Doctors groups pushed back Tuesday against a proposal to end a requirement that advanced practice registered nurses have collaboration agreements with physicians.
The physicians raised concerns with the measure (HB 177) before the House Health Committee, saying that ending the requirement could jeopardize patient care.
Advanced practice nurses have argued the legislation is needed in order to promote more access to care in underserved communities, and that it won’t hinder collaboration among medical professionals. (See Gongwer Ohio Report, April 30, 2019)
A panel of doctors representing a handful of state associations voiced their opposition to the measure Tuesday.
Monica Hueckel, senior director of government relations for the Ohio State Medical Association, said the group does not believe independent practice for APRNs would expand access to care in rural areas, she said. “Anyone, physician or APRN in Ohio right now, can practice in our rural areas,” she said. “There is nothing in statute right now that prevents them from working in rural areas. They’re just not doing it.”
Rep. Janine Boyd (D-Cleveland Hts.) asked if the lack of APRNs in rural areas is due to a lack of collaborative opportunities.
Ms. Hueckel said there are still more physicians in rural areas than there are APRNs, and APRNs should be able to find collaborators in rural areas. “We don’t have mileage restrictions in Ohio, so you could be a nurse that lives in an urban area, your collaborator could be in an urban area, but you could practice 45 minutes outside of an urban area,” she said. “You could still find a collaborator in an urban area and either you yourself live in a rural area or practice in a rural area.”
Ms. Hueckel said the recent expansion in the number of APRNs a physician can collaborate with went from three to five has greatly expanded the ability of APRNs to find collaborative agreements.
“APRNs currently represent an important part of the care team, but that it is safer and more appropriate to work to increase access to care in ways that preserve the physician-led, team-based care model, such as increasing access to telemedicine, or providing incentive for more medical students and residents to remain in Ohio to practice as physicians,” she said. “This care model is evidence-based and patient-preferred. Allowing APRNs to practice fully unsupervised is not the answer.”
Dr. Elizabeth Muennich, a dermatologist testifying on behalf of the Ohio Dermatological Association and the OSMA, said the legislation would “terminate the current method by which physicians and APRNs work together safely and efficiently.”
“One thing that the years of clinical training taught me is to be able to know what I don’t know and be able to do the next steps appropriate to find the answer,” she said.
Dr. Brenda Prince, an emergency medicine physician in northeast Ohio, said APRNs serve an important role in the health care team but they are not interchangeable with physicians.
Rep. Don Manning (R-New Middletown) asked if there was a difference in competency between an APRN with 15 years of experience and one with a year of experience.
That experience helps, Dr. Price said, but medical school is needed in order to practice medicine.
Dr. Anna McMaster, president-elect of the Ohio Academy of Family Physicians, said the measure would “further fragment patient care.””The skills, knowledge and abilities of APRNs and physicians are not equivalent, but they can be complementary,” she said. “The most effective way to maximize the talents and skill sets of both professionals is to work together as a team to care for patients in a physician-led, team-based approach. Independent practice for additional health professionals undermines team-based care creating silos and further fragmenting patient care.”
Rep. Allison Russo (D-Upper Arlington) said witnesses in support of the bill told the panel the collaboration agreements are largely transactional and not very collaborative.
Ms. Hueckel said about 1% of APRNs in the state work in APRN-only practices. “While there were a handful of individuals that testified to issues, my guess is it is a small but vocal few that are having these collaborative issues,” she said. “We are willing to sit down and talk about what is going on and can we address them outside of the legislative arena.” “We want collaboration agreements to be flexible,” she added. Those agreements have gotten more flexible over the years to alleviate concerns as they come up, she said.
Dr. McMaster said one of her current nurse practitioners speaks with her several times a week on clinical decisions. “That is a good collaborative agreement that we have,” she said. “Not every collaborative agreement is that good.”
Other nurse practitioners don’t communicate with physicians, and not all physicians communicate with nurse practitioners, she said.
Rep. Russo asked what physicians could do to ensure collaboration between physicians and APRNs.
Collaboration agreements have changed significantly in the past 20 years, Ms. Hueckel said. They used to be more prescriptive and detail situations where the physician should be called, and to have mileage restrictions. “I don’t think that it is overly common to have these transactional agreements,” she said.
Collaboration agreements help ensure nurse practitioners have someone to consult with when they have questions, Dr. Price said.