‘Unfettered nursing’ required for Coloradans desperate for care

By Jane Hoback

When Karen Zink opened Southwest Women’s Health Associates for primary care and women’s health in Durango in 1989, it was one of the first nurse practitioner owned and operated practices in the U.S. But it’s only been since 2010 that Zink has been able to practice without a doctor’s supervision.

Zink and other advanced practice nurses in Colorado and throughout the United States say their medical training and expertise can help meet the burgeoning demand for primary health care. But they argue that resistance from physicians and a slow-to-change insurance industry are creating unnecessary obstacles. And they fear that burdensome restrictions in the law governing nurse practitioners are driving many of them out of state.

“We are desperate for good-quality, high-functioning primary care,” Zink says. “And some things are beginning to change. But we need to unfetter nursing.”

Karen Zink meets with a patient in her Durango office. (Photo by Shaun Stanley.)

Karen Zink meets with a patient in her Durango office. (Photo by Shaun Stanley, www.shaunstanley.com.)

In Colorado, advanced practice nurses – which include nurse practitioners, clinical nurse specialists, nurse midwives and nurse anesthetists — are governed by the 2010 Nurse Practice Act. They must be licensed registered nurses with master’s degrees and have passed a national certification exam.

Their “scope of practice” allows them to diagnose, treat, order tests and prescribe medication for patients independent of any supervision or collaborative agreement with a physician, which had been required before the 2010 law.

Generally, advanced practice nurses see patients for physical exams, treat acute minor illnesses such as bronchitis, strep throat or urinary tract infections, for example, and chronic conditions such as asthma, diabetes and high blood pressure. They deliver babies. They administer anesthesia.

In addition to primary care, Zink’s practice includes gynecology and women’s health issues – breast and pelvic exams,

Karen Zink (Photo by Shaun Stanley.)

Karen Zink (Photo by Shaun Stanley, www.shaunstanley.com.)

contraception and menopause.

Rule driving nurses out of state

But a major sticking point in the law is a provision known as the “3,600-hour rule.” The provision requires that advanced practice nurses must complete 1,800 hours of practice in which all their prescriptions are co-signed by a physician. They then must complete another 1,800 hours with a formal mentorship agreement with a physician who must review their prescribing pattern.

Once those additional hours are completed, they also are required to get a one-time physician signature attesting to the existence of an articulated plan outlining their practice guidelines. That gives them what’s known as full prescriptive authority and the ability to practice independently.

Amy Barton, associate dean for clinical and community affairs at the University of Colorado College of Nursing, says the provision was a negotiation between the Colorado Medical Society and nurse practitioners that was intended to give advanced practice nurses the ability to “launch a truly independent practice.

Amy Barton

Amy Barton

“But a completely unintended consequence is that nurse practitioners are not able to find a physician to mentor them or provide the one-time signature for their plans and they’re not able to get jobs. So a lot of them are moving out of state.”

That comes at a time when the need for primary care is growing, as thousands sign up for health care under the Affordable Care Act and thousands more are qualifying for Medicaid while the number of primary care physicians is declining. The Association of American Medical Colleges projects that physician shortages nationwide will reach 62,900 doctors by 2015 and 91,500 by 2020.

A recent Colorado Health Institute study estimated that about 2,800 full-time primary care doctors practice in the state. But they are usually concentrated in urban areas, leaving rural areas in the Eastern Plains and the mountains with shortages.

A 2010 Colorado Health Institute study focusing on the advanced practice nurse workforce reported that about 4,000 advanced practice nurses were registered in the state. A 2011 update showed that about 2,370 advanced practice nurses held either provisional or full prescriptive authority.

Zink says her Southwest Women’s Health Associates practice is one of a handful of independent nurse practitioner offices in Durango. Southwest Women’s Health’s three nurse practitioners, two registered nurses and one licensed practical nurse treat about 4,000 patients “from 12 to 90 years old.”

Kaiser Permanente added 26 advanced practice nurses last year alone in Colorado, bringing the total to 135, says Terrie Rill, senior director of nursing services for Kaiser in Colorado.

Kaiser’s advanced practice nurses are members of teams that include physicians as well as registered and licensed practical nurses, specialists, pharmacists and others, depending on the patient, Rill says. In urban areas, the teams always include physicians, although nurse practitioners with prescriptive authority do treat patients and “they own that visit,” Rill says.

In certain cases, where it might take three or more days to schedule an appointment with a doctor, patients often can see a nurse practitioner on the same day. “If we didn’t have advanced practice nurses, there might be a longer wait and the patient could get sicker,” Rill says.

Rural care critical

Kaiser also has obstetric/gynecological clinics and clinics in mountain communities that are run by advanced practice nurses, Rill says.

“Where we might not have been able to hire a lot of physicians for a small community, we have advanced practice nurses,” she says. “Once they have (prescriptive authority), they can go into these rural communities and provide care that otherwise patients would have to drive a long way to get or maybe not go at all.”

To help advanced practice nurses get the required 3,600 hours, “we have completely revamped our recruitment and hiring process so we can expedite getting them through the system,” Rill says. “Advanced practice nursing is one of the roles we need to recruit and support to meet the need.”

University of Colorado Hospital includes three midwifery practices that function collaboratively with – meaning alongside, not under the supervision of – doctors.

“They probably do more of the low-risk births than the physicians,” Barton says. “And when there are new procedures or new practices, there is active discussion (among the doctors and advanced practice nurse midwives) about who should be providing care to these particular patients.”

For example, she said a discussion about whether women who were set to deliver vaginally after having had a previous Caesarian section were too high risk for midwives resulted in development of a standard of care that has allowed midwives to successfully deliver those births.

A report by the Institute of Medicine in 2010 recommended removing barriers to independent advanced practice nurses, and the National Institute for Health Care Reform supports allowing more advanced practice nurses to practice independently to expand primary care capacity.

Quality of care in some ways better

A widely read report in the publication Nursing Economics in 2011 included a systematic review of more than 100 published studies from 1990 to 2008 examining the impact of advanced practice nurses on primary care patient outcomes compared with those of medical doctors. The results showed that care provided by advanced practice nurses was similar to and in some ways better than care provided by physicians alone.

Still, formal opposition from physician organizations remains largely unchanged.

The American Medical Association, the American Academy of Family Physicians and the Colorado Medical Society oppose independent nurse practitioners without direct supervision by physicians, arguing that advanced practice nurses lack the education and training to safely provide the same services doctors do.

“With a shortage of both physicians and nurses and millions more insured Americans, health care professionals will need to continue working together to meet the surge in demand for health care. A physician-led team approach to care – with each member of the team playing the role they are educated and trained to play – helps ensure patients get high quality care and value for their health care spending. With a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage,” the AMA states.

The Colorado Medical Society participated in the agreement that resulted in the 2010 Nurse Practice Act.

“We wanted to make sure that the process was arduous, that the articulated plan would have the training and appropriate education and experience to write a broad number of prescription medications,” says Colorado Medical Society President John Bender. “Nurses become nurse practitioners with varied backgrounds. The goal in this accord was to make certain that any person applying for prescriptive authority would have the appropriate training.”

Bender says some of the challenges nurse practitioners have finding jobs or physicians to mentor them “is really a function of infrastructure.” For example, Bender says his company includes 22 providers and five nurse practitioners, some of whom had to go through the required process before they received prescriptive authority. Physicians review prescriptions written by nurse practitioners through electronic health records.

He acknowledges that nurse practitioners who are not affiliated with a large group and don’t have electronic review are likely to have more difficulty.

In rural areas, for example, “they can be independent, but they should still be part of an integrated system,” that includes a physician, Bender says. “We want nurse practitioners communicating with physicians.”

However, he says, if the 3,600 hour requirement can’t be accomplished through an articulated plan with a physician, “their training has to happen in some other way,” for example, another year of school with emphasis on prescriptive education.

In addition, from the doctor’s perspective, Bender says, “We want to make sure that physicians feel supported. Physicians worry about their own liability because if they’re supervising a nurse practitioner, when happens if there is a medical error? We want to make sure there’s good information about what the real risks and obligations are.”

The CMS and the Colorado Society of Anesthetists challenged a 2010 decision by then Gov. Bill Ritter that allows certified registered nurse anesthetists to administer anesthesia to Medicare patients without a physician’s supervision. The Court of Appeals sided with the governor’s ruling, but the Colorado Supreme Court has agreed to take the case. No date has been set for the hearing.

Karen Zink opened one of the first advanced nurse practice offices in the U.S. in 1989. (Photo by Shaun Stanley, www.shaunstanley.com)

Karen Zink opened one of the first advanced nurse practice offices in the U.S. in 1989. (Photo by Shaun Stanley, www.shaunstanley.com)

Advanced practice nurses also sometimes find it difficult to get privileges at hospitals, which often is a requirement for reimbursement by insurance companies. Zink had practiced for more than two decades in collaboration with a well-known and respected doctor in Durango before the 2010 law allowed her to practice independently with full prescriptive authority. But she says the doctor’s support was critical in helping her finally win privileges at the local hospital.

“Out of 90 people on the hospital board, he and an orthopedic surgeon were the only ones who voted in favor of it,” Zink says.

While some insurance carriers have been slow to credential advanced practice nurses so they can be reimbursed, they are coming on board. Zink has contracts with Cigna, Rocky Mountain Health Plan and United Healthcare.

Anthem added independent nurse practitioners to its network last year. “We did so to be as responsible as possible to member needs while also containing costs,” Anthem said in a statement.

Change is slow going. The Nurse Physician Advisory Taskforce for Colorado Healthcare, known as NPATCH, which consists of five doctors and five nurse practitioners, meets regularly to make recommendations for policy and rule-making entities. But Barton notes that any legislative change is unlikely during an election year.

Other efforts are aimed at changing provisions in the Affordable Care Act as well as federal regulations that would eliminate the patchwork of state rules that currently govern nurse practitioners. Those rules range from complete independent prescriptive authority to states that allow no independent practice at all. Colorado is the only state with the 3,600-hour requirement.

Meanwhile, Kaiser continues to streamline its recruitment policy “before we have a need. We have a strategy in place,” Rill says.

CU College of Nursing’s Barton has submitted a proposal that would create a residency program for nurse practitioners to help them build independent practices in rural communities as well as underserved urban areas.

“The scope of practice has been established.” Barton says. “It’s not a matter of moving beyond their existing scope. It’s being able to function at their full scope to enable this expanding body of patients to receive access to quality care.”

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