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

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.”