By Rose Hoban
Debbie Varnam runs a busy primary care practice in the Brunswick County town of Shallotte. The town is small enough that her 2,500 or so patients at Seaside Wellness make up a sizable portion of the town.
Varnam says she’s also got a collegial relationship with other practitioners in the area, including the specialists she refers to and who refer patients needing a primary care home back to her.
One strange thing about her practice, though, is that Varnam needs a supervisor, even though she’s been the boss since 2006.
That’s because she’s a nurse practitioner.
“We hire him to supervise us which sounds really odd when you say it out loud,” Varnam said. “But that’s how it works, I own the business, but I’m still required to have a supervisor, so he receives a monthly amount for the supervision.”
Currently under North Carolina law, even though Varnam opened the practice, pays the bills, employs another nurse practitioner and a half dozen or so support staff, she could not do that unless she has what’s called a collaborative practice agreement with a physician to whom she pays about $1,000 a month for his signature every six months.
“If he came up tomorrow and said, ‘Debbie, I can’t supervise you any more,’ I would have to shut this practice down with all these patients,” she said.
That’s why, in what’s become a biennial ritual, dozens and dozens of nurse practitioners, nurse midwives, nurse anesthetists and students in advanced nursing disciplines descended on the legislative building in Raleigh on Tuesday to press lawmakers to update the laws that govern nursing practice in North Carolina. Their ask: Make the supervision requirement go away.
“$500,000 wasn’t enough”
Tuesday’s advocacy day coincided with legislators from the Senate and the House of Representatives filing identical bills to change nursing practice in North Carolina to bring the state in line with 22 other states and the District of Columbia. Those states and the district all allow these advanced practice nurses (known collectively as APRNs) to practice without contracting with physicians who oversee their practice.
Bill sponsor Sen. Ralph Hise (R-Spruce Pine) said his quest to make it easier for APRNs to practice in rural areas began when he was serving two terms as mayor of his small Mitchell County town of Spruce Pine. At that time, the Golden Leaf Foundation gave the town a half million dollars to recruit a doctor.
“Quite frankly, after a year, $500,000 wasn’t enough to add a physician to our hospital. Rural western North Carolina, all of rural North Carolina struggles with getting practitioners in the state,” said Hise, who is one of the most powerful members of the Senate.
“Most of the counties I represent you will find that from 5 p.m. on Friday to 9 a.m. on Monday your only option for health care is the emergency room,” he said.
Hise cited research showing that APRNs are more likely than physicians to practice in a rural area and North Carolina data showing that nurses who train locally are more likely to practice in a rural area than physicians.
Next door, or several counties away
Physician supervision for APRNs doesn’t mean that there’s a physician standing over the nurse’s shoulder, Varnam explained. A supervising physician can practice next door or in the next county or even several counties away.
She said she abides by the letter of the law, which means that when she was starting out, her physician supervisor sat down with her once a month, “meeting just like you would with any new supervisor.”
“We did that for the required amount of time, then we went to every six months visits because that’s what’s required,” she said. “He comes to our office once every six months and we sit and have a conversation about patient care, we might talk about a specific patient, we might talk about a clinical issue and then we document it on paper and then we both sign it.”
On occasion, Varnam calls her supervisor for advice, but more often, she calls the specialists she is referring a patient to. Sometimes, though, she has to send her supervisor forms to sign.
“One example of that is North Carolina disability paperwork for the state… nurse practitioners can no longer sign that form,” she explained. “So in that situation, it’s our patient that we know, we see the patient, we complete the form and fax it to him for his signature. He knows us and that we provide quality comprehensive care, he sends the form back knowing that we’ve done what we said that we’ve done.”
Bill sponsor Rep. Gale Adcock (D-Cary), who is a nurse practitioner, runs an employee health clinic at SAS Institute. She said the battle over supervision between doctors and APRNs isn’t a turf battle so much as it’s a fight over money.
“The money is not the higher earning potential of APRNs, it’s about the income losses that physicians will face when they are no longer able to charge nurse practitioners and midwives large sums for the physician supervision that current law requires although the supervision exists in name only,” she told reporters.
“None of it is a secret,” Varnam said. “But people are hesitant to talk about how much we have to pay because they’re afraid that whoever their supervisor is is going to back out on them.”
Newfound optimism
In the past few years, nurses’ groups have amassed a war chest of several hundred thousand dollars to be used to open doors at the legislature. While the amounts pale in comparison to the financial power of physicians’ organizations and hospitals, campaign money helps, Adcock said.
She also said APRNs have started to understand that will be necessary in order to get a change in the law, especially when the powerful North Carolina Medical Society is in opposition.
“This is not just a question of we show you the evidence and a good decision gets made, all these decisions are made in a political soup and they’ve got to be political and that means choosing a good candidates, working in their campaigns, giving them money and educating them and staying with them,” she said. “We’re doing that in ways we’ve never done before.”
Hise, Adcock and their co-sponsor, Rep. Josh Dobson (R-Nebo) all said they felt like this was the best shot ever for making these changes to APRN practice. This year, there are many moving parts in the health care system, with Medicaid being privatized at year’s end, the possibility of expanding Medicaid to cover more low-income workers, spiraling health care costs and with a shift in the legislature’s balance of power. And the lawmakers have some other powerful advocates as allies this year, such as AARP and provider groups.
And while the Medical Society has argued in the past that APRN practice would be less safe, dozens of studies and the experience of providers such as Varnam show differently.
“None of us work in a vacuum,” Varnm said. “I think that’s what the fear is… that all of a sudden there’s gonna be rogue nurse practitioners out there.”
“Well, I’m gonna be the same nurse practitioner when this legislation finally happens as I was before it happened.”
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As a practicing physician who interacts with NPS regularly I can say they definitely have a role to play in a team approach to medicine. But to eliminate supervision is not only dangerous, it should be criminal.
Physicians have a responsibility to our patients and by extension the general public to act in their best interest. NPs do not have the knowledge base or experience to act independently. Residency training in this country (and continuing medical education and board certification) are highly regulated for a reason, we have to ensure that standards are met to give patients appropriate care.
I can tell you in my experience that I often have to go “doc to doc” because the NP who ordered the study doesn’t have the knowledge base or background to manage the results appropriately. Luckily the NPs I work with are excellent and recognize their role as a supportive team member and it’s easy for me to communicate with the lead physician.
Criminal? And yet in 22 States in this country it works just fine. All of the research support it. The article clearly states that NP’s would not work in a vacuum. Removing the mandate does not remove the legal responsibility for NP’s to practice within their scope of practice. It’s called referring out. Since no MD co-signs every chart nor even evaluates a proportion of delivered care, stop pretending it has to do with patient safety and admit that it’s your ego and money driven.
Since no MD co-signs every chart nor even evaluates a proportion of delivered care, stop pretending it has to do with patient safety and admit that itâs your ego and money driven?