Doctors, nurses in showdown over expanding health care access in rural Pennsylvania

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By Tyler Arnold

Six years of college. Two degrees. Commitment to working with a doctor under a three-year, 3,600-hour collaboration agreement.

Those credentials don’t impress Pennsylvania doctors, who refuse to countenance the idea that advanced practice registered nurses (APRNs) can operate independently in their fields of specialty, even in rural areas where access to health care is a real challenge.

State Sen. Camera Bartolotta, who represents one such district in western Pennsylvania, wants to put a dent in the cartel.

“(This bill) will give our nurse practitioners the autonomy they deserve,” said Bartolotta, a Republican who represents Beaver, Greene and Washington counties, south and west of Pittsburgh.

APRNs in the commonwealth are not permitted to practice without a doctor’s supervision. Under current law, they must have a contract with two doctors, and can pay up to $1,000 monthly for the privilege, even though the supervising doctors never have to be on-site. But the doctors do have a say in patient care.

Bartolotta’s bill, which has 30 co-sponsors in the Republican-led Senate, would allow APRNs to treat patients following completion of that three-year, 3,600-hour collaboration agreement with a doctor.

For now they remain, in effect, a 21st-century version of indentured servants.

While state regulations make it difficult for APRNs to make the best use of their training, they make life dangerous for many rural residents, forcing them to pay more and travel farther to get health care.

Many, particularly the elderly, simply choose to avoid the hassle of a long trip to see a doctor, according to Bartolotta.

In Pennsylvania, the number of doctors per capita in cities and suburbs is almost double that in rural areas. Overall, more than 35 percent of Pennsylvanians do not have adequate primary care, according to a report by the Kaiser Family Foundation.

Lorraine Bock, president of the Pennsylvania Coalition of Nurse Practitioners, said that some APRNs can’t find a doctor to enter into an agreement with, particularly outside of urban areas. If a physician in a collaborative agreement moves, the APRN has to choose between following the doctor, finding another or closing down their practice.

In some instances, she said, the onerous costs of maintaining a collaborative agreement also led to shuttering their operations.

Team-based care

The Pennsylvania Medical Society is rallying against Bartolotta’s bill.

“The best care for patients is team-based care,” PAMED President Charles Cutler told Watchdog.

Cutler said he wants nurses to be able to make the best use of their training, but that they cannot substitute for a physician. Both play important roles, he said, but neither role can be eliminated.

“They can practice to their fullest ability … but, the physician is a backup,” Cutler said.

Cutler, a suburban Philadelphia internist, also questioned whether loosening the restrictions on APRNs would address the shortage of care in rural areas, suggesting that most would continue practicing in the same geographic areas as doctors anyway.

And, without being specific, he questioned academic studies that showed expanded responsibility for nurses was good for patients, arguing that not enough studies have been done and that those that have been done do not necessarily represent full nurse autonomy.

A paperwork issue

Bartolotta said Cutler’s concerns about independent care are misplaced, pointing out that “highly technical treatments” are not covered by her legislation, nor would it give APRNs the same authority as a physician.

“This is a paperwork issue, not a practice issue,” Bock said. “We are already providing care” and “just want to increase access.”

Twenty-one states and the District of Columbia already have laws on the books similar to the measure being considered by the Pennsylvania Senate.

Holly Lorenz, chief nurse executive at the University of Pittsburgh Medical Center, said that providing greater autonomy for APRNs would not break down a team-based health care structure.

“Team-based, patient centered care is part of an APRNs core philosophy, not a regulatory or collaborative agreement construct,” she said.

While nurses would independently practice up to their level of training, under Bartolotta’s bill care for patients with more complex problems would still be handled by physicians, Lorenz added.

By the numbers

The Center for Health Outcomes and Policy Research at the University of Pennsylvania says overhauling the system would mean more nurses, better care and lower costs.

According to the Penn study, the number of nurse practitioners in the state would likely grow 13 percent if the restrictions were eased. The study also estimated that health care costs would go down by about $6.4 billion over the next 10 years.

Others researchers found much the same.

According to a study by researchers at Duke University, nurse practitioners provide comparable — and sometimes superior — care to doctors. A report by the Rand Corporation about a similar policy in Ohio found that granting nurses autonomy has led to an increase in health care access and utilization, although not necessarily in rural areas.

But from 2008 to 2014, only nine states saw a net gain in primary care migration to rural areas, Ann Peton director of the National Center for the Analysis of Healthcare Data, told state lawmakers two years ago in testimony about a similar proposal.

Out of those nine, seven were states in which nurses are permitted to practice independent of physicians.

Tyler Arnold is a journalism and media fellow for a project of the Franklin Center for Government & Public Integrity, a non-profit organization dedicated to the principles of transparency, accountability, and fiscal responsibility.

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