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◼️ Nurse practitioners replace doctors for newborn care at a Charlotte-area hospital amid national push to cut costs
◼️ Physicians claim it’s ‘dangerous’ for babies
◼️ Hospital staffer: Nurses ‘are better than a doctor’ and ‘more experienced than a pediatrician’
By Michelle Crouch
When you go to the hospital to have a baby, you might assume that a doctor will carefully examine your newborn after you deliver, making sure your little bundle of joy is completely healthy.
But if you deliver at Lake Norman Regional Medical Center in Mooresville, that’s no longer the case.
In March, the hospital brought in a team of neonatal nurse practitioners to replace the board-certified pediatricians and neonatologists who used to see the newborns. That means no doctors are doing checkups on the babies there.
The changes at Lake Norman Regional are part of a growing national trend of replacing physicians with nurse practitioners, eliciting vigorous debate about how much independence to give the highly trained nurses.
Supporters say they can lower healthcare costs and give patients more access to care at a time when doctors are in short supply, especially in rural areas. But doctors worry that healthcare facilities are using nurse practitioners to cut costs at the expense of patient care.
Physicians protest: Lake Norman Regional’s decision prompted more than 200 members of a Charlotte area women’s physician group to sign a letter addressed to CEO Clyde Wood asking him to reconsider the decision. The letter said critical medical issues can arise quickly and without warning in infants, and it takes “attuned and well-trained eyes” to spot subtle signs that can signify a health problem.
“A trained physician with years of clinical experience can be the difference between life and death in these situations,” the letter said. “Your decision to replace physicians and neonatologists with nurse practitioners is dangerous and purposefully jeopardizes the care and well-being of our most valuable asset — newborns.” (See the full letter here.)
It’s not unusual for smaller hospitals to staff neonatal care units with nurse practitioners. A small study published in an Oklahoma medical journal found that the quality of the care didn’t drop under that arrangement.
But it’s unclear how common it is for a medical center to have no doctors at all seeing their babies. The maternity centers at the Novant and Atrium hospitals in the Charlotte area as well as Iredell Memorial in Statesville, Piedmont Medical Center in Rock Hill and CaroMont Regional in Gastonia all have physicians who examine their newborns.
However, Davis Regional in Statesville also relies on neonatal nurse practitioners instead of doctors. Davis Regional and Lake Norman Regional share the same leadership team and are both owned by Community Health Systems Inc., a large for-profit hospital operator.
The hospital responds: Lake Norman Regional spokeswoman Leigh Whitfield declined to answer specific questions from The Ledger or to make administrators available to talk about the change, but she emailed a series of statements in response to questions.
She said the hospital’s maternity center provides “safe, high-quality care” and emphasized that the hospital’s neonatal nurse practitioners “are highly-specialized in infant care with extensive neonatal intensive care nursery backgrounds.”
Whitfield said the hospital’s neonatal care center dropped from a Level II center to a Level I in March, when the nurse practitioners came on board. Level I nurseries can care only for the healthiest babies who are born after 35 weeks gestation.
When babies need advanced medical care, Lake Norman Regional transfers them to hospitals in Charlotte and Concord, Whitfield said. The neonatal intensive care units (NICUs) at Atrium’s Carolinas Medical Center and Novant Presbyterian are both Level IVs, the highest level.
Not enough sick babies: Lake Norman Regional had two staff neonatologists until last year, when one left for another job. Instead of filling the position, hospital administrators used temps to fill her shifts. (A practice known in the medical community as “locum tenens.”)
The hospital laid off the other neonatologist when it brought in the nurse practitioners. Neonatologists are physicians who specialize in the treatment of newborn babies, especially those who are premature or sick.
Dr. James Zolzer, an OB/GYN who delivers babies at the hospital, said administrators told him Lake Norman Regional did not have enough newborns with serious health issues to justify keeping neonatologists on staff. According to PayScale, neonatologists earn a median salary of $227,943 per year, compared to $107,330 for neonatal nurse practitioners.
The Ledger asked if the hospital has lowered its charge for newborn care, since replacing neonatologists with neonatal nurse practitioners should result in significant cost savings. Whitfield did not respond to the question.
N.C. requires physician supervision: Nurse practitioners are specially trained nurses who have advanced skills and at least a master’s degree. They can order and interpret diagnostic tests, prescribe medications and administer treatments, but they have less training and fewer clinical hours than physicians.
At least 22 other states to allow nurse practitioners to practice without a doctor’s supervision, and a bill before the legislature would drop North Carolina’s oversight requirement as well.
For now, however, the state requires nurse practitioners to be “supervised” by a physician. The law doesn’t say the doctor has to provide direct oversight; it requires only that doctors have an agreement with nurses they supervise and meet with them once every six months.
Claims of physician ‘supervision’ disputed: In one email, Whitfield said the hospital’s neonatal nurse practitioners work “under the direct supervision of a Neonatologist.”
That’s not true, said Dr. Ashleigh Maiers, a Charlotte cardiologist who was the lead author on the letter to the hospital CEO. Or at the very least, she said, the hospital is stretching the definition of “direct supervision.”
Maiers said a hospital administrator told her neonatologists are available to the nurse practitioners through telehealth, and that an off-site pediatrician signs patient notes written by the nurse practitioners at end of the day, but doesn’t see the babies himself.
“He doesn’t have to touch the baby. He doesn’t even have to talk to the nurse practitioner,” said Maiers, who had her babies at Lake Norman Regional.
A physician at the hospital who did not want to be named confirmed the arrangement.
Maiers says it’s also troubling that the hospital isn’t being more transparent with patients. On its website, Lake Norman Regional Medical Center proclaims that its maternity care team “features knowledgeable, board-certified obstetricians and neonatologists.”
What is the hospital telling patients? The Ledger called the main number of Lake Norman Regional to see what they tell patients about the level of care newborns receive. We were transferred directly to the maternity center.
The woman who answered the phone said the neonatal nurse practitioners are highly qualified and work in Level IV NICUs in Charlotte. “They’re better than a doctor,” she said. “I know it sounds scary, but they are the ones who really care for these babies. They can place lines, intubate, everything a neonatologist can do. They are more experienced than a pediatrician is with sick babies.”
If nurses have questions or concerns, she said, they can call a neonatologist or ask one to come to the hospital.
If a baby is unexpectedly born early or with health problems, the staff stabilizes the baby and then transfers the child by air or ambulance to a bigger hospital, the woman said. A nurse practitioner stays with the baby.
But if a new mom wants to be with her baby, she’ll either need to be transferred or she will have to request an early discharge from Lake Norman Regional and travel to Charlotte or Concord.
Why aren’t pediatricians doing baby checkups? When the Ledger asked Whitfield why local pediatricians stopped visiting babies in the hospital, she implied that the doctors made the choice to quit: “It is a physician’s choice how she or he structures their practice. When … a physician transitions to primarily outpatient care, it means they have decided not to provide care in the hospital which includes rounding on patients.”
The woman who answered the phone in the maternity center had a similar explanation: “They decided they don’t want to come in on the weekends and in the middle of the night.”
It is true that many pediatricians nationwide no longer visit their patients in the hospital. But many hospitals hire a staff pediatrician to serve that role.
The Ledger was unable to reach any pediatricians who used to visit babies in the hospital. However, a doctor at the hospital told The Ledger that after the nurse practitioners were brought in, the hospital told pediatricians they could no longer round in the hospital because the nurses had an exclusive contract.
After pushback from the medical community, the hospital relented, but the pediatricians decided not to return. “By that time, they felt like they weren’t welcome,” the doctor said. “The hospital basically pushed them out.”
OB/GYN misses “layer of safety”: Zolzer, the OB/GYN, said the changes at the hospital won’t impact the vast majority of his patients, who have normal pregnancies and healthy babies. But he now must send some of his high-risk patients to other hospitals for their deliveries.
He said he has had one patient with a high-risk pregnancy deliver at Lake Norman Regional since the change, and the neonatal nurse practitioner “handled it exactly appropriately — the same as if a neonatologist had been there,” he said.
Still, he said he would prefer to have a neonatologist in the hospital. “They can manage more complicated issues, and mom and baby can stay in the same facility,” he said. “It’s another layer of safety.”
Michelle Crouch is a freelance writer and a regular contributor to The Ledger who often writes about healthcare. Send her story tips at firstname.lastname@example.org.