Citing a physician shortage that is bound to worsen as millions of patients become insured under the Affordable Care Act next year, California nurse practitioners are fighting for the right to treat patients without oversight from doctors. The battle intensified on August 13, when a key committee of the California State Assembly passed an amended version of the bill that would allow nurse practitioners to operate independently only in a hospital, clinic, or other group setting. In addition, the provision eliminated a pathway to autonomous practice after 6,000 hours of supervised work. California nurse practitioners plan to continue supporting it and the California Medical Association, a physician group, still plans to oppose it. In addition, the national nurse practitioner group withdrew its backing of the bill. Thus, healthcare analysts predict that increasingly bitter fights will take place in coming weeks.
A nurse practitioner is a registered nurse (RN) who has undergone additional training; however, that training is significantly less than that of a family physician. Nurse practitioners should not be confused with a physician’s assistant, who have less training and can only practice under a doctor’s supervision. Nurse practitioner can serve as patients’ primary health providers. They are trained to examine, diagnose and treat patients, manage acute and chronic illnesses and can prescribe medications, including controlled substances (e.g., narcotics), in all 50 states.
The degree of doctor supervision varies widely between states. In 17 states and the District of Columbia, nurse practitioners can open a practice and treat patients autonomously. Twelve states require them to be supervised, to varying degrees, by a physician or other health authority. In the remaining 21 states, nurse practitioners must have a “collaborative” agreement with a physician. Those agreements also vary widely between states. For example, the percentage of patient treatments a doctor must review and which tests the nurse practitioner can order.
Last May, the bill that would let nurse practitioners in California practice autonomously passed the state Senate. Those in support of the bill note that, according to federal government surveys, only 16 of California’s 58 counties have sufficient primary care doctors. However, the California Medical Association, which represents approximately 37,000 doctors, has spent more than $1 million to defeat the bill, arguing that allowing nurse practitioners to open practices without physician oversight would “ultimately harm patients and decrease quality of care.”
It has been predicted that by 2025, the United States will have a shortfall of 65,800 primary care physicians. As a result, the National Governors Association and the Institute of Medicine have pressed state legislatures to ease laws restricting nurse practitioner practices. Beyond the ongoing nurse practitioner debate, many physicians are increasingly delegating duties to non-physicians; they are promoting a team approach to medical care and setting up team approaches to patient care. However, the American Medical Association and other physicians groups stress that a medical doctor remain in charge of such teams.
The American Academy of Family Physicians has noted that nurse practitioners receive, on average, five to seven years of education and 5,350 hours of clinical training compared to 11 years and 21,700 hours for most physicians. Last year, the academy issued a report stating that substituting nurse practitioners for doctors cannot be the answer. “We must not compromise quality for any American and we don’t have to.” Nurse practitioner advocates point to studies that have found that both medical doctors and nurse practitioners deliver safe and high-quality care. These studies note that states that require greater doctor supervision of nurse practitioners do not have better patient safety records; in addition, in states that grant nurse practitioners more independence, more of these healthcare professionals are working in rural and underserved areas. California has many rural and underserved areas; thus, many would agree that a community that has a local nurse practitioner is a better alternative than no local medical care at all.
Given a choice, most patients would prefer to see a medical doctor rather than a nurse practitioner. Last June, the journal Health Affairs published a survey of 2,053 Americans that found that about half would rather have a physician as their primary care provider; however, almost 60% said they would prefer to see a nurse practitioner or physician assistant today than wait a day to see a doctor.