Allowing nurse practitioners to practice without oversight of physicians could help address access to care shortages in Mississippi, particularly in rural areas. However, physicians, including those in the state and American Medical Association, say there is no substitute for the advanced education and training doctors receive.
Dustin Barnes/The Clarion-Ledger
Virginia Cristophe’s checkup at Montgomery Family Clinic in Gluckstadt one recent morning starts with a hug and inquiries about family before Susan Montgomery leads her back to an exam room.
“If it wasn’t for her, I wouldn’t be sitting here,” Cristophe says of Montgomery, whom she has seen since the clinic opened about seven years ago. “I had multiple medical issues, and I was not aware they existed … I had a thyroid that was no longer working … I wouldn’t trade her for anyone.”
Other patients offer similar endorsements: “She treats us all like family,” says Amanda Murray, whose husband and two children also see Montgomery. Both Cristophe and Murray said Montgomery occasionally refers them to specialists for various issues or tests, but they come to her for their primary care.
Montgomery is an experienced primary care provider. On top of more than eight years of secondary schooling, including four at postgraduate-level, she worked 15 years in emergency rooms, the University of Mississippi Medical Center’s infectious diseases unit, a neonatal intensive care unit and for the state Department of Health.
But Montgomery is not a medical doctor. She’s a nurse practitioner, with a doctor of nursing practice degree. She has two “collaborating” physicians who technically oversee her clinic by checking over some of her patient charts each month.
In Mississippi and nationwide, there is a long-running debate over the level of autonomy nurse practitioners should have. With a nationwide shortage of physicians — Mississippi ranks worst — and an acute shortage of primary care doctors, particularly in rural areas — Mississippi also ranks worst — there’s been a push for more independence for nurse practitioners.
States allowing ‘full practice’
Advocates of expanding scope of practice for nurse practitioners point to numerous studies that show care from them is on par with that from physicians — sometimes rated better by patients.
“It really is a no-brainer,” said Ricki Garrett, director of the Mississippi Association of Nurse Practitioners. “… We are a rural, medically underserved state, and by allowing nurse practitioners to practice at their full scope, we can greatly expand access to care for the citizens of Mississippi … It’s a way we can increase access to care without costing a dime.”
Opponents say there is no substitute for the advanced training and education physicians receive and that physicians should remain at the top of any medical team to provide the best care and safety for patients.
“I’m a big fan of nurses — my wife’s a nurse,” said Dr. Lee Voulters, president of the Mississippi State Medical Association and a neurologist at Memorial Hospital at Gulfport. “Nurse practitioners are a vital part of the health care community … But we think replacing doctors with nurse practitioners is a negative thing, and it goes against the well-established continuum of care of a physician-led team.”
The American Medical Association, which has generally opposed more independence for nurse practitioners, has said advanced nurses’ training of two to three years postgraduate education and typically less clinical hours than a first-year resident doesn’t compare with a physician’s seven or more years of postgraduate education and more than 10,000 hours of clinical experience.
A growing number of states — 22 now plus Washington, D.C. — allow “full-practice authority” for nurse practitioners, defined by the American Association of Nurse Practitioners as allowing “nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments — including prescribe medications — under the exclusive licensure authority of the state board of nursing.”
Some other states tightly restrict their practice. Mississippi, after some recent changes, falls in the middle, considered “reduced practice.”
Mississippi is one of few states that still places geographic limits on collaborative agreements nurse practitioners must have with doctors. Last year, although legislation to ease restrictions on nurse practitioners died again at the statehouse, the Mississippi Board of Medical Licensure agreed to change its restrictions to allow nurse practitioners to practice up to 75 miles away from their collaborating physicians. The limit prior had been 15 miles, one of the most restrictive regulations in the nation.
Nurse practitioners practicing outside a doctor’s office are required to have a collaborating physician each month review 10 percent of their patients’ charts, or 20 charts, whichever is least.
‘Turf is turf’
Dr. Tom Delbanco, a longtime professor of general medicine and primary care at Harvard Medical School, said the debate over what advanced practice nurses can do has been going on for 60 years across the country.
“I find that it’s usually marketplace driven,” Delbanco said. “For example, when we had too few OB-gynecologists in a part of Massachusetts, they welcomed nurse midwives with open arms. When they had enough OB-GYNs, they thought nurse midwifes should have limited scope of practice.
“Turf is turf in every profession,” Delbanco said. “And that’s the real text here. The subtext is, ‘Can they do this? Can they do that?’ But I’m a utilitarian. If we’re thinking about the greater good for the greater number, if you’re in an underserved area, would it be better to have a nurse practitioner or not? That’s like asking would it be better to have antibiotics or not …
“The ideal is that doctors and nurses team together. But beyond that, if you’re in the Mississippi Delta and there’s no doctor around for 100 miles, but a nurse practitioner could be there, then for God’s sakes, let them do it.”
Delbanco said: “Nurses are much better than doctors at some things. Doctors will deny this and get mad at me, but it’s true … Doctors are socialized to make a diagnosis and figure out what’s wrong with a patient. Nurses are less interested in establishing a diagnosis and more intent on hanging in there with a patient and seeing him or her through an illness … Every time it’s measured in an objective way, as far as I know, the quality of care for nurse practitioners is very high.”
Delbanco said the lack of primary care and family practice physicians “is a national crisis.”
A recent report by the Association of American Medical Colleges ranked Mississippi 50th among states for active physicians per 100,000 population, with 184.7. Mississippi is well below the national median of 251 doctors per 100,000 people. For active primary care physicians, Mississippi had 64.5 per 100,000 people, also ranked 50th.
Garrett said many of Mississippi’s 3,500 nurse practitioners could help fill gaps in access to care by the state’s 5,500 doctors (of which only about 1,900 are in primary care) without costing the state money.
Delbanco said there are many reasons for the shortage of primary care physicians, “but one reason is very simple.” He’s a full professor at Harvard Medical School, a longtime primary care physician who ran the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston for 30 years.
“I make less money than a young radiologist does three years out of training,” Delbanco said. “Everyone has inequities in salary, and feels they’re being screwed. But the disparities in income among doctors are enormous. Compound that with the enormous debt doctors have when they come out of training, and no one wants to go into primary care.
“But we will never have enough doctors, and we couldn’t afford them even if we did.”
Nearly 90 percent of the state’s nurse practitioners work in primary care, a vital statistic for a rural state with problems dealing with access to health care.
‘Terrible access issues’
The loosening of the geographic restrictions in Mississippi last year was a political deal cut between the Medical Licensure Board and lawmakers to kill a measure offered by Senate President Protem Terry Burton, R-Newton. Burton’s measure would have allowed nurse practitioners with 3,600 or more hours of clinical practice to work without collaborating physicians. Burton said it would likely have passed, which prompted the licensure board to cut a deal.
“Certainly in a state like Mississippi, where there’s terrible access to care issues, and terrible availability of care, and terrible transportation problems, and where doctors don’t want to do primary family medicine,” Burton said, “I don’t think doctors should have to sign off on nurse practitioners’ practice.”
Garrett said the 75-mile limitation and required collaboration with physicians are unnecessary, burdensome and expensive.
“The collaborating physician is often not in the clinic with the nurse practitioner and doesn’t see the nurse practitioners’ patients,” Garrett said. “The only thing the physician does is sign off on 10 percent of the charts. Unfortunately, the nurse practitioner is having to pay anywhere from $4,000 to $10,000 per month to that physician for that signature. I think there is some misunderstanding among the public that the physician is actually supervising the practice.
“If they weren’t having to pay a collaborating physician thousands of dollars every month, they could use that money to purchase equipment, hire other nurse practitioners and open more clinics,” Garrett said. “That could have a significant impact.”
The only hospital in rural Quitman County closed last September, and the resulting lack of health services is severe. District 3 County Supervisor Johnny Tullos said he’s open to any ideas to provide more health care access to his community, including lifting restrictions on nurse practitioners.
“I could see how it would help,” Tullos said. “I’ll admit I don’t know all the pros and cons, but it sure sounds like something that could help these small communities a lot, where a doctor might not want to take on a small town, but a nurse practitioner might. Seems like anything like that might help us right now.”
Garrett said her group and others plan to continue the push in the Legislature for full practice rights.
‘If you want to be a doctor, go to medical school’
But, as in the medical community, there are differences of opinion in the Legislature.
Senate Public Health and Welfare Chairman Dean Kirby, R-Pearl, said, “There’s a real need for nurse practitioners. I just think it should be under collaboration with a doctor
“Nurse practitioners can and they are providing needed services … But I think they need to be under a doctor. What’s next — nurses wanting to perform the same function as nurse practitioners, who want to be doing the same function as doctors? The whole emphasis needs to be on what’s best for people.”
Kirby, along with House Public Health and Human Services Chairman Sam Mims, R-McComb, said they had hopes the Medical Licensure Board’s easing of geographical restrictions would resolve the debate.
“Nurse practitioners and physicians assistants play a great role in our health care system today,” Mims said. “But I’m not one to be in favor of expanding the scope of practice, and I’ve been very consistent with that over 14 years in the Legislature … We have a goal, and I continue to try to pass legislation to bring more medical professionals of all types to Mississippi.”
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Mims notes the state has funded a more than $70-million expansion and upgrade to the medical school at UMMC, the state’s only academic medical center, that will allow medical school class sizes to be increased from 145 students a year to more than 165. Mims said the Legislature also has passed a measure making it easier for nurses, doctors and physical therapists in other states to move to Mississippi and practice.
In 2007, the Legislature created the Mississippi Rural Physicians Scholarship Program aimed at addressing the rural physician shortage. It provides $30,000 a year for medical training in return for doctors serving in medically underserved areas. Doctors must enter residency training in family medicine, general internal medicine, pediatrics or OB/GYN. The program’s website says that by this year, it will have about 30 practicing physicians in rural Mississippi.
But the program will take years to have a major impact, the shortage of physicians remains and so does the debate over nurse practitioners.
Garrett said: “All the data shows nurse practitioners practice at the same level of a physician doing primary care,” Garrett said. “They are just as safe or safer. They are just as effective or more effective, and one reason is they tend to spend more time with the patients and focus on more preventative care.”
But Voulters said: “With all due respect — nurses are great, nurse practitioners are critical — but if a nurse practitioner wants to practice as a doctor, then they should go to medical school and become a doctor.”
Contact Geoff Pender at 601-961-7266 or firstname.lastname@example.org. Follow him on Twitter.
At a glance
- A nurse practitioner is an advanced practice nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor. Other APNs include nurse anesthetists and nurse midwives.
- Nationwide, nurse practitioners and other APNs have pushed for their states to allow them “full practice” without oversight or collaboration from physicians. The American Medical Association and other physician groups have fought this.
- More autonomy of nurse practitioners can help provide more access to care, particularly in rural states like Mississippi, proponents say. Physicians warn this reduces quality of care and patient safety. But many studies have shown care from nurse practitioners is on par with that from physicians.
Mississippi Physician workforce
- Mississippi has 5,530 active physicians, according to a 2015 report by the Association of American Medical Colleges. This includes 1,930 primary care physicians.
- Mississippi ranks last among states in physicians per 100,000 people with 184.7 and last in primary care physicians per 100,000 at 64.5, according to the AAMC.
- Mississippi has 4,336 advanced practice nurses, of which 3,495 are nurse practitioners, 807 are nurse anesthetists and 34 are nurse midwives, according to the Mississippi Association of Nurse Practitioners. Of the nurse practitioners, 90 percent are in primary care.
- According to Census info, 51 percent of Mississippi’s population lives in rural areas, making it the fourth-most rural state. This makes access to physicians a challenge.
- 22 states plus Washington, D.C., allow “full practice” of nurse practitioners, without oversight or collaboration of a doctor. These include: Alaska, Arizona, Colorado, Connecticut, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, South Dakota, Vermont, Washington and Wyoming.
- Some states greatly restrict nurse practitioners, requiring a doctor to sign off on their work and-or not allowing them to prescribe medicine. Mississippi falls in the middle, considered “reduced practice.” Practitioners must “collaborate” with one or more doctors within 75 miles of the NP’s clinic.
- Fees for doctors to check 10 percent or 20 of an NP’s patient charts (whichever is less) each month — required by Mississippi regulations, can cost an NP $10,000 a month. NP advocates say this money would be better spent purchasing medical equipment or hiring more nurses.
- Nurse practitioners are reimbursed by Medicare at 85 percent of the fees paid a physician for the same care, according to a Kaiser Family Foundation report. They are reimbursed at the same rate by Medicaid in Mississippi, but can be reimbursed up to 100 percent of the physician rate depending on provider shortages.
- Mississippi also has a “severe” shortage of practicing child and adolescent psychiatrists, with only 54 statewide according to a 2015 report by the American Academy of Child Adolescent Psychiatry. A court-ordered report on Mississippi’s child mental health system suggests more use of psychiatric nurse practitioners and others below M.D. level could help make services more available.
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