Debate Over Role of Nurse Practitioners in Primary Care Responsibilities

An estimated 6 million Californians will be eligible for insurance under Obamacare -- about 5 million through the Covered California marketplace and more than a million people via the Medi-Cal expansion.

Yet, just 16 of California's 58 counties have enough primary care doctors right now. To try to improve access, California legislators are moving bills to expand "scope of practice" for such midlevel health providers as pharmacists and nurse practitioners. In general, such bills would allow certain health providers to practice more independently. Right now, in many cases, they must be overseen by physicians. More autonomy could open access for underserved groups.

But some of those ideas are being hotly debated in Sacramento.

The toughest scope-of-practice sell right now seems to be nurse practitioners. Earlier this week, SB 491, which would expand nurse practitioner duties, failed to get out of committee. It will be up for a vote again next week. State Sen. Ed Hernandez (D-West Covina), an optometrist himself, joined KQED Forum Friday to discuss the bill. He said California needs to "utilize providers within their training" to help ease this "huge access problem in primary care."

California, as it turns out, is among only a handful of states with the most restrictive policies (see map) around nurse practitioners and patient care. Paul Phinney, a pediatrician and president of the California Medical Association, said "allowing nurse practitioners to practice independently fragments care." He agreed there is tremendous primary care need, but said a better way to address the problem would be to "have physicians and nurse practitioners work collaboratively in teams."

Hernandez agreed a team approach is best, but pointed to many studies (he didn't say specifically, but this one from the Institute of Medicine is a good start) that have found nurse practitioners are "just as qualified" to provide safe primary care as physicians are. Right now, 17 states currently allow independent practice for nurse practitioners.

Of course, that means 33 states do not allow fully independent practice, countered Phinney.

Debra Bakerjian, senior director of clinical education at the UC Davis School of Nursing, talked about structural barriers that further limit the practice of nurse practitioners. For example, Medi-Cal recipients face not only a primary care shortage but also a shortage of physicians who will accept Medi-Cal. Since nurse practitioners must be aligned with a physician, if the physician does not accept Medi-Cal, neither can the NP. With changes in regulations, like SB 491, "We could expand and provide access to care to people who don't have it already," she explained.

Bakerjian stressed that NPs want to be part of a health care team, but argued that "physicians should be required to be part of a team as well."

Forum is a call-in discussion program, and a call from a woman who identified herself as Aurora was especially pointed. She said that she is a psychiatric mental health nurse practitioner who works with severely mentally ill adults and children in an urban area.

We have a "huge waiting list," she said, adding that severely mentally ill children might face a one-year wait to get into a clinic. "We cannot get physicians to collaborate with us," Aurora said. "Often there are no physicians available to do that."

SB 493 -- which would permit more practice options for pharmacists -- has already passed out of committee. A third scope-of-practice bill, also by Hernandez, would permit optometrists to diagnose and treat more conditions. Like the NP bill, it will be heard next week as well.

Still, California Healthline reported that California, a trendsetter in so many ways, is behind the curve on the scope-of-practice issue for nurse practitioners, according to Tay Kopanos of the American Association of Nurse Practitioners:

"In Oregon, a nurse practitioner can manage care completely from diagnosis to prescribing treatment, but step over the border into California and barriers are thrown up that prevent care," Kopanos said. "We are concerned that when legislators begin setting up state-based requirements for team care, they might be shortchanging everyone by requiring a physician to be the head of every team."

"We're not sure that's the best way to do it," Kopanos said. "We can see circumstances in many states from Kentucky to California, where having somebody other than a physician -- maybe a nurse practitioner or maybe some other provider -- heading teams in underserved areas would be best for patients."

"That's what we think should be the driving force behind states' decisions -- what's best for patients," Kopanos said.

Listen to the Forum discussion: