they expect to find opposition from medical societies and their lobbying groups, which have come out swinging in defense of the status quo.

Sen. Gale Adcock talks to a group of nurses who attended advocacy events at the legislature on Feb. 28. during a party held afterwards at the NC Science Museum. Credit: Rose Hoban

Anesthesiologists wield power

Sen. Ralph Hise is frustrated by the lack of movement on the issue. 

During the Feb. 28 news conference, the Republican from rural Spruce Pine bluntly laid the impasse between the House and Senate at the feet of one group. “Anesthesiologists,” Hise said. 

For certified registered nurse anesthetists to practice, an anesthesiologist is supposed to be in the same building and can bill for the half of the work of each of up to four nurse anesthetists at a time. Hise said that in his experience, there’s not always an anesthesiologist around when nurse anesthetists are working.

“I’ve represented hospitals that didn’t even have an anesthesiologist,” Hise told NC Health News. “I have Polk County. St. Luke’s didn’t, Blue Ridge Hospital … didn’t at the time.

“And when you’ve got large hospitals, it’s still nurse anesthetists” doing much of the anesthesia work, with only occasional overview from the physician anesthesiologist, he said. “There’s just one anesthesiologist taking care of multiple rooms at the same time, but the work is done on the ground by the nurse anesthetists.”

Anesthesiologists argue that their longer training and medical knowledge surpasses that of the nurse anesthetists. They contend their involvement in cases is vital to ensuring patients’ safety.

“In North Carolina, there is always a physician involved when providing anesthesia care — whether it is the surgeon or physician anesthesiologist,” Labron Chambers, the NC Society of Anesthesiologists president, said in a statement emailed to NC Health News. “The SAVE Act would eliminate physician involvement in anesthesia care. Removing physician involvement compromises patient safety and is opposed by the vast majority of North Carolina voters, who want a physician to respond to an anesthesia emergency during surgery.”

Certified registered nurse anesthetist (CRNA) Stacy Yancey retorted there are plenty of medical facilities where there’s no anesthesiologist on site — only a nurse anesthetist working with physicians who are doing the procedures — and she and her colleagues function safely.

“So Ashe Memorial Hospital, Spruce Pine Hospital, Cannon Hospital, Anson Hospital, Allegheny Hospital,” she said. “There are more that are just CRNAs at night, but these are just CRNAs all day.”

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