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California edges closer to letting nurse practitioners see patients on their own

California edges closer to letting nurse practitioners see patients on their own

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(Photo by Joe Raedle/Getty Images)
(Photo by Joe Raedle/Getty Images)

When nurse practitioner Theresa Ullrich drives through the rural areas east of Sacramento to visit her son, she sometimes dreams of opening her own clinic there. It would be her way of giving back, serving one of the many areas in the state facing a shortage of primary care providers.

For now, that’s only a pipe dream, in part because of the requirement that nurse practitioners (NPs) must have physician oversight in California.

“If I wanted to open my own practice, that would be huge barrier,” said Ullrich, who currently works at La Amistad Family Health Center in Orange. That’s because finding a physician to oversee a solo practice can be too logistically complicated.

California is on track to change that, allowing NPs like Ullrich to practice independently. Last week, the California State Assembly passed AB 890, which would give “full practice authority” to nurse practitioners, which are registered nurses who have completed a master’s or doctoral degree and fulfilled additional clinical training. 

If the Senate passes the bill, sponsored by Assemblymember Jim Wood, D- Santa Rosa, California would join about half of U.S. states that allow NPs to practice independently. Supporters say that could help ease the state’s primary care shortages by encouraging NPs to practice in underserved areas as well as attracting out-of-state providers previously turned off by the state’s restrictive approach. More than 75% of practicing NPs provide primary care, according to the American Association of Nurse Practitioners.

California has expanded health care coverage to millions of Californians, but our primary care provider network is on an alarming decline,” Wood told the Center for Health Journalism in an email. “California has always been a policy leader, especially in health care, so when we lag behind the progress made by more than two dozen states in allowing full practice authority to nurse practitioners, it is with irresponsible disregard for our fellow Californians …”

The potential change isn’t without hurdles, though. Physician groups such as the California Academy of Family Physicians (CAFP) oppose the bill. They say the bill does not include enough provisions and details, such as an accredited residency program for nurse practitioners before they’re able to practice independently or regulation and oversight by the Medical Board of California.

CAFP member Dr. Carla Kakutani said the organization has long championed a team-based model that allows all providers to practice “at the top of their license,” or to the full extent of their education, experience and training.

But family physicians believe that NPs diagnosing, prescribing, and caring for patients independently of physician supervision constitutes practicing medicine, she said.

“ … We believe that if NPs want to independently practice medicine, they should have a similar level of training, testing and oversight as physicians,” Kakutani said.

The California Medical Association  posted a statement about the bill, urging members to rally against a “dangerous” bill that “would remove critical patient protections.” The organization added that the bill does not include any requirements to serve underserved populations or regions.

Working without oversight

In California, nurse practitioners can already diagnose, prescribe medications, conduct physical exams and order screenings or preventative therapies, said Ullrich, the immediate past president of the California Association for Nurse Practitioners.

Current state law requires that nurse practitioners work with physician oversight, with a four-to-one ratio of NPs to physician. But that doesn’t mean that the doctor is actively reviewing their charts, advising on individual patients or even located in the same building, she said.

In theory, that physician is supposed to be available for consultation by phone, though Ullrich rarely sees that kind of interaction. If a NP encounters a problem that’s outside their expertise, they can consult a specialist, such as referring a patient with persistent allergies to an allergist. Ullrich does refer some patients to the clinic’s primary care doctor because he does joint injections for knee and shoulder pain, a skill she doesn’t have.

“You’re required to practice to the scope of your education and training,” she said, adding that won’t change under the proposed legislation.

Despite the limited involvement by the overseeing physician, the requirement can cause logistical hassles. When the Orange County clinic where Ullrich works recently expanded, they struggled to find a physician willing to sign on, something they needed to satisfy the required ratio.

The bill lifting the oversight requirement would allow NPs to open their own practice without needing to find that overseeing physician, or without worrying about the future of the practice if the physician retires, advocates say. It would also remove the financial costs: Physicians currently bill time for overseeing NPs, with costs ranging from about $5,000 to $15,000 annually, according to the California Health Care Foundation.

Assemblymember Wood, a dentist, has acknowledged the importance of on-the-ground training and experience before practicing independently — for all providers. That’s why he added a requirement that NPs have three years of experience involving physician oversight if they’re in a team environment such as a hospital and up to six if they’re practicing as a solo practitioner.

Reaching a tipping point

After multiple attempts to give nurse practitioners more independence in California, supporters say the bill may be finally gaining traction now as the country is reaching a tipping point. Enough states have allowed independent practice without reports of negative consequences, advocates say.

Studies have shown that the quality of primary care provided by NPs is comparable to physician care. Other peer-reviewed studies have found that NPs are playing a key role in tackling the primary care shortage.

If the bill passes, Ullrich said she doesn’t expect there will be a mad rush of NPs to rural areas to hang their own shingle. But she does think the independence will allow NPs the flexibility to be more entrepreneurial.

She mentions a NP she knows who has moved to a rural area in Northern California. He’s doing house calls for frail elderly patients, something he’s only able to do because he’s navigated the hurdle of physician oversight.

“I think you’d see more NPs do more entrepreneurial things that fill the gap like he did,” she said. “I think you’ll see some creative solutions to some of the problems that are vexing us.”


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Physicians want the nurses to know “their place” more than facing the reality!

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Chrysoula: you are absolutely correct with that statement. They are also concerned with losing that extra 15k annually PER supervised NP.

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That's fantastic! Having NPs practice independently could really help in addressing the shortage of primary care doctors. I'm sure they'll be great at what they do.

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One of the worst leadership errors for those responsible for health care workforce is to produce too many graduates. This results in too much competition for jobs, jobs taken despite poor treatment, and employers that dictate exactly how to do jobs - even if not best for the employee or the patient.

NP leaders have engineered a massive, massive expansion of NP graduates from 10,000 past 35,000 since the 1990s. They are still increasing at over 2500 more a year. This is a rate 10 - 12 times the population growth level slowed to 0.6%. Even the demand increase due to aging is only a 1.2% growth level - and the graduates will still be around long after the aging of America has slowed.

This is bad for NP in many ways.
1. Too many devalues NP and limits their independence and autonomy
2. Too many puts NP at the mercer of health employers who are fewer and larger - and are tending toward more oppressive - as nurses long have known
3. Too many too fast has resulted in the least experienced workforce in the last 100 years of history of our nation. Each passing year dumps out substantially more with no experience as an NP (experience as an RN is quite different). Only the diploma mill decades of medical education 100 years ago have any similarity.
4. Physician assistant, osteopathic, and Caribbean schools are also pumping out graduates at 8 to 10 times the population growth level.

Physician leaders worked to curtail preceptorships and diploma mill training schools over 100 years ago. They worked to match the physician workforce to population needs for nearly a century, to prevent having periods with too many and too few. Up until 2003, this conservative medical education growth policy was present, but not since 2003 as US MD is up 30% and increasing at 6 times the population growth level

The evidence demonstrates that the growth of MD DO NP and PA is predominantly about procedural, technical, hospital and highly specialized workforce. Clearly this expansion has been a primary means to the end of increasing revenues generated by systems and practices. This has also worked to concentrate workforce in places where the workforce has long been concentrated. About 1% of the land area involving 1100 zip codes has about 40 - 50% of the health care workforce despite only 10% of the population. Not surprisingly the rest of the nation suffers from lack of workforce, lack of health care dollars, and lack of the economic and other benefits of health care dollars. This is also why expansions of health insurance fail to help most Americans as only 10 cents on the dollar goes to these locations.

So why do shortages exist?

Shortages in primary care, generalists, general specialists, rural areas, and areas with lowest concentrations of health care workforce are entirely about the financial design. Half of the nation's population has half enough of these basic health professionals and half enough team members delivering care.

The financial design is much more powerful than any training. For example, the national share of 38 billion in 2008 for primary care in 2621 counties lowest in health care workforce with 25% of MD DO NP and PA primary care. Growth of population numbers, demand, and complexity would require 80 billion for sufficient primary care at the national average and according to HRSA standards of 90 physicians (or equivalents) per 100,000.

Even worse, HITECH to MACRA to Primary Care Medical Home to Value Based has subtracted 8 billion a year from these practices - leaving them at 30 billion to invest in primary care - far below 80 billion for sufficient and 90 - 100 billion for higher functioning primary care for these 2621 counties. Higher functioning primary care and patient centered primary care require more and better team members - not fewer and lesser as dictated by CMS and health insurance "payers."

NP leaders and numerous journals and magazines and experts that claim that NP is a solution for shortages - completely ignore the financial design limitations. They ignore high turnover and departure rates of NP and PA with increases in turnover in MD and DO. They ignore the massive expansions in these 5 sources of workforce that have utterly failed to improve access.

The massive expansions will eventually require the closing of many NP programs across the nation

There will likely be lawsuits regarding bait and switch - programs that appeared to offer the promise of a job but no job or no good job as too many graduates have entered the workforce.

And these will impact NP PA DO and MD schools and programs that have expanded. The expansions only benefit those who do the training and collect the tuition as well as those all too happy to make more profits from financing student debt.

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I honestly doubt we will ever see the end of the shortages of medical professionals. At least not in my lifetime.

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No one (MD,s) ever defines oversight or supervision. No MD has time to review every case, review charts, critically analyze symptoms for that one obscure diagnosis the ‘less educated’ NP might miss. MD’s barely have time to keep their own documentation up to CMS or insurance standards or defend a malicious malpractice case. Who’s kidding who? No clinician should practice with no experience under their belt. But MD’s have found an easy revenue source by charging NPs thousands of dollars for two signatures a year. It has nothing to do with ensuring excellent care for patients as much as ensuring excellent income for themselves.

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I think that NPs that have been in practice for 6 years should be allowed to practice independently. I think that they need the practice of 6 years at least first since I precept MEPN students and they have very limited training in school. I think that the NP schools are just pushing out students without making sure they are ready to practice. I think the factory mentality of pushing out NP students will be the downfall of the NP

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