The Basics: How the nurse practitioner bill could change health care

The state House has given final approval to a controversial bill that would give nurse practitioners more independence, a measure that both supporters and opponents say could have a major effect on health care in Connecticut. Gov. Dannel P. Malloy, whose administration proposed the measure, is expected to sign it.

What does the bill do?

The proposal would allow nurse practitioners to practice independent of doctors after they’ve worked for at least three years in collaboration with a physician.

Nurse practitioners can already prescribe medication and treat patients. They’re also allowed to run their own practices, but state law requires that they can only do so if they have a collaborative agreement with a licensed physician.

Nurse practitioners are nurses with at least a graduate degree in nursing or related field and certification from a national organization. They’re sometimes referred to as advance practice registered nurses, or APRNs.

Although not in the measure that passed Monday, Democratic legislators agreed to amend a separate bill to require that nurse practitioners practice for at least 2,000 hours under a collaborative agreement with a physician. That change was made in response to concerns that an APRN could fulfill the three-year requirement by working one day a week and not gain enough experience. The amendment would also bring the continuing education requirements for nurse practitioners in line with those required for doctors.

What does the bill not do?

The proposal doesn’t call for nurse practitioners to be paid equal to doctors.

Who does it affect?

The bill most directly affects nurse practitioners and doctors, but it also has implications for anyone who gets health care in Connecticut. Supporters of the bill have pitched it as a way to expand access to primary care in Connecticut at a time when demand is expected to grow as thousands of state residents gain insurance as part of the federal health law. But critics say the change could lower the standard of care by removing a requirement that guarantees that patients who see APRNs have access to a doctor.

What started it?

Until 1999, state law required nurse practitioners to work under the supervision of doctors. Then the law was loosened to require a collaborative agreement.

Nurse practitioners say the requirement that they have a collaborative agreement with a doctor is still too restrictive and is a barrier to opening their own practices. They say APRNs are vulnerable to losing their practices if the doctor they collaborate with dies, retires or severs the agreement.

But doctors say the agreements are important to ensuring that all patients have access to a physician when needed.

What’s the debate?

The level of oversight or independence APRNs should have has been a contentious matter for years. Among the biggest sources of contention: differences between doctors and nurse practitioners, and patient safety.

Many doctors and physician groups point out that physicians have more extensive training. They say doctors are better equipped to treat patients with complex health needs and to differentiate between routine issues and bigger problems. And while 17 other states allow APRNs to practice without an agreement with a physician, they note that many of those states require more oversight of nurse practitioners or restrictions on their practice than the proposed bill would.

APRNs say there is no evidence to suggest that removing the requirement that they practice in collaboration with a doctor would harm patients. That position was echoed in a report by a committee organized by the state Department of Public Health that recently reviewed APRNs’ scope of practice.

Supporters say the measure could expand access to primary care because nurse practitioners could work in areas that have typically been underserved, such as poor or rural communities. But critics say there’s no evidence that the change will improve patient access.

Some doctors also worry that using nurse practitioners to help meet the demand for primary care could undermine or substitute for efforts to ensure that there are enough primary care doctors in the state. And because nurse practitioners are typically paid at lower levels than doctors, some doctors’ organizations have expressed concern that insurers or Medicaid could meet network adequacy requirements by including more APRNs rather than ensuring they have enough doctors.

What else should I know?

Access to primary care has been a key issue of concern as the federal health law known as Obamacare rolls out. A 2010 survey by the Connecticut State Medical Society found that more than a quarter of internists and family physicians were not accepting new patients — a rate that could grow with increased demand from newly insured patients and the retirement of aging physicians.

National figures suggest that Connecticut has a relatively high supply of primary care doctors, but also an aging physician population.

In 2012, Connecticut ranked 11^th highest in the rate of active primary care doctors per 100,000 state residents, and 14^th in the percentage of active physicians aged 60 and older — 28.8 percent, according to the Association of American Medical Colleges.

And Public Health Commissioner Dr. Jewel Mullen said in testimony on the proposal that the geographic distribution of primary care providers is uneven, and access is especially challenging for uninsured and underinsured people.

States’ practice requirements for APRNs vary.

Seventeen states and Washington, D.C., allow APRNs to practice without an agreement with a physician, according to the American Association of Nurse Practitioners. New York is set to join this category next year.

Twenty-one states require nurse practitioners to have a collaborative agreement with someone from an outside health field. (This count includes Connecticut and New York, which are changing their requirements.)

And 12 have more restrictive requirements that call for nurse practitioners to have supervision, delegation or team-management by someone in another health care field, according to the association.

How they voted:

The House voted 110 to 35 to pass the bill.

The bill previously cleared the Senate 25 to 11.