Photo by Elliott Woods
Nurse practitioner Pete Hill envisions a bleak outcome for the 5,000 patients of the primary care clinic he opened in rural Elkton if the supervising physician suddenly left.
Without a replacement — and physicians in eastern Rockingham County are already scarce — the nonprofit, faith-based practice would close regardless of the medical credentials of Hill and his fellow nurse practitioner.
Nurse practitioners are advanced practice registered nurses (APRN) with master's or doctoral degrees. They have advanced training in diagnosing and treating routine and complex medical conditions.
Virginia is one of 12 states that require a nurse practitioner to work under the supervision of a physician. The doctor must regularly practice at the same medical setting — a clinic, for instance. The physician oversight requirement is a barrier that threatens "care that is affordable, acceptable and accessible," said Hill, who testified last summer before the Virginia Board of Health Professions, which studied the issue.
Physician supervision may change after the Virginia Council of Nurse Practitioners (VCNP) and the Medical Society of Virginia (MSV) reached agreement on a draft bill last fall. It would allow a team-based model requiring collaboration and consultation and eliminate the supervisory language. The two organizations asked Del. John O'Bannon, R-Richmond, a physician, to sponsor the bill in the General Assembly, which convenes this month. The statute governing supervision of nurse practitioners has not been updated since 1973.
"One way that 'collaboration and consultation' within patient care teams is different from 'supervision,' is that it affords more flexibility for nurse practitioners to practice remotely to reach underserved populations, which isn't the case now," said Cindy Fagan, VCNP president.
The agreement could reduce the number of site visits by physicians, and they would not have to "regularly practice" in the facility, she said.
Following the General Assembly's failure in 2010 to remove the supervisory requirement, the nurses and physicians groups met frequently to hammer out a compromise. Their goal was to provide nurse practitioners with more autonomy and to increase the public's access to care, especially in medically underserved inner cities and rural areas.
Virginia has a shortage of family or primary care physicians in 80 counties and cities statewide, according to the state Department of Health Professions.
Federal health care reform is expected to add as many as 425,000 new Medicaid recipients in Virginia. "We think we can help fill some of those gaps in patient needs," Fagan said.
Other proposed changes include streamlined paperwork and flexible requirements for chart reviews and electronic health record reviews.
AARP Virginia supports giving nurse practitioners greater autonomy, but wants more, said David DeBiasi, associate state director for advocacy. "This is an incremental step in the right direction toward increasing access to care for Virginians," he said.
While the compromise eliminated the supervisory language, physician leadership remains vital, said Mike Jurgensen, senior vice president, Health Policy & Planning for MSV.
"Nurse practitioners will practice as part of a health care team with the physicians providing management and leadership to that team," Jurgensen said. "Regardless of practice setting, a physician must still be a part of that team."
Hill has concerns about the compromise. If clinics like his must continue to depend on a physician's management, "then this compromise still does not address the 'fatal flaw' of M.D. participation," he said.
"Anything that limits nurse practitioners from serving as they have been trained to safely and effectively do is something that members of my community can ill afford," Hill said.
Robin Farmer is a freelance writer based in Mechanicsville, Va.