Health care: Nurse practitioners push for greater role

As California contends with a shortage of primary care doctors, some legislators are pushing to have nurse practitioners fill in the gaps.

Assembly Bill 890, which is now headed to the Senate, would remove the requirement that nurse practitioners practice under a physician’s supervision. The idea is that this would free them to open practices in underserved areas and assist more low-income Medi-Cal patients.  California would follow the 28 states already giving nurse practitioners full practice authority.

A nurse practitioner is a registered nurse with a master’s or doctoral degree.  Like a doctor, a nurse practitioner can diagnose and treat conditions, prescribe medications and be board-certified in specialties.

“Nurse practitioners are highly educated, well-trained professionals and are quite capable of providing a variety of primary care services to patients,” said Jan Emerson-Shea, chief spokesperson for the California Hospital Association. “We believe nurse practitioners are an important piece of the overall healthcare workforce. They should be able to practice to the top of their license capability.”

But the bill is opposed by the California Medical Association, which claims it is a “dangerous” move and will remove critical patient protections.

“Nurse practitioners and doctors do not receive the same training,” said Beverly Hills doctor Deborah Ishida in a January letter to the editor in the Los Angeles Times. “Doctors go to medical school for four years and then have specialty training after that. That is not to say nurse practitioners don’t have skills (they do), but they are not interchangeable with physicians.”

Critics of AB 890 also say approval of the bill will give California a two-tiered health care system — one where patients access highly trained doctors and one with less qualified nurse practitioners.

A nurse practitioner is a registered nurse with a master’s or doctoral degree.  Like a doctor, a nurse practitioner can diagnose and treat conditions, prescribe medications and be board-certified in specialties such as women’s health or family practice. The main thing nurse practitioners can’t do that doctors can is perform surgery independently.

Some doctors have a high student loan debt from medical school, leading many to go into higher paying specialties over primary care and low Medi-Cal reimbursement rates.

Assemblyman Jim Wood, D-Santa Rosa, who authored AB 890, said the bill is necessary to get care to underserved Californians. He points out that less than half of the 139,000 licensed physicians in California are actively serving patients and of those only 32 percent are primary care physicians. Certain regions of the state are especially seeing shortages- the San Joaquin Valley, the Inland Empire and rural areas.

“We’re not able to train the primary care providers that we need,” he said, adding that there are not enough spots in residency programs and the number of primary care physicians keeps decreasing.

The reasons for the shortage include high student loan debt from medical school, leading many doctors to go into higher paying specialties over primary care and low Medi-Cal reimbursement rates. Young doctors often prefer working in metropolitan areas with more options for their families than remote rural areas.

In her letter to the editor, Ishida said other reasons include burnout, electronic health records and “having to get permission to admit patients to the hospital by talking to people who have no idea of medical diagnoses.”

If the nurse practitioner’s supervising physician retires or moves, that can in some cases mean closing a practice.

While there’s no guarantee that nurse practitioners would go to underserved areas if restrictions on their practice were lifted, that has happened in other states, Wood said.  “This is not a magic bullet,” he said. “This is one more piece of the puzzle that will help to get us there.”

Wood added he has not seen any peer-reviewed research that says nurse practitioners are a danger to the public, just opinions. “We have reams of articles saying that it’s working and it’s a good idea,” he said.

Under current law, a physician does not have to be physically present to supervise a nurse practitioner; the doctor just has to be available by phone call.

Theresa Ullrich, a nurse practitioner in Orange, said that in her office, the requirement effectively means that she keeps a document showing a relationship with a physician. Day in and day out, she and other nurse practitioners are just helping patients. “We’re doing what we’re educated and trained to do,” she said.

If the nurse practitioner’s supervising physician retires or moves, that can in some cases mean closing a practice. “When you’re tired to a physician, it can all blow up in a heartbeat,” she said.

But removing the tie to supervising physicians doesn’t mean nurse practitioners won’t consult doctors from time to time. “We will always collaborate,” she said. “It doesn’t mean we want to go out and run rogue. We have professional ethics and standards to abide by.”

Andrew Acosta, spokesperson for the California Association for Nurse Practitioners, pointed out that the California Future Health Workforce Commission supports giving nurse practitioners full authority. The group includes prominent health, policy, workforce development and education leaders in the state.

AB 890 fits in with the state’s overall goal to expand healthcare access to residents, he said. Patients will benefit from greater access to nurse practitioners.

“We should be expanding to do more than what we have, not limiting it,” he said.