Malloy: Let nurse practitioners in CT work independent of doctors

Nurse practitioners would be allowed to treat patients and prescribe medications independently under a proposal by Gov. Dannel P. Malloy’s administration, a potentially significant -- and controversial -- change in the medical landscape aimed at expanding access to primary care.

The ability of nurse practitioners to work independently of doctors has long been an issue of contention between the two professions, and states vary widely in how they allow nurse practitioners to practice.

But the federal health law commonly known as Obamacare puts the debate in a new context: The expansion of insurance coverage to thousands more people is expected to raise the demand for primary care, at a time when the state already faces a shortage of primary care doctors and an aging physician population.

Connecticut law requires nurse practitioners -- also known as advanced practice registered nurses, or APRNs -- to practice in collaboration with a licensed physician. The Malloy administration’s proposal would still require APRNs to work in collaboration with a physician for the first three years after becoming licensed. But after that, an APRN would be allowed to practice alone.

“We’d like to see increased access to health care at lower costs, and that’s what this will give us,” said Anne Foley, undersecretary for policy development and planning at the state Office of Policy and Management, Malloy’s budget office. “We really do feel that the studies are indicative that APRNs can provide comparable outcomes compared to physicians.”

APRNs in Connecticut are required to have a graduate degree in nursing or a related field and certification from a national organization that certifies nurses in advanced practice.

Physicians have opposed previous legislative efforts to allow nurse practitioners to practice independently, saying that lawmakers shouldn’t reduce the training and education needed to provide medical care. And some doctors have argued that if APRNs practice independently, patients wouldn’t necessarily have access to a doctor to help address complex issues.

The fact that this year’s bill comes from the governor gives it added weight in the legislative process. A measure last year that would have made similar changes, added as an amendment to another bill, had enough support to pass the House but was never taken up for a vote, Foley said.

Barrier or benefit?

Until 1999, Connecticut required APRNs to be supervised by doctors. Then lawmakers changed the requirement, calling instead for nurse practitioners to work “in collaboration” with a physician.

This is a map showing which states allow nurse practitioners to practice independently, with some reduced scope of practice and with restrictions.

American Association of Nurse Practitioners

In 17 states and Washington, D.C. (in green), nurse practitioners can practice independently. In 21 states (in yellow), including Connecticut, they must work in collaboration with someone from another health field. And in 12 states (in red), they must be supervised by someone from another health field.

But nurse practitioners have said that the requirement still presents barriers to those who want to open their own practices. In some cases, nurse practitioners have had trouble finding a collaborating doctor or faced unreasonable demands from the collaborating physician or fees as high as $30,000 per year, according to the Connecticut Advanced Practice Registered Nurse Society.

In a survey, the society found that 22 of 94 members had negative experiences with mandatory collaborating agreements.

“Respondents noted that physician retirement, death, re-location, or other severance of the mandatory agreement, automatically renders the APRN practice illegal,” the organization said in a 2012 report submitted to the state Department of Public Health.

“Many fear having to involuntarily abandon their patients,” the group wrote.

The APRN society has argued that nurse practitioners would still work with other health care providers in caring for patients, but that removing the requirement would improve patient access to APRNs and could allow for innovation in care delivery, such as the creation of nurse-managed health centers in underserved places like rural areas or housing projects.

A review by DPH

After receiving a request from the APRN society, the state health department launched a review of the scope of practice requirements for nurse practitioners. The review committee included representatives from 23 groups.

This is a photo of Dr. Jewel Mullen, Connecticut's public health commissioner

Arielle Levin Becker / The CT Mirror

Public Health Commissioner Dr. Jewel Mullen

Public Health Commissioner Dr. Jewel Mullen said the process “did not uncover any documentation to suggest that the elimination of the collaborative practice agreement impaired safety.”

Mullen, a primary care physician who said she has worked with nurse practitioners since medical school, said it’s important to note that the proposal would not turn APRNs into doctors.

“It’s not a proposal to suddenly say, ‘The playing field is equal,’” she said. “The governor’s proposal is around patients’ access to health care.”

Ken Ferrucci, senior vice president of government affairs at the Connecticut State Medical Society, said the physician organization understands concerns about access to health care but wants to make sure that APRNs aren’t simply being used to fill the role of doctors.

“We would like to think that if this is a policy decision that legislators and the administration want to make, there needs to be a discussion as far as patient safety issues, understanding of training and education, and ability to prescribe medication without any collaboration of a physician,” he said. “And if there are going to be increased independence then there just needs to be increased understanding of what the capabilities are.”

Mullen said it's also critical to ensure that doctors choose and stay in primary care, including by increasing their compensation.

“We’re not going to totally fix the problem [of a shortage of primary care doctors] by just eliminating a collaborative practice agreement,” she said. “We need doctors, too.”

Mullen noted that the proposal doesn’t allow a nurse practitioner to come out of training and practice independently, since he or she would need to work in collaboration with a doctor for three years first.

A national issue

States vary in how they allow nurse practitioners to practice.

Seventeen states and Washington, D.C., allow nurse practitioners to treat patients and prescribe medications independently, according to the American Association of Nurse Practitioners.

Connecticut is one of 21 states that requires nurse practitioners to have a collaborative agreement with someone from another health care field to provide patient care.

And in 12 states, nurse practitioners’ practice must be supervised, delegated or team managed by someone from another field, according to the association.

In a 2012 paper, the National Governors Association suggested that states consider changing the practice restrictions on nurse practitioners. “Expanded utilization of [nurse practitioners] has the potential to increase access to health care, particularly in historically underserved areas,” the paper said.

At the end of 2012, there were 3,841 APRNs and 17,130 physicians with active licenses in Connecticut, according to DPH. The Malloy administration said there are now 4,025 licensed APRNs.

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