By Rose Hoban
When you add a half million people to a state’s health care system, can providers keep up?
That’s one of the questions that North Carolina legislators raise as they discuss expanding Medicaid access to some 500,000 to 600,000 more people in this state. The fear is that adding nearly 5 percent of the state’s population to the federally and state-funded insurance plan would increase wait times for patients and put pressure on health care providers already struggling to keep up with demands on them.
Opponents of expansion argue that now is not the time to add that kind of tension as hospitals wrestle with a wave of resignations, nursing homes struggle with staff shortages and clinics have been closing their doors.
The coronavirus pandemic has exposed health care access disparities that could have been less glaring had North Carolina not been one of the 12 states that has resisted adding low-income workers who qualify for the subsidized government health insurance plans to Medicaid rolls.
Some Republican lawmakers are warming to the idea of taking advantage of the Affordable Care Act and funneling available federal funds to North Carolina for expansion despite being staunchly opposed to such a notion for years. Others are reluctant to shift their stance.
Knowing that, lawmakers on the Joint Legislative Committee on Access to Healthcare and Medicaid Expansion, a committee expected to have a recommendation for or against expansion by late summer, have been discussing controversial health care issues that have been debated for years. The notion is that if some of these old issues are shoehorned into a new Medicaid expansion recommendation, some of the more fierce Medicaid expansion critics might be more willing to come on board.
One of those issues is whether advanced practice registered nurses should have more independence to care for patients without being directly supervised by physicians, a proposed change the powerful medical lobby has blocked for years.
The North Carolina Nurses Association has been lobbying for looser oversight for years. After an attempt to change the law hit a deadend in 2020, the SAVE Act was introduced In March 2021 in the House with 76 sponsors and in the Senate with 25 sponsors to add another potential path toward more nurse autonomy.
But even as more lawmakers have signed onto the SAVE Act, lobbying organizations for physicians outspent nurses by more than two to one in the most recent cycle.
A review of campaign finance reports for 2020 and 2021 done by North Carolina Health News shows that anesthesiologists, for example, made 158 donations averaging more than $2,500 each for a total of $397,420. In contrast, nurse anesthetists made 98 donations with an average of $1,626 per donation for a total of $159,400.
And a political action committee affiliated with the NC Nurses Association made a total of $106,850 in donations to various lawmakers during the 2020-2021 election cycle. Meanwhile, physicians’ groups, including the lobbying arm of the NC Medical Society, made $186,500 in donations. All of the organizations gave to legislative leaders, including many members of the committee hearing arguments for and against the bill.
Dueling research
In past years, when the topic has been debated, advanced practice nurses — nurse practitioners, certified nurse-midwives and certified registered nurse anesthetists, have been able to cite dozens of research studies showing that these practitioners have excellent outcomes and receive high marks from patients. Meanwhile physicians have raised the specter of unsafe practice with little data to back up their claims.
“We have comparable outcomes,” Vincent Guilamo-Ramos, dean at the Duke University school of nursing and a nurse practitioner, told committee members on March 29. “Where there is a significant effect is that clinically comparable outcomes, but the patients actually enjoy the nurse practitioners more. They feel that there is more of a relationship, there’s more time, it’s a different kind of care.”
Guilamo-Ramos told the lawmakers that in the three decades since the first states authorized what’s known as “full practice authority” in 1994, there are now dozens of states that have loosened physician supervision and oversight rules for all three types of advanced practice nurses.
“Once passed … there’s never been a state that has repealed this,” he said.
Guilamo-Ramos was not the only speaker to cite research about advanced practice nurses. A representative from the National Association of State Boards of Nursing, a speaker from the American Academy of Nurse Anesthesiology and representative from the American College of Nurse-Midwives also presented information for the lawmakers to consider.
This year, though, advocates for physicians came prepared with their own studies.
McNeil Cronin, an anesthesiologist at Piedmont Triad Anesthesia and incoming head of the state association for anesthesiologists, spoke about the years of training that physicians receive and cited a study that he claimed shows mortality for patients receiving anesthesia from an advanced practice nurse was higher in the 30-days after surgery than for anesthesiologists.
His arguments were bolstered by a presentation by Karen Smith, a Hoke County-based family practice physician, who suggested that loan repayment programs and other financial incentives might induce physicians to relocate in rural areas.
“When making decisions about entrusting the health and safety of your fellow citizens, your constituents, even family members, err on the side of safety and choose for others what you would choose for yourselves,” she said. “Patient safety first.”
Rep. Kristin Baker, (R-Concord), who is a psychiatrist, had prepared points for rebuttal, complete with citations. In particular, she cited an overview study from the Cochrane Collaborative, a group that reviews mountains of data to reach consensus conclusions, to argue that the evidence in support of advanced practice nurses was weak.
Future of nursing
Joanne Spetz, a health economist from the University of California San Francisco, questioned whether Baker had provided a full and accurate picture of what the Cochrane paper concluded.
“In the limited studies they found to be rigorous to their standards, the advanced practice nurses provided similar quality care, that patients are more satisfied on average with [nurse practitioner] care than physician care. And there were really not significant safety concerns and not strong evidence about differences in test ordering, or prescribing or any of the other outcomes,” she said “I mean, the Cochrane Review was pretty clear on that.”
Spetz, a nationally known expert in workforce issues, said that over the past decade, there’s been more data to show that nurse practitioners provide comprehensive care, especially in a primary care setting.
“Nurse practitioners understand what they can do with respect to needing to refer patients out, just as a primary care family physician would need to,” she said in a phone conversation after the committee hearing. “It’s not like a family physician [is] providing oncology services. Neither is a nurse practitioner. They understand what a referral is and what they can do.”
There’s a lot of evidence patients have high satisfaction rates with nurse practitioner care, Spetz said. She also pointed to states that have adopted advanced practice nurse “residencies,” temporary supervision periods of several years where advanced practice nurses work alongside physicians to hone their skills before being able to hang out their own shingle.
That’s even as some states are rolling back the amount of time nursing practitioners in such residency programs are directly supervised by the physicians, Spetz added.
“Colorado’s [residency program] used to be, I think, three years, and they actually revised it down to six months,” she said.
During the pandemic, a dozen states waived supervision requirements for advanced practice nurses in an attempt to get more care in rural areas.
If anything, support for loosening physicians’ oversight of advanced practice nurses has gained momentum. In 2021, the National Academies of Sciences, Engineering, and Medicine published a large overview on the future of nursing, which recommended removing practice barriers that prevent nurses from more fully addressing social needs and social determinants of health and improve health care access, quality, and value. The report also suggested that “federal authority should be used to supersede restrictive state laws, including those addressing scope of practice.”
Over the past weekend, New York became the latest state to remove the supervision requirement over nurse practitioners when Gov. Kathy Hochul signed a bill that passed with a wide majority.
What is supervision anyway?
The requirement for physician supervision of advanced practice nurses doesn’t mean that a physician is looking over the shoulder of an advanced practice nurse. Under North Carolina law, the supervising physician doesn’t even have to be in the same vicinity.
Guilamo-Ramos explained that primarily, physician supervision is a paperwork requirement.
“That doesn’t mean that the physician and the nurse practitioner are co-located in the same place,” Guilamo-Ramos said. “They can be geographically apart from one another. It’s a chart review that occurs and there may be times when there’s review of cases. But it’s not the case that they are sort of working hand-in-hand at all times with patients.”
Cronin acknowledged that supervising anesthesiologists are not always co-located with the nurse anesthetists they supervise and that nurse anesthetists are able to put a patient under without an anesthesiologist nearby.
“Why is the anesthesiologist so opposed when they know that they cannot be in every hospital, they cannot be in every clinic, they cannot be in every facility?” Rep. Donna White (R-Clayton) asked Cronin. “In my opinion, it comes down to a large amount of money that a nurse anesthetist has to pay the anesthesiologist to precept them, but there is not a clinical perception. It’s a technical administrative perception.”
Cronin answered that the anesthesia care team “is the highest and safest quality of anesthesia care in this state. And I’m aware that this anesthesia care team does not deliver care in 100 percent of the state.”
He argued that steps should be taken to increase the number of anesthesiologists so that this team model of care could be more widespread.
In the rural mountain counties he represents, Sen. Ralph Hise (R-Spruce Pine) argued that there are two small hospitals that lack anesthesiologists on their staff. Instead, there are only physicians that haven’t specialized in anesthesia, “and everything done at that hospital is done by this physician and the nurse anesthetist.”
Other lawmakers representing rural areas expressed concern that North Carolina’s nurse practitioner oversight law limits access to care for their constituents by adding costs.
“If that supervision is adding value to health care, then it’s necessary and it’s needed and … it’s valuable,” said Sen. Kevin Corbin (R-Franklin) after the meeting. “We should protect that. If it’s not adding value. If it’s a matter of signing something every six months and not working on a case-by-case basis, then I question whether it adds value and perhaps it’s adding cost.”
As the meeting was ending, Sen. Joyce Krawiec (R-Kernersville) told the story of an advanced practice nurse in her constituency.
“Her supervising physician lives in Tennessee,” Krawiec said. “He’s still licensed in North Carolina. He flies in, according to her, every six months and signs her authorization and she pays him $15,000 a year. And she doesn’t ever see him except that one time every six months.”
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Just a few years ago, North Carolina saw several newborn babies die under the care of unsupervised midwives at birthing centers (they were supposed to be supervised – but the MD in “charge” was nowhere to be found when complications arose). NCDHHS could not even get into these places to “investigate” without consent/cooperation because they had no authority over the centers. It was a big story that crashed and burned out without very much being done about what happened. Laws were drafted/never passed.
In 2o2o, as a Board-certified Pediatrician, I was told to my face (by a corporate Medical Director – ED-trained – sucking up to his private equity bosses) that I could be “replaced by a nurse” (at a hospital that, at the time, covered a high-risk OB service). Of course, I couldn’t (and I wasn’t – after being canned for reporting “deficient” newborn care – as identified by NCDHHS – the deficiency is public record), but this is EXACTLY the vibe that inpatient Pediatricians are hearing everywhere – from “the suits”. Not too long ago, Lake Normal Regional replaced its Pediatricians with mid-levels – this publication reported on it. Hundreds of doctors protested. I have no idea if the hospital reversed course – because again, we rarely hear the end of the story.
Corporate medicine (a massive presence in NC) is about making money. Period. They don’t really care about patients or “providers” (a word that lumps everyone together regardless of training or experience). They ONLY care about MONEY. Over the years, this philosophy has bled into even the non-profit and academic sectors. The politicians in this state have done NOTHING in over twenty years to protect doctors from “corporate” (medical whistleblower protection/labor reform) – in fact, everything that was done during the pandemic was about legally shielding and propping up hospitals – no matter how unprepared they were or how horribly they performed.
This is what politicians should be talking about – instead of just turning things over to nurses/midlevels – who are being primed to fiscally use and abuse – just as employed and contracted MDs have been.
I’m a Licensed Psychological Associate in NC (LPA), which means I’m licensed at the master’s level, and fully independent practice is not allowed in NC, according to statute. Many of the arguments for expansion of advanced practice nurses also apply to allowing independent practice for qualified, experienced master’s level psychologists in NC. The North Carolina Association of Professional Psychologists (NCAPP) has been advocating for a path to independent practice for experienced, qualified master’s level psychologists for many years. Some progress has been made, primarily in the form of reduced supervision requirements. However, the NCAPP has met with the NC Psychology Board, which has stated that they cannot eliminate supervision altogether for experienced, qualified master’s level psychologists without a change in the statute that would required legislative approval.
With the possible expansion of Medicaid in NC, the need for independent master’s level psychologists will be greater, just as it will be for advanced practice nurses. There is an additional argument for independent practice for experienced, qualified master’s level psychologists, however. There are already at least two similarly qualified and trained groups of practitioners who treat behavioral health conditions independent of supervision in NC, specifically Licensed Professional Counselors and Licensed Clinical Social Workers. Training and experience for those professional groups is similar to that of Licensed Psychological Associates (LPA’s), yet LPA’s are required to have lifelong supervision under the current law. Consequently, allowing a pathway to independent practice for experienced, qualified master’s level psychologists would not only benefit NC citizens, especially those who have Medicaid coverage or get it in the future, but would address a disparity in equitable treatment of LPA’s in comparison to other similarly trained professionals.