May 13, 2016
Senate Bill 717, scheduled for consideration by the Consumer Protection and Professional Licensure Committee on Wednesday, May 18th, eliminates a longstanding requirement for certified registered nurse practitioners (CRNPs) in Pennsylvania to collaborate with physicians. It gives CRNPs the expanded authority to diagnose, treat and prescribe to patients without restriction and without physician oversight.
The Pennsylvania Medical Society (PAMED) strongly opposes SB 717. On behalf of physicians, residents and medical students across the Commonwealth, we urge you to vote “NO” on this legislation and to preserve the standard of physician-led, team-based care that our patients—your constituents—currently receive.
Proponents of SB 717 underestimate the clinical importance of physician education and training. They cloud the issue with claims that nurse practitioner (NP) independence will lead to better access to care, particularly in rural and underserved areas of the commonwealth. However, the evidence fails to support these claims.
A majority of states require NPs to have physician collaboration in order to practice and prescribe, with many of these states requiring far more stringent oversight and restriction than what currently exists in Pennsylvania. In states where NPs have succeeded in gaining practice autonomy, neither access to care nor cost savings have substantially increased; NPs continue to practice in the same areas that physicians practice. These states continue to seek solutions to the same access-to-care problems that plague Pennsylvania. In testimony presented before the House Professional Licensure Committee in October 2015, the Director of the National Center for the Analysis of Healthcare Data (NCAHD) reported on healthcare workforce trends nationwide, stating, “There are many reasons for this maldistribution of providers, but there doesn’t appear to be a correlation between states with independent nursing practice and an increase in primary care access in rural communities.”
An amendment to SB 717 has been proposed that would require NPs to have a minimum amount of post-licensure experience under a collaborative agreement with a physician before they can practice independently. While well-intentioned, the logic of this amendment is flawed. A stipulation on independence that requires just three years and 3,600 hours of practice experience completely lacks meaningful details. There is no required curriculum for the completion of these hours/years, no assurance of the quality of mentors and oversight, and, unlike the 3-7 years of heavily-supervised residency training a physician must complete, no accreditation or inspection of the “training” sites of NPs. Requiring a minimum number of years or hours of work experience in an unstructured setting with highly variable experiential learning does not replace the expertise and support that comes with physician oversight.
NPs in our Commonwealth already have wide latitude and authority to practice to the full extent of their education and training. They can see patients independently, order lab or diagnostic tests, make referrals, and prescribe controlled substances as outlined in their collaborative agreement. Collaboration with a physician as a parameter of practice is not a burden, but rather an assurance of greater expertise immediately available in the care of patients. By eliminating collaborative agreements between CRNPs and physicians, SB 717 would give NPs equal authority and clinical autonomy to do everything a physician can do, without the necessary education and training.
While CRNPs are integral and valuable members of the health care team, the depth and the breadth of their education and training does not sufficiently prepare them for the wide array of challenges that confront the independent practitioner. As acknowledged recently by Lorraine Bock, president of the Pennsylvania Coalition of Nurse Practitioners, “We [CRNPs] have the training and the experience to deal with 80 percent of the issues that occur” [TribLive.com, 5/9/16]. Nurses are not doctors, and increasing the responsibility and clinical authority of CRNPs is not an appropriate solution to a perceived shortage of physicians.
Finally, current licensure standards are not arbitrary; they serve an important function in supporting critical safety and quality objectives. At a time when there are repeated calls for increased education and training of prescribers to combat the devastating prescription drug crisis facing our state, it would be irresponsible and nonsensical for the legislature to broadly lower the standard of education and training required to independently prescribe.
PAMED strongly supports a physician-led, team-based approach to patient care, which emphasizes increased collaboration and integration among health care providers, rather than provider autonomy. With the complexity of our health care system ever increasing, patients need both physicians and nurse practitioners, coordinating care and sharing information for the benefit of the patients. The collaborative agreement serves to ensure that patients have direct access to a physician when their care requires a more highly trained professional. Eliminating this network of support would not only be contrary to proven concepts of team based medicine, but has the potential to jeopardize patient care.
For over 150 years, PAMED has worked to advance quality patient care and the ethical practice of medicine in the commonwealth. Central to that mission has been our dedication to demanding rigorous training and education standards for all health professionals, commensurate with scope of practice. As physicians, we have great respect for nurses and other nonphysician clinicians. This is not about criticism of the nursing profession; it is a great one. It is about patient care and what would be in the best interests of our citizens in Pennsylvania. We ask that you oppose SB 717, with or without amendment.
Scott E. Shapiro, MD, FACC, FCPP President
Pennsylvania Medical Society