Should nurses be allowed to fill gaps left by physician shortages?
Full practice authority debated in Tennessee
Nashville may have a reputation as a health care business capital, but patients in Tennessee face many barriers to accessing quality health care.
The state faces significant physician shortages and consistently ranks poorly on health outcomes. Without enough primary care physicians, many Tennesseans go without preventive or basic care and face long wait times to see specialists. A Robert Graham Center study found that the state will need more than 1,100 new primary care physicians to maintain current care levels in the state by 2030, adding pressure to an already strained system.
A longtime discussion on how advanced practice nurses, such as nurse practitioners or physician assistants, could impact these shortages and improve access for health care consumers is seeing renewed debate this year in the state legislature.
While some argue that regulations on these providers should allow them to practice more autonomously, others say that could be dangerous for patients.New regulations debated
Bills on both sides of this issue have been submitted to the legislature in recent years. One called the Healthcare Improvement Act was debated at the state capitol last week.
The Healthcare Improvement Act, which was ultimately put on hold in both House and Senate committees, would have established physician-led care teams, requiring advanced nurses to work under the “collaborative supervision” of a physician.
The Tennessee Medical Association, which first put forth the bill in 2015, said these provider teams would lead to better coordinated care and improved health care delivery in Tennessee.
“Our bill creates a safety net of good medicine,” Dr. John Hale, TMA president, told legislators. “Our goal is good quality and access to care.”
Opponents to the bill included certified registered nurse anesthesiologists, nurse practitioners, physician’s assistants and other non-physician providers, as well as legislators who expressed concerns over how the bill would affect patient ability to access care in their communities.
“These providers are capable of managing diabetes, prenatal care, obesity, hypertension,” said Rep. Matthew Hill. “They are expected to provide these services … why are we not allowing them to do that?”
This debate has raged on in Tennessee and in other states for many years. At odds are nursing associations that want what is called “full practice authority,” and other groups that want to keep physicians as necessary supervisors in clinical cases. Full practice authority means you could visit a nurse practitioner for most primary care services and they could diagnose, treat and prescribe medication to you without necessarily consulting a physician. They would still be expected to refer a physician for issues beyond their scope of training.
Access and quality
Those in favor of looser regulations say they allow more providers to treat patients who otherwise could not see a primary care physician in their communities.
For example, you may currently face long wait times to see a physician, especially if you live in a rural area where there are fewer practicing. Many patients say the timeliness of their care is more important than whether they see a physician or a nurse practitioner, according to an Association of American Medical Colleges study.
On the other hand, those against full practice authority for mid-level providers say they endanger patients and reduce care quality by heightening a risk that these providers treat complex cases beyond their scope.
Currently in Tennessee, mid-level providers do not have full practice authority. Existing regulations require them to have a contract in place with a supervising physician that authorizes what the nurse practitioner is allowed to treat and prescribe. If you see an advanced nurse for your care in Tennessee, a physician is supposed to review 20 percent of his or her charts, and 100 percent of charts where a controlled drug has been prescribed.
Legislators from rural communities already facing physician shortages expressed concerns that forcing advanced nurses to practice in even more regulated care teams could eliminate the primary care services they currently provide.
“We don’t have an anesthesiologist in the hospital in my community,” Rep. Jeremy Faison said. “We have a nurse anesthesiologist … if there’s anything we do with these healthcare professionals, it shouldn’t be to limit them.”
But representatives of the TMA said the proposed legislation would improve health care in the state by regulating best practices and putting a more highly trained provider in a leadership role, even where nurse practitioners are already providing primary care services.
Ultimately, the Healthcare Improvement Act was put on hold in favor of creating a task force that will review these issues and provide recommendations for a “transformative health care delivery system” next January. Until then, groups on both sides will continue to debate an issue that affects so many health care consumers in Tennessee.
This column originally appeared in the February 24th edition of The Tennessean.
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