Kansas Nurse Practitioners Want An End to Doctor Contracts, But Hit Statehouse Roadblocks Again
Based on evidence about the quality of care by advanced practice nurses, more and more states have ditched the requirement that nurse practitioners work only under contracts with doctors. But physicians say the arrangements protect patients.
A proposal to let nurse practitioners do their jobs — without contracts that can require them to pay thousands of dollars a year to doctors — got stymied again in the Kansas Legislature this session.
The bill died in the House this month without a vote. A technical maneuver in the Senate keeps the legislation alive, but it remains in committee with no vote scheduled.
To free advanced practice nurses to open more clinics, half of states no longer make them ink contracts with doctors. The Department of Veterans Affairs made a similar switch in 2016.
But the trend comes over loud objections from physicians, who say that the contractual requirements protect people by ensuring oversight of advanced practice registered nurses, or APRNs.
“I want APRNs as part of a medical team,” Vicki Whitaker, executive director of the Kansas Association of Osteopathic Medicine, told lawmakers at a hearing last month. “I just don’t want APRNs out (there) with no one to at least look at what they’re doing and say, ‘Are you sure this is what’s going on?’”
But nurse practitioners and other advanced practice nurses counter that the contracts often are little more than sources of money for doctors who live far away or never actually review care.
In other cases, they say, the physician-oversight rules help doctors keep advanced nurses out of their markets.
“Why would they sign this,” asked Jamie Harrington, president of the Kansas chapter of the American College of Nurse-Midwives, “for an APRN that is going to open a competing business, possibly in the same town?”
A 2014 Federal Trade Commission paper warned that requiring the contracts puts doctors in the position of “gatekeepers” able to block or drive up the overhead costs for potential competitors.
Cost and education differences
Some doctors say changing the rules for nurse practitioners will cut into physician practices — only to benefit corporate interests.
“It is people outside the state of Kansas, such as the big box stores, the Walgreens, the big hospital organizations that run hospitals within Kansas, and also the insurance companies,” said Kristie Clark, president of the Kansas chapter of the American Academy of Pediatrics. “(They) want to hire nurse practitioners and cut out the physician because they can do it for less.”
The state labor department says the average nurse practitioner in Kansas earns $100,000 a year, compared to $230,000 for the average family doctor.
Physicians complete four years of medical school, followed by residencies that last three or more years depending on their area of practice.
Many nurse practitioners have two-year master’s degrees, though doctorates are becoming increasingly common as schools shift to a four-year approach.
Still, a 2011 report from the National Academy of Medicine says research doesn’t support claims that advanced practice nurses “are less able than physicians to deliver care that is safe, effective, and efficient … or that care is better in states with more restrictive scope of practice regulations.”
A VA study released last year didn’t find any differences in clinical outcomes for patients who saw nurse practitioners instead of doctors for primary care, though “patients’ satisfaction and preference for the holistic, patient-centered care provided by NPs was a distinct difference.”
To be sure, experts say, advanced practice nurses and doctors have different levels of expertise. But both receive training to consult with or refer patients to specialists when something goes beyond what they know.
Doctors who favor retaining oversight of advanced practice nurses say the contracts ensure the nurses will consult more educated professionals when needed.
The Federal Trade Commission report has questioned that argument, saying collaboration happens even in states where the nurses aren’t subject to physician control.
Cathy Gordon told lawmakers her nurse practitioner-based clinic in Johnson and Wyandotte counties found itself pressed when the doctors listed on their contracts died, retired or came down with serious illness.
“I lost sleep at night,” she said. “I called physicians after hours at 10 p.m. one time, asking ‘Could you please cover us?’”
Primary care shortage
More than one in four Kansans live in an area without adequate primary care.
Researchers have found that nurse practitioners are more likely than doctors to see people of color, rural residents and patients who don’t have insurance or who get their coverage through Medicaid, which pays a lot less than Medicare and private health insurance.
During the COVID-19 crisis, Kansas passed a law temporarily letting advanced practice nurses work without physician oversight to help with pandemic response. That rule expires at the end of this month.
Under the proposed permanent law that has stalled in the Kansas Legislature, advanced practice nurses would need 4,000 hours of work under their belts before they could ditch their contracts with physicians. Such transition rules exist in some of the other states that have granted advanced nurses full authority to work without doctor permission.
A similar bill in 2019 made it out of committee, but lost out on the floor in the wrangling for an ultimately unsuccessful attempt to expand Medicaid coverage to more Kansans.
This year, it’s unclear whether the bill will make it that far.
The Kansas Advanced Practice Nurse Association says Rep. Brenda Landwehr, chairwoman of the House health committee, told its lobbyist her committee would vote on the bill but later reneged her statement and let the bill die.
Landwehr didn’t answer four requests for an interview with the Kansas News Service.
Celia Llopis-Jepsen reports on consumer health for the Kansas News Service.
You can follow her on Twitter @celia_LJ or email her at celia (at) kcur (dot) org. The Kansas News Service is a collaboration of KCUR, Kansas Public Radio, KMUW and High Plains Public Radio focused on health, the social determinants of health and their connection to public policy.
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