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(Slideshow) Scope of practice debate in primary care spreads to 8 states


Primary care shortages lead many states to reform laws that restrict midlevels



As the shortage of primary care physicians grows, the debate over giving nurse practitioners (NPs) more autonomy in treating patients will only intensify. The American Academy of Family Physicians (AAFP) remains vocal in its position that physicians need to lead patient-care teams. “Given family physicians' extensive education and training, we believe patient safety and care quality are best served by ensuring that many of the services provided by allied health professionals are done so only under supervision of a physician,” the AAFP says.

Despite opposition from physician advocates, the scope of practice debate is playing out in at least eight states-California, Connecticut, Florida, Kansas, Massachusetts, Minnesota, Nebraska, and New York. This slideshow offers a state-by-state look at policy questions under consideration.

(Photo courtesy of the American Association of Nurse Practitioners)





In 2013, California’s bill to expand the scope of practice for NPs stalled in the state legislature due to last- minute changes that caused the American Association of Nurse Practitioners and the AARP to pull their support.

Thirty percent of California’s doctors are nearing retirement age, and fewer than 30% of the state’s counties have the number of physicians recommended by the federal government, according to California Healthline.  

Facing pressure from the California Medical Association, language in the bill that would have allowed NPs to operate without a physician after 6,240 hours of supervisory experience was removed. The bill’s author, State Senator Ed Hernandez, vowed to reintroduce the bill in 2014.





A bill that would remove physician supervision restrictions from advance practice nurses is currently moving through the Minnesota legislature, designed to address the more than 100,000 patients added to the state’s healthcare system this year due to the Affordable Care Act, its supporters say.

Only 5% of Minnesota’s nurses are advance practice nurses, and if the bill passes, they would have to complete residencies in existing clinics before practicing independently, according to the Minnesota Daily.

With an estimated physician shortage of more than 2,000 and challenges in reaching rural populations, supporters of the bill also say that passing it would keep qualified nurses from practicing in neighboring states that place fewer restrictions on midlevel providers.





NPs in Nebraska are a final approval away from doing away with a 2,000-hour physician oversight requirement that can cost them up to $10,000 a year.

The bill would require NPs to be mentored for two years, and the mentor could be another NP. The high costs of the current practice agreements, which nurse practitioners are required to have with physicians, have caused up to 70% of nurses who specialize in mental health to leave the state, according to the Omaha World-Herald.




Beginning Jan. 1, 2015, NPs in New York with more 3,600 hours of experience will be able to treat patients without a written practice agreement with a physician.

The Nurse Practitioners Modernization Act passed as part of the state’s budget. The Nurse Practitioner Association of New York State praised the bill’s passage as a “tremendous step forward that advances greater patient access to care and recognizes the important role that Nurse Practitioners play as independent, autonomous health care professionals in New York State.”

New York needs an additional 1,200 physicians to fill its shortage, according to a 2012 Haney’s survey by the Healthcare Association of New York State. Although the bill is designed to help meet that goal, New York physician advocate groups argue that the gap in training may threaten patient safety.




A bill giving advanced practice registered nurses (APRNs) the ability to independently practice is moving through the Connecticut legislature. The measure passed the state Senate earlier this month, and is now headed to the House for a vote.

Currently, APRNs must work “in collaboration” with licensed physicians, according to the Connecticut Mirror. However, this new law would allow APRNs to work independently after three years.

Physicians have expressed concern over the discrepancy in training and the lack of continuing medical education requirements in the bill, but APRN organizations argue that the legislation is necessary to increase access to care. The Connecticut Department of Health reported that the state had 3,841 APRNs and 17,130 physicians at the end of 2012, the Connecticut Mirror reported.




A bill that would allow NPs in Massachusetts to practice without physician oversight is undergoing committee review in the state legislature. The Joint Committee on Public Health has until May 20 to release House Bill 2009/Senate Bill 1079 “An Act Improving the Quality of Healthcare and Reducing Costs,” according to the Massachusetts Coalition of Nurse Practitioners (MCNP).

The MCNP has been a fierce advocate of the bill, which they say “would allow NPs and CRNAs (certified registered nurse anesthetists) to practice to the full scope of their education and training and greatly improve access to care. “Physicians groups in the state have expressed strong opposition, however.




If a Florida bill becomes a law, NPs in the state will be able to practice with more authority, reports the Tampa Tribune.

The bill would allow “specialized nurses” with graduate degrees to prescribe controlled substances and involuntarily commit patients with mental issues. Florida has 44,804 doctors, and 5,600 of them are expected to retire in the next five years, according to the Sun-Sentinel.

Meanwhile, a second bill that would allow NPs to practice without a supervising doctor is likely not going to progress further because of staunch opposition in the state Senate and from the Florida Medical Association.




Nurses in Kansas have been fighting to gain more independence from physicians, but the latest effort has stalled in the state legislature, according to the Wichita Business Journal.

APRNs have been seeking greater freedom to treat patients independently, including allowing APRNs to prescribe drugs without the authorization of a physician, provide counseling, serve as a primary care provider, and lead a health team, the Journal reported.

The APRNs argue that expanding their scope of practice will help alleviate the physician shortage. But physicians groups, including the Kansas Medical Society, have opposed the bill. Of Kansas’ 105 counties, 90 have been designated as federal health professionals shortage areas.

While the latest reform bill has stalled, the Journal reports that a compromise is in the works that could be considered in 2015.

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health