Proponents say a proposal before the Kansas Legislature regarding Advance Practice Registers Nurses (APRNs) will lower medical costs and improve Kansans’ access to medical care. However, opponents say the legislation could accelerate a nursing shortage and result in suboptimal health care.
Senate Bill 174 would allow nurse practitioners to practice in Kansas without having to procure a collaborative practice agreement with a physician.
Elizabeth Patton, executive director of Americans for Prosperity, said the legislation simply scraps the mandate requiring APRNs to get a permission slip from a doctor in order to provide services in the state.
Under the collaborative practice agreements, the physicians carry malpractice insurance for the nurse practitioner. The legislation would require APRNs to get their own medical malpractice insurance.
“Oftentimes, the collaborative practice agreements cost tens of thousands a year, and the physicians are liable even if they’ve never even seen these patients,” Patton said.
Casualties of the current law
Sharon Foster is a former nurse-midwife, but she allowed her license to lapse in 2018 when she was unable to find a physician to sign a collaborative practice agreement.
“I attended over 1,300 births in the 17 years I was employed at Associates of Women’s Health and had privileges at the Wichita hospitals,” Foster told the Senate Public Health and Welfare Committee in written testimony last week. In 2016, the physician group ended her contract after deciding not to support midwifery.
“I had to find providers for 30 patients,” she said. She helped most find physicians, and she assisted one-third of them in home births.
“I am a casualty of the current laws requiring Kansas APRNs to have a physician-signed authorization to practice,” she said.
Tarena Sisk, a nurse practitioner in Winfield, opened a freestanding birth center and clinic after practicing for 10 years in the community and delivering thousands of babies. Initially, the physician overseeing her agreed to continue their collaborative practice agreement. Sisk said he decided not to renew when he realized she might take business from him.
“At this point, I had already invested thousands of dollars into a new business that I could not legally practice in without finding another physician to sign this agreement,” she said. “Where I live and practice is a small town with only two OB/GYN physicians. They work in the same practice, and it would be unlikely for one to sign without the other. To practice, I would need to move my entire family, uproot our lives and recover financially from a business that I had already invested my heart and soul into.”
Right to earn an honest living
Sam MacRoberts, litigation director for the Kansas Justice Institute, says APRNs have a right to earn an honest living free from unreasonable government restrictions. (Kansas Policy Institute owns KJI and the Sentinel.)
“Advanced practice registered nurses shouldn’t need a permission slip from a physician to be able to treat their nursing patients,” he said. “APRNs already have the necessary education and training.”
He told the committee that the right to earn an honest living is a fundamental right. MacRoberts currently represents an Olathe eyebrow threader who is suing the state board of cosmetology over occupational barriers. He says the Kansas Constitution forbids outrageous occupational licensing regimes.
“The Kansas Constitution forbids occupational barriers that are not appropriately tailored,” he told the legislative committee.
Increasing provider access and lowering health care costs
Kansas ranks 40th in the nation for the number of physicians per 100,000 people, according to an AARP Public Policy Institute survey. AARP predicts that there will be 49,000 fewer primary physicians by 2030. The state ranks 42nd for health care quality and 24th in the county for access to health care.
Twenty-two other states and the U.S. Veterans Administration allow APRNs to practice without oversight from a doctor. In many of those states, access to health care statewide increased after removing occupational barriers for nurse practitioners.
“It is important to note that none of these states have gone back to remove or add restrictions to those statutes,” Michelle Knowles, a family nurse practitioner in Hays, told the committee. “Many of the states are in the Midwest and had the same worsening access to care issues that we have.”
Within two years of scrapping collaborative practice agreements, the number of primary care nurse practitioners increased by 40% in Nebraska. In Arizona, the number of APRNs increased by 73%.
Improving rural health care access
“Access to healthcare is a growing problem in Kansas,” Cathy Gordon, a licensed family nurse practitioner, told the committee. According to the Kansas Department of Health and Environment, more than 90 Kansas counties have some sort of health care shortage and there are no mental health services available in 102 Kansas counties.
Allowing Advanced Practice Registered Nurses to practice without a collaborative agreement with a physician could help fill that void, according to Gordon.
“It will allow for more health care providers in our state to actually provide health care in many counties currently lacking adequate providers,” she said. There are nurse practitioners ready to serve in areas where there are no physicians.”
APRNs work in suburban, urban areas
However, opponents of the Kansas legislation say the majority of nurse practitioners will practice in urban and suburban areas. Arizona, for example, allows nurse practitioners to practice in rural areas without supervision, but only 11% of all non-physicians — like APRNs and certified nurse midwives, work in rural areas, and they serve only 15% of the state’s rural residents, Dr. Jennifer Bacani McKenney, President-elect of the Kansas Association of Family Physicians, said.
She noted that APRNs can work anywhere in Kansas.
“We have a shortage of nurses in Kansas. We do not have an APRN shortage in Kansas,” Bacani-McKenney said. “We do have a distribution problem though because most APRNs in Kansas practice in urban areas. There is no reason to believe that this bill will entice more APRNs to come to Kansas or practice in rural communities.”
Under the current collaborative agreements, APRNs order and interpret diagnostic tests, establish diagnoses, prescribe medications, and provide referrals to other healthcare providers. The legislation removes the mandate for an agreement with a doctor.
“The complexity of rural medical care is why, included in my 20,000 clinical hours preparing to be a family physician, I had nearly 1,000 hours of clinical training in psychiatry, nearly 1,000 hours of clinical training in trauma and ER care, and another 1,000 hours in neurology,” Bacani-McKenney said. “These specialty experiences alone are already beyond the total number of hours of clinical experience obtained by APRNs during their entire training.”
Opponents voice concerns about training for APRNs
In order to become medical doctors, physicians have a minimum of 11 years of education; four years of college, four years of medical school, and three to eight years of residency and fellowship. Nurse practitioners have six to eight years of schooling; four years of college, and two to four years of nurse practitioner school. Licensed APRNs complete 4,000 clinical hours or instruction hours for four years in order to collaborate with a physician.
Dr. Christine White, a Johnson County pediatrician, said she taught seven different nurse practitioner students.
“I think each of these students are lovely, smart, caring, capable people, but not one would be capable of practicing medicine independently for at last another 4 to 5 years after finishing school,” she said. “They didn’t know enough basic science or how to take a thorough history. Their physical exam knowledge and skills were very limited. They couldn’t come up with a good list of possible diagnoses for a patient after we had seen them. And once we decided on a diagnosis, their knowledge of how to treat most conditions was quite limited.”
Bacani-McKenney said medicine requires a collaborative approach that includes both nurses and doctors.
“Team-based care prevents disease, keeps people well, and saves lives,” she said. “At no time in history has this been more evident than during this pandemic when we rely on respiratory therapists, housekeepers, lab technicians, physicians, nurses — the whole team — to keep people safe and keep people alive. No one can or should be responsible for patient care alone.”