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Nurse practitioners say they could ease rural health care shortage with more authority, but doctors say it won’t work

The Pennsylvania Capitol is seen, Feb. 6, 2024, in Harrisburg. Associated Press File Photo

HARRISBURG — Joyce Knestrick can independently give physical exams, diagnose health conditions, prescribe select medications, and make referrals as a nurse practitioner at a clinic in West Virginia.

But when she crosses over the border to Pennsylvania, where she lives in Washington County, she needs physician oversight to do the same work.

Nurse practitioners, who receive advanced clinical training that emphasizes preventive care, are more specialized than registered nurses. Pennsylvania law requires that to practice, these nurses must partner with a doctor who gives input on patient care — a standard that is commonly referred to as a collaborative agreement.

Knestrick, the former president of the American Association of Nurse Practitioners, compared the oversight requirement to having a driver’s license but being allowed to operate a car only if someone supervises.

For the past decade, lawmakers in both parties have tried to give Pennsylvania's roughly 20,000 nurse practitioners more leeway. Removing the doctor oversight restriction, they hope, could expand access to health care.

Bipartisan bills currently before the state House and state Senate would have Pennsylvania join the 27 other states — including three of its neighbors — that have granted full practice authority to nurse practitioners so they can examine, diagnose, and treat patients without physician oversight. And unlike many initiatives in Harrisburg, it has bipartisan appeal. Of the upper chamber’s 50 members, 32 have signed on as co-sponsors, including 17 Democrats and 15 Republicans.

The measure is also supported by a wide swath of interest groups, from the state’s hospital association to the Commonwealth Foundation, a conservative free market think tank.

But opposition from key lawmakers and the Pennsylvania Medical society, a professional group that represents doctors, appears to have again stalled the legislation.

And in the meantime, those health care provider shortages remain.

“I understand sometimes there are doctors who feel [practitioners] are going to encroach on their territory,” state Sen. Camera Bartolotta, R-46th, who has sponsored the nursing expansion, told Spotlight PA. But “this bill wouldn’t replace them any more than a general practitioner replaces a heart surgeon.”

Studies have found that the availability of primary care physicians is associated with better health outcomes. But according to federal data collected by health research group KFF, 380,000 Pennsylvanians live in areas, many of them rural, where there is a dearth of these physicians.

Altogether, KFF estimates the state needs at least 70 new professionals to meet that need. That’s the 11th lowest need in the country.

Population studies show that rural communities tend to have high numbers of older residents who rely on Medicare and Medicaid, which reimburse health systems at lower rates. This can make it hard for health care providers to make money in more remote areas, resulting in service cuts and closures. In an April report, the Center for Healthcare Quality and Payment Reform, a policy group, estimated that seven of Pennsylvania’s 41 rural hospitals, for instance, are at immediate risk of closing.

Melany Chrash, a nurse practitioner in Fayette County, said that preventive care and patient education are core to her work. She said full practice authority would give providers like her the flexibility to plan appointments around patient needs and reach underserved areas. And if there’s an issue she can’t handle, Chrash said she has no problem referring patients to a specialist.

“It wouldn’t change how we practice,” she told Spotlight PA. “It would change the fact that we can be independent and run our own practice the way we see fit, and we’re not sharing our salaries with someone else.”

Studies have come to varying conclusions about the effect that expanding credentialed nurses’ authority would have on health care access and quality.

A 2023 research review found that nurse practitioners can provide better care to individuals dealing with multiple chronic conditions than a primary care physician because their training emphasizes “whole health,” which includes social and psychological wellness.

Some studies have also suggested that states that give nurse practitioners more authority have lower health care costs. However, a 2023 working paper on nurse practitioners in veterans health system emergency rooms found that they didn’t improve care and used more resources.

Doctors who oppose the legislation emphasize the difference in training between themselves and nurse practitioners. Before setting up a private practice or signing a script, a board-certified physician has accumulated up to six additional years of schooling and 15,000 more hours of training, they note.

Kristen Sandel, a Berks County emergency physician and president of the Pennsylvania Medical Society, defended collaborative agreements. While everyone involved in a patient’s medical treatment has a role to play, “the people who have the most training and the people who have the most expertise are the ones that should be leading that team,” she told Spotlight PA.

Amid widespread cuts and closures in rural health care, practitioners’ arguments have won over a number of legislators.

The state legislature has considered bills that would expand practitioners' authority since at least 2013, according to a Spotlight PA analysis. In the decade since, these proposals have received a dozen or so floor and committee votes, but never made it to the governor’s desk for a signature.

The version of the bill currently before the state Senate, sponsored by Bartolotta and Lisa Boscola, D-Lehigh, would give nurse practitioners full practice authority once they fulfill a three-year, 3,600-hour collaborative agreement requirement with a physician.

“Most health initiatives put forward by lawmakers are expensive to implement but changing the scope of practice laws costs taxpayers nothing,” David Mitchell, a health care economics professor at Ball State University, told a state Senate committee earlier this year on behalf of the Commonwealth Foundation.

Bartolotta noted that she’s toughened the language over the years. At first, the proposal required a practitioner working without a doctor to take only 30 hours of additional continuing education.

The changes to the legislation, however, have so far not swayed the doctors who oppose the measure. They have been boosted by their industry’s significant presence in Harrisburg and the backing of top legislators.

The exact scope of lobbying in the Pennsylvania General Assembly is hard to grasp under the state’s laws. Lobbies are not required to note what bills they advocate for or against, and interest groups often juggle multiple priorities.

But since 2013, the Pennsylvania Medical Society alone has spent $6.6 million lobbying the General Assembly. In the same period, the nurse practitioners coalition spent $668,000. (Although over that span, the coalition has employed two well-known lobbying firms, including the recent hire of former top GOP state Sen. Joe Scarnati’s firm.)

Versions of the full practice authority bill first began to pass the state Senate in 2016, but didn't make it through the state House. Former House Speaker Mike Turzai, R- Allegheny, was skeptical of the initiative, according to a source familiar with the Republican’s thinking, and the measure never got a floor vote in the lower chamber during his tenure.

After Turzai retired in 2020, the new House leaders agreed to a measure that would have created a six-year pilot program giving nurses full practice authority in federally designated health care shortage areas. However, it passed late in the session and never got a state Senate vote.

The groups representing doctors and nurse practitioners pointed fingers at each other over that failed compromise. Bartolotta told Spotlight PA that she saw the pilot as a way of “making us sit down and be quiet.”

“We already had a pilot program,” she said. “Half the country was a pilot program.”

Then, in 2021, state Sen. Kim Ward, R-Westmoreland, took over as her chamber’s majority leader. She had been one of the state Senate’s handful of consistent no votes against full practice authority for nurse practitioners, saying in 2017 that she worried about “unintended consequences.”

Since Ward ascended to leadership, no full practice authority bill has passed the state Senate.

In a statement, Ward’s spokesperson Erica Clayton Wright said that the senator “continues to do her due diligence on the matter” and that Ward wants to ensure that “Pennsylvanians not only have access to health care but also ensure health care workers treating patients are positioned to deliver the high-quality health care they were trained to provide.”

Clayton Wright added that Ward’s “leadership position has no bearing on the trajectory of this legislation.”

With new leadership at the nurse practitioners coalition, the Pennsylvania Medical Society, and in the legislature, Amanda Laskoskie, president of the nurse practitioner's coalition said advocates hope to soon meet “with all involved stakeholders to help solve the patient access to health care crisis.”

But getting doctors on board will take more work. Sandel agreed that more individuals needed access to care, but didn’t think expanding the scope of nurse practitioners’ practice would help.

She noted a national analysis by the American Medical Association that found nurse practitioners are as scarce as other providers in underserved areas such as rural counties.

“We’ve looked at other states where they do allow independent practice for nurse practitioners, the access to care issue has not gone away,” Sandel told Spotlight PA.

She suggested that Pennsylvania incentivize doctors to establish themselves in rural areas and others areas without care through targeted medical school debt forgiveness programs.

“The hope is that if we are able to assist physicians with their loan repayments, and they do practice in these areas, that they establish a relationship with that community,” Sandel said.

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