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.
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.”
Anesthesiologists argue, however, that the presence of other physicians on site provides the needed supervision. Yancey disagrees, arguing that those physicians are relying on the nurse anesthetists to oversee that portion of a procedure.
“For reimbursement with the Center for Medicare and Medicaid Services, we have to have a supervising physician signature, and that can be the surgeon we work with, for the hospital to get reimbursed. But during these cases, we’re the only anesthesia provider there,” Yancey said. “The surgeon probably hasn’t given anesthesia since they were, you know, medical students rotating through their anesthesia rotation.”
Following the research
The situation for nurse practitioners and nurse midwives is slightly different. Unlike the nurse anesthetists, they are required to have a contract agreement with a physician — any physician — to work. For many advanced practice nurses, that requirement is easily satisfied when they work in a clinic or hospital alongside physician colleagues. It’s not so easy in situations like Brinson’s, where advanced practice nurses go out on their own.
Physicians maintain that their opposition to giving more autonomy to the nurses is all about the patients, not about ceding their authority.
Physician advocacy organizations countered the nurses rally last week with a full court press of their own. The newly formed North Carolina Patient Safety Coalition issued a statement citing a survey that shows support for physicians remaining in the lead, saying it is for safety’s sake. The NC Medical Society and Old North State Medical Society, which represents Black physicians, followed up with a joint letter.
“The requirements for licensure are strict because that is what patient safety requires,” the joint letter reads. “Although other members of the clinical care team have requirements for licensure, their requirements differ significantly in years of education, training, and direct, hands-on patient care. Allowing other members of the care team to provide medical care that a medical school graduate could not legally provide in the state does not put the patient first.”
But there are few studies to back up assertions of eroded patient safety with nurse practitioners. The Patient Safety Coalition has highlighted a study conducted in Veterans Administration system emergency departments that found nurse practitioners, especially earlier in their practice, ordered more tests that pushed up the cost of care while delivering poorer outcomes.
In contrast, the advanced practice nurses tout several decades of research showing positive outcomes and strong patient satisfaction ratings.
The research on nurse anesthetists is less conclusive. One meta analysis cited by the nurse anesthetists, done by the international Cochrane Collaboration comparing them to anesthesiologists, found “no definitive statement can be made about the possible superiority of one type of anesthesia care over another.” Another study in the journal Health Affairs, funded by the American Association of Nurse Anesthetists, found no evidence of harm when nurse anesthetists work without physician supervision.
Many of the advanced practice nurses say loosening restrictions is unlikely to lead to whole cloth abandonment of their ties to physicians. That is not what happened in the dozens of states that allow for a wider scope of practice, they say.
“We always provide collaborative care anyway, I don’t understand why we have to have this,” Brinson said. “[It] makes no sense and puts barriers to care, and prevents us from being able to do the things that we’d really want to do in the clinic, because there’s money being taken out of our pockets.”
Sen. Joyce Krawiec (R-Kernersville) said she’s heard stories from advanced practice nurses around the state about how the supervision process is abused. She recounted the story of one constituent, an advanced practice nurse from Forsyth County.
“Her supervising physician is still licensed in North Carolina but retired to Tennessee,” she said at a news conference to announce the bill filing. “He flies in every six months, signs her documents and she pays him $20,000 a year. That’s just one story.”
Other nurse practitioners have similar stories of remote supervision, like Bette Ferree, who spent several decades as a family nurse practitioner and worked as a nurse practitioner in a Minute Clinic before she retired last year.
“My physician was in New York. So how supervising could that be?” she said. “The collaborative physicians were all over. And I never saw them. But I heard from them on the phone. And if I needed help, I called them.”
Money talks
The battle over scope of practice is increasingly looking like a monetary arms race, with each side raising and spending more and more each election cycle.
Nurse anesthetists made donations totaling $159,400 in 2020 and 2021. In the runup to the 2022 election, the nurse anesthetists increased their giving, with their political action committee donating $203,809 to state legislators’ campaigns.
But they can’t keep up with the anesthesiologists.
A review of campaign finance reports for 2020 and 2021 done by North Carolina Health News showed that anesthesiologists made a total of $397,420 in donations. And they’ve ramped up giving in the past year. Donations made to General Assembly candidates by eight political action committees formed by anesthesiologists totaled $627,650 in 2022 ahead of last November’s election.
Nearly 10 percent of the campaign spending by anesthesiologists — $61,600 — went to House speaker Tim Moore, who plays an instrumental role in deciding what topics and bills the full House will take on each session.
These numbers don’t include all campaign contributions from physicians or political action committees related to them, such as NC Citizens for Patient Safety.
NC Citizens for Patient Safety spent more than $138,000 in support of Pitt County emergency physician Tim Reeder alone. He beat incumbent Brian Farkas, a co-sponsor of the 2021 version of the SAVE Act, by 354 votes, about one percent, in their race for the House of Representatives.
Meanwhile, physicians’ groups, including the lobbying arm of the NC Medical Society, made $186,500 in donations in 2021. All of the organizations gave to legislative leaders, including many members of the committee hearing arguments for and against the bill. This past year, the NC Medical Society’s PAC made $149,300 in campaign donations.
On the other side of the issue, a political action committee affiliated with the NC Nurses Association made a total of $106,850 in donations to various lawmakers during the 2020–21 election cycle. That political action committee also ramped up its spending to $126,850 in 2022.
Hise said the anesthesiologists continue to fiercely guard their interests in other ways. He claimed anesthesiologists have resisted coming to the table.
He holds a powerful place on the Senate appropriations committee as one of three co-chairmen and supports the changes proposed in the SAVE Act. Some physicians have softened their stance against more autonomy, Hise said, such as OB-GYNs who have been willing to sit down with Senate negotiators.
“We’ve had a lot of conversations with OB-GYNs about what it would look like,” Hise said.
“The offer is still open for [anesthesiologists] to come sit down at the table and to negotiate what this needs to look like,” Hise added. “Up until this point they have refused to do so. They won’t even meet with us on the issue — unlike almost every other doctor group.”
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