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Nurses say autonomy would improve health care in rural PA. • Spotlight PA

HARRISBURG – Joyce Knestrick can independently perform physical exams, diagnose health problems, prescribe certain medications and make referrals as a nurse practitioner at a clinic in West Virginia.

But when she crosses the border into Pennsylvania, where she lives in Washington County, she needs a doctor’s supervision to do the same work.

Nurse practitioners, who receive advanced clinical training that emphasizes preventive care, are more specialized than registered nurses. Pennsylvania law requires that in order to practice, these nurses must work with a physician who provides input on patient care — a standard commonly called a cooperative agreement.

Knestrick, the former president of the American Association of Nurse Practitioners, likened the supervision requirement to having a driver’s license but only being allowed to drive a car if someone is supervising.

Over the past decade, lawmakers from both parties have tried to give Pennsylvania’s roughly 20,000 nurses more leeway. They hope that removing the restriction on physician oversight could increase access to health care.

Bipartisan bills currently before the state House and Senate would have Pennsylvania join the 27 other states — including three of its neighbors — that have granted full practice authority to nurses, allowing them to examine, diagnose and treat patients without supervision of a doctor. And unlike many other initiatives in Harrisburg, it has a bipartisan appeal. Of the 50 members of the Senate, 32 have signed on as co-sponsors, including 17 Democrats and 15 Republicans.

The measure also has support from a wide range of advocacy groups, from the state hospital association to the Commonwealth Foundation, a conservative free-market think tank.

But opposition from key lawmakers and the Pennsylvania Medical Society, a professional group that represents doctors, appears to have stalled the legislation again.

And in the meantime, shortages of healthcare providers persist.

“I understand that sometimes there are physicians who feel like (practitioners) are going to encroach on their territory,” Sen. Camera Bartolotta (R., Washington), who has sponsored the nursing expansion, told Spotlight PA. But “this bill would no more replace them than a general practitioner replaces a heart surgeon.”

Research has shown that the availability of primary care physicians is linked to better health outcomes. But according to federal data collected by health research group KFF, 380,000 Pennsylvanians live in areas, many of them rural, where there is a shortage of these doctors.

All told, KFF estimates the state needs at least 70 new professionals to meet that need. That’s the eleventh lowest need in the country.

Population studies show that rural communities tend to have large numbers of older residents who rely on Medicare and Medicaid, which health care systems reimburse at lower rates. This can make it difficult for healthcare providers to make money in more remote areas, resulting in cuts and closures of services. In an April report, a policy group at the Center for Healthcare Quality and Payment Reform estimated that seven of Pennsylvania’s 41 rural hospitals, for example, are at immediate risk of closing.

Fayette County nurse Melany Chrash said preventative care and patient education are at the core of her work. She said full practice authority would give providers like her the flexibility to schedule appointments around patient needs and reach underserved areas. And if there’s a problem she can’t handle, Chrash says she has no problem referring patients to a specialist.

“It wouldn’t change the way we practice,” she told Spotlight PA. “It would change the fact that we can be independent and run our own practice as we see fit, and not share our salaries with anyone else.”

Studies have come to varying conclusions about the effect that expanding the authority of registered nurses would have on access to and quality of health care.

A 2023 study found that nurses can provide better care for people dealing with multiple chronic conditions than primary care physicians because their training emphasizes “whole health,” including social and psychological well-being.

Some studies have also suggested that states that give nurse practitioners more authority have lower health care costs. However, a 2023 working paper on nurses in the veterans health system’s emergency rooms found that they did not improve care and used more resources.

Doctors who oppose the legislation emphasize the difference in training between themselves and nurses. Before setting up a private practice or signing a script, a board-certified physician has accumulated up to six years of additional education and 15,000 additional hours of training, they note.

Kristen Sandel, a Berks County emergency physician and president of the Pennsylvania Medical Society, defended collaborative agreements. While everyone involved in a patient’s medical treatment has a role to play, “the people who have had the most training and the people who have the most expertise are the ones who should be leading that team,” she said to Spotlight PA.

Amid widespread cuts and closures in rural health care, practitioners’ arguments have won over some lawmakers.

According to a Spotlight PA analysis, the state legislature has been considering bills that would increase practitioners’ authority since at least 2013. In the decade since, these proposals have received a dozen votes on the floor and in committee, but they are never reached the governor’s desk for signature.

The version of the bill currently before the Senate, sponsored by Bartolotta and Lisa Boscola (D., Lehigh), would give nurse practitioners full practice authority once they comply with a three-year, 3,600-hour collaborative agreement with a physician.

“Most health care initiatives proposed by lawmakers are expensive to implement, but changing the scope of practice laws comes at no cost to taxpayers,” David Mitchell, a professor of health care economics at Ball State University, told a representative of the Commonwealth earlier this year Senate committee. Foundation.

Bartolotta noted that she has honed the language over the years. Initially, the proposal required a non-physician physician to complete only 30 hours of additional continuing education.

However, the changes in the legislation have so far not upset the doctors who oppose the measure. They are energized by their industry’s significant presence in Harrisburg and support from top lawmakers.

The exact scope of lobbying in the Pennsylvania General Assembly is difficult to grasp under state law. Lobbies do not have to note which bills they argue for or against, and interest groups often juggle multiple priorities.

But since 2013, the Pennsylvania Medical Society alone has spent $6.6 million lobbying the General Assembly. During the same period, the coalition of nurses spent $668,000. (Although the coalition has hired two well-known lobbying firms during that period, including the recent appointment of the firm of former top GOP state Senator Joe Scarnati.)

Versions of the full practice authority bill first passed the Senate in 2016 but failed to pass the state House. Former House Speaker Mike Turzai (R., Allegheny) was skeptical of the initiative, according to a source familiar with Republican thinking, and the measure never gained a majority in the House during his time in office.

After Turzai retired in 2020, new House leaders approved a measure that would have created a six-year pilot program that would give nurses full practice authority in federally designated areas with health care shortages. However, it was passed late in the session and never received a vote in the Senate.

The groups representing doctors and nurses pointed fingers at each other over that failed compromise. Bartolotta told Spotlight PA that she saw the pilot as a way to “let us sit down and be quiet.”

“We already had a pilot program,” she says. “Half the country was a pilot program.”

Then, state Sen. Kim Ward (R., Westmoreland) took over as her chamber’s majority leader in 2021. She was one of the few consistent no votes in the Senate on full practice authority for nurses, saying in 2017 that she was concerned about “unintended consequences.”

Since Ward ascended to leadership, no full practice authority bill has passed the Senate.

In a statement, Ward’s spokesperson Erica Clayton Wright said the senator “continues to do her due diligence on this matter” and that Ward wants to ensure that “Pennsylvanians not only have access to health care, but also ensure that health care workers who treat patients in the position because of the high-quality health care for which they have been trained.”

Clayton Wright added that Ward’s “leadership position has no bearing on the trajectory of this legislation.”

With new leadership at the Coalition of Nurses, the Pennsylvania Medical Society, and in the Legislature, Amanda Laskoskie, President of the Coalition of Nurses,

The advocates hope to soon “meet with all relevant stakeholders to help solve the patient access healthcare crisis.”

But it will take more work to get doctors on board. Sandel agreed that more people needed access to care, but didn’t think expanding nurse practitioner practice would help.

She noted a national analysis from the American Medical Association that found nurses are as scarce as other healthcare providers in underserved areas such as rural counties.

“We have looked at other states where they are allowing independent practice for nurses, but the access to care problem has not gone away,” Sandel told Spotlight PA.

She proposed that Pennsylvania encourage doctors to settle without care in rural areas and other areas through targeted medical school debt forgiveness programs.

“The hope is that if we can help physicians repay their loans, and they practice in these areas, they can build a relationship with that community,” Sandel said.

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