Kansas’ growing doctor shortage could be addressed by allowing nurses with advanced skills to work more independently of physicians, say those advocating a change in state law that would make that possible.
Currently under Kansas law, advanced practice registered nurses (or APRNs) must work under a so-called "collaborative practice agreement" with a supervising doctor before providing health care services within the nurse’s certified level of training.
A proposal expected to soon be before legislators would free APRNs from that requirement and allow them to diagnose, treat, and prescribe medications for their patients without an agreement with a physician.
APRN scope of practice bill (pre-introduction)
Similar bills have been proposed in previous years at least as far back as 2009, but failed to advance. And the state’s leading doctor group already is signaling its opposition to this year’s proposal.
A bill could be introduced Wednesday in the Senate Ways and Means committee, according to members of the Kansas APRN Task Force, which is pushing the measure.
"Established practices are doing well," said Merilyn Douglass, an advanced practice registered nurse from Garden City and chair of the task force. "The biggest barrier that the signed physician agreement presents is in starting a practice. If we want to improve access to care for Kansans, we need more providers out there so that patients can call and get an appointment in a reasonable period of time. Patients deserve access to care, not to have to wait months to establish with a physician.”
She said she knew of at least one example in southwest Kansas where a nurse working for a soon-to-retire physician wanted to keep the clinic going but was having trouble finding a new supervising doctor to step in.
"Just like a lot of other states, we have a big population of Kansans who are going to need a primary care provider. There's not enough physicians for all those new people, let alone an aging population that requires more visits and more complicated care," Douglass said.
Nurse Practitioner State Practice Environment, 2013
Across the U.S., there are three basic practice arrangements for nurses:
- Restricted: 12 states require direct supervision by a doctor in order to provide patient care;
- Collaborative practice: 21 states including Kansas require APRNs to have an agreement with a doctor, who oversees patient care to the degree the doctor deems necessary; or
- Unrestricted: 17 states and the District of Columbia have passed laws that allow APRNs to treat patients independent of physicians. Iowa and Colorado are among the unrestricted states.
As proposed in the bill draft, Kansas nurses would still have to undergo a "transition-to-practice" period under the supervision of a physician. That period would be 2,000 hours (about one year). That's at least twice the length proposed in the plans put forth in previous years, said Mary Ellen Conlee, a lobbyist for the nurses. The longer period was a recommendation from a study group of the state nursing board, she said.
Jerry Slaughter, executive director of the Kansas Medical Society, the state’s leading doctor group, said he saw no reason to change the state’s current law dictating nurse practice arrangements.
"The system we have today has a long history of working pretty well. It provides a high degree of flexibility (without) requiring over-the-shoulder supervision," of the nurses by doctors, Slaughter said.
"We can't support the (nursing group’s) proposal as written,” he said. “There aren't any limitations — at least that we've seen — in the bill that would restrict APRNs from doing anything that a physician does. For example, we don't see anything in the proposed bill that would prohibit a nurse from doing surgical procedures."
Holes in access to coverage
House Speaker Pro Tem Peggy Mast, an Emporia Republican, said she is among the legislators who support the nurses' proposal, in part, because of her own family's experience with patchy health care access in the northwest part of the state.
Mast said her daughter went into premature labor over a weekend while she was in the Norton area.
"She went into labor and we ran her into the hospital, but the closest doctor that was there actually flew in from Wichita in order to take care of her. This is what we're seeing occur in what we call the 'frontier' areas — where the nurse practitioners are really called upon to fill that gap, that need for good care," Mast said.
"We realize we already have a shortage of individuals who can provide medical care in rural areas," Mast said. "This (concept) has already been proven in other states that have expanded scope of practice. So I do support the expansion of scope of practice for nurse practitioners."
Barrier to care?
Douglass of the Kansas APRN Task Force said the change in law was essential if access to care is to be improved in rural Kansas and other underserved areas.
She said the current law’s restrictions are blocking some efforts to provide or expand services. She gave an example of a psychiatric nurse practitioner she knows that is trying to start a practice in Garden City.
"Psychiatrists are scarce in western Kansas, let alone find one who will sign a practice agreement,” Douglass said. “This nurse practitioner found a psychiatrist to sign an agreement, but at a price: $16,000 per year. How does that ensure safe care? Fees paid to physicians to sign an agreement only add to healthcare costs.”
Kansas Medical Society Newsletter
But the Kansas Medical Society also has characterized the nurses' initiative as driven more by dollar considerations than patient care.
"Despite their (the nurses' ) claims to the contrary, their bid for an unlimited scope of practice unnecessarily puts business pursuits ahead of patient safety and quality care. APRNs can practice in rural, underserved areas now, if they choose," the society said in its most recent newsletter to members.
A 2011 report from the Institute of Medicine found that among other things, "Restrictions on scope of practice ... have undermined (nurses’) ability to provide and improve both general and advanced care."
A 2012 report from the National Governors Association said that APRNs could expand access to care, particularly in underserved areas:
APRNs "may be able to mitigate projected shortages of primary care services ... Existing research suggests that (nurse practitioners) can perform a subset of primary care services as well as or better than physicians."
Federal Trade Commission on APRN Scope of Practice
In March, the Federal Trade Commission cited those two reports and others in a letter to the Connecticut legislature, which was considering a bill similar to the proposal the Kansas nurses are offering. The letter, in part, read:
Removing (the collaborative practice) requirement has the potential to benefit consumers by expanding choices for patients, containing costs, and improving access. Accordingly, we encourage legislators to consider whether the existing requirement is necessary to assure patient safety in light of your own regulatory experience and the expert findings of the IOM, as well as the literature review and conclusions of the National Governors Association.
Maintaining an unnecessary and burdensome requirement is likely to deprive consumers of the benefits that increased competition can provide. Therefore, the Connecticut legislature should carefully consider the safety record of APRNs in Connecticut. Absent countervailing safety concerns regarding APRN practice, (the bill) appears to be a procompetitive improvement in the law that would benefit Connecticut health care consumers."
Americans for Prosperity-Kansas, an anti-tax group that champions limited government, is supportive of the nurses’ bill, said the group’s director Jeff Glendening.
"It's allowing for the free market in the occupational licensure world," he said. "If I'm in town, I will definitely be testifying along the lines of this being a great example of economic freedom in action and the benefits of the free market, where people in underserved areas will have more options."
AFP-Kansas also is supports a similar proposal to expand the scope of practice for dental hygienists.
Those two issues are among the three health policy issues that AFP-Kansas is focusing on this year, Glendening said. The third is the group's opposition to Medicaid expansion "on the grounds that it’s expanding Obamacare," he said.
The KHI News Service is an editorially independent initiative of the Kansas Health Institute. It is supported in part by a variety of underwriters. The News Service is committed to timely, objective and in-depth coverage of health issues and the policy-making environment. All News Service stories and photos may be republished at no cost with proper attribution, including a link back to KHI.org when a story is reposted online. An automatically updated feed of headlines and more from KHI can be included on your website using the KHI widget. More about the News Service at khi.org/newsservice or contact us at (785) 233-5443.