RALEIGH, N.C. -- Some doctors in North Carolina are voicing their support for legislation to cut red tape for Advanced Practice Registered Nurses (APRNs).
More than 20 states and the District of Columbia already grant licensed APRNs full practice authority, meaning they don't need to pay a doctor to supervise them.
The SAVE Act, introduced in North Carolina this year, would remove
supervision requirements.
Dr. Elizabeth Golding, medical director for palliative care services at Cone Health, said there wouldn't be enough palliative medical care available in the state without APRNs, and believes supervision requirements, which often cost APRNs thousands of dollars, are a hindrance to patients' getting high-quality care.
"They really do nothing to improve the quality of care, and in my opinion are really, in truth, unnecessary and are just costly
administrative hoops," Golding argued.
While individual physicians are speaking out, the North Carolina Medical Society has repeatedly opposed allowing APRNs to practice independently, arguing eliminating doctor supervision would increase safety risks for patients.
Dr. William Long, a primary care and geriatric physician in Charlotte, explained supervision requirements do not
require doctors and APRNs work closely together. Long added some supervising physicians live hours away, or even in another state, from their collaborating APRN.
"I just don't think that's the spirit of what the law is," Long contended. "I think the law should be modified so that after a certain period of time, and pick your number, two years, three years, whatever, those individuals are very competent in the scope of practice that they're in."
Dr. Jessica Cannon, a retired
OB/GYN physician in Wilmington, pointed out full-practice APRNs could help more North Carolina women have healthy pregnancies and healthy babies, especially in rural counties.
"We know that in states where certified nurse midwives have independent practices, that the outcomes are known to be just as safe as traditional OB/GYN outcomes, and in many cases, they have superior outcomes," Cannon observed.
Research shows APRN midwives lower risks for women and babies. Compared with obstetricians, midwifery care has led to much lower intervention rates and reduced the odds of Cesarean delivery by 30% for women having their first baby.
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The legislative committee considering Medicaid expansion and access to health care in North Carolina took up the contentious issue of allowing nurses with advanced degrees diagnose illnesses and prescribe medicine without doctor supervision.
In a sometimes testy debate that lasted for more than three hours, doctors, nurses, and legislators went back and forth, referencing studies that appeared to draw conflicting conclusions whether advanced practice registered nurses who can work without doctors checking patient charts add more medical professionals to rural areas and whether their work leads to lower health care costs.
The freedom from supervision is something advanced practice nurses – which include nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists – have wanted for years.
Rep. Carla Cunningham
A clear majority of the state’s 120 House members and half of the state’s 50 senators appear to want it, too. The SAVE Act, which would give APRNs the authority to practice that they’ve been seeking, has widespread, bipartisan support in both chambers. Both Rep. Carla Cunningham, a Charlotte Democrat, and Sen. Ralph Hise, a Republican representing six mountain counties, both argued vigorously for letting the nurse practitioners work without doctors’ supervision.
Doctors don’t want it.
Two doctors told the committee Tuesday that patients are safer when doctors, who spend years studying and training, are supervising nurses’ work.
Rep. Kristin Baker, a Cabarrus Republican and a psychiatrist, came to the meeting ready to challenge studies that showed benefits of giving nurses greater freedom to practice.
Groups as diverse as the John Locke Foundation and AARP back giving nurses practice authority.
“We have a regulatory reform issue that limits access to critical services and raises costs,” said the Locke Foundation’s Jordan Roberts.
Bills like the SAVE Act “are about access to care, patient choice and making the most of our scarce healthcare resources, “said Winifred V. Quinn of the AARP Public Policy Institute. “They are not about a turf war between nurses and physicians. They are about patients and families.”
North Carolina is one of 10 states that requires nurse practitioners to have supervision agreements with doctors, according to the American Association of Nurse Practitioners. North Carolina is one of three states requiring supervision of certified midwives, according to the American College of Nurse Midwives.
Sen. Ralph Hise
Vincent Guilamo-Ramos, dean and vice chancellor for nursing affairs at the Duke University School of Nursing, said supervision of nurse practitioners in North Carolina often means doctors coming in to periodically review patient records. The doctor and nurse don’t have to work at the same place, he said.
In sorting conflicting information, he urged legislators look at overall trends in research, the strength of the research, and whether it is objective and independent.
“When you do that you see that the care outcomes are comparable and that it actually does save costs,” he said of giving nurses authority to practice without supervision agreements.
“The U.S. has the most expensive health-care delivery system in the world of any developed country and the worst outcomes in terms of mortality and morbidity,” Guilamo-Ramos said. “We need to move to something different that will ensure health equity and will improve outcomes.”