Take the chains off nurse practitioners

Take the chains off nurse practitioners

Give them ability to practice to their full potential

HISTORICALLY, MASSACHUSETTS HAS BEEN a leader in healthcare reform. However, antiquated, restrictive laws and licensing requirements leave Massachusetts among only 13 states in the country – and the only state in New England – that does not currently allow nurse practitioners to practice to the full extent of their education and training. Limitations to nurse practitioners’ practice authority has led to limitations in healthcare delivery.

Legislation pending on Beacon Hill would modernize Massachusetts licensure laws and provide nurse practitioners with full practice authority, maximizing their education, certification, and training. Nurse practitioners are already providing comprehensive health services to patients and working closely with members of the healthcare team, but are required to practice under the supervision of physicians. They are registered nurses with advanced master’s or doctoral-level education, nationally certified in advanced-practice nursing specialties, and have the knowledge and experience needed to deliver high-quality, cost-effective healthcare to patients – yet, despite a burgeoning healthcare need across the state, they remain underutilized.

Providing nurse practitioners with full practice authority would provide millions of dollars in crucial healthcare cost savings for the Commonwealth; increase access for patients, particularly in underserved areas of the state; and deliver additional resources to combat the ongoing opioid epidemic plaguing Massachusetts.

The cost of healthcare is on the rise for both the Commonwealth and its patients. It is essential that we identify cost savings for the system and improve utilization of nurse practitioner-delivered care that will translate into large cost savings for Massachusetts and for patients. When treated by nurse practitioners, the cost of a patient’s office visit can be 20 to 35 percent lower than a visit with a physician – and without compromising quality of care.

Nurse practitioners are already performing physical examinations; prescribing medications; ordering and interpreting diagnostic tests; and treating and managing acute, episodic, and chronic conditions. And they are often treating some of the most vulnerable members of society, including the elderly, people living in poverty, patients with complex chronic illnesses, and patients with opioid addictions. According to a recent Gallup poll, nurses are the most trusted professionals in the United States and nurse practitioners are well recognized for delivering high quality, cost effective healthcare.

Boston prides itself as a hub for healthcare and is home to some of the highest-rated hospitals in the nation. However, outside of the city, there are areas of the state where patients lack basic access to primary and specialty care, primarily in areas of western Massachusetts and Cape Cod. Due to supervision requirements in the current law, nurse practitioners cannot practice to the full extent of their education and training and, as a result, patients suffer.

In 2013, a group of nurse practitioners based out of Quincy were providing mental health treatment and support services to over 1,000 patients when, unexpectedly, they were forced to turn their patients away after the supervising physician abruptly left the practice. Because of restrictions outlined in the current law, these highly competent Nurse Practitioners could no longer provide their patients with the same level of continued care, primarily prescribing medications. As a result, these men and women were suddenly left searching for mental health services, and for many of them it meant an inability to receive and renew their prescriptions. This is just one example of many like it. Passing the legislation pending on Beacon Hill and providing nurse practitioners with full practice authority would help close these gaps and increase access for patients in need.

As Massachusetts continues to face a rising number of opioid-related deaths, with 2,016 deaths reported in 2016, nurse practitioners stand ready to do their part and offer treatment services for those suffering from opioid dependence. Passing this bill would remove an additional barrier that currently exists for patients seeking medication-assisted treatment for their drug dependence.  Many patients looking for help are met with long wait times and limited access to providers trained and able to provide the treatment they need. There are 28,000 actively licensed physicians in Massachusetts and less than 10 percent of them have received medication assisted treatment waivers to provide treatment to patients suffering from opioid dependence. While many nurse practitioners have attained the waiver for medication-assisted treatment, they are prohibited from providing treatment without a physician who is willing to provide supervision. This requirement impairs the ability of nurse practitioners to respond to the escalating opioid crisis.

Meet the Author

Stephanie Ahmed

Chair, Massachusetts Coalition of Nurse Practitioners' Legislative Committee
For many patients, the nurse practitioner is already the face they are used to seeing in the office, the person answering their calls and overseeing their care and treatment. Granting full practice authority to nurse practitioners means more patients can have access to the high-quality care that they deliver, and at a lower cost for everyone.

Stephanie Ahmed, chair of the Massachusetts Coalition of Nurse Practitioners’ Legislative Committee and former president of the coalition.

  • Victor

    Physicians received 15,000 hours of clinical training before they are licensed to practice independently. Petsmart dog groomers receive 800 hours before being allowed to be independent. Nurse Practitioners received 500 hours of clinical training before they are licensed.

  • Anonymous

    Practicing medicine is a privilege, not a right. Insinuating that supervised practice is in any way similar to slavery is both ignorant and offensive. Patients are being harmed every day by NPs from these for profit online NP mills and the data will take a while to catch up but so far they are prescribing more inappropriate antibiotics, more opioids (and have lost their right to prescribe controlled substances without physician supervision in some states because of it), order more tests and refer more… and they do not go to rural areas any more than physicians. There is data to substantiate all of these things already and no doubt more to come. Sadly, those statistics we all see coming and are waiting for are actual people. The worst part is that patients not only do not save a dime when they pay their copay for an NP vs a physician, but they actually spend more because they pay copays for more medications, more referrals, and more testing. Furthermore, NPs are advertising that they are “board certified” when in reality they have take a LICENSING exam and they are advertising that they specialize in fields like Internal Medicine, Dermatology, and even Pediatrics when in reality they are not eligible to sit for the board in any of these fields with their online degrees and 500 hours of self reported shadowing. The 500 hours it seems is not even a firm requirement as many places require “encounters” – for example at a prominent East TN university, a “family practice” NP is required to get “20 hours or 10 encounters in OBGYN” each semester over 3 semesters. That’s supposed to be a total of 60 hours of OBGYN (so less than a week of a medical residency if measured in hours) but in reality, who takes 2 hours to see a patient? At best it takes a day and a half (so 16 hours) to see 30 patients and then some online trained NP can go out and harm patients by claiming to be experts in OBGYN. It’s crazy irresponsible! Ironically, NPs do not fall under Stark laws, are not exempt from overtime, and they are supervised by the state nursing boards largely made up of RNs who cannot hold them accountable to an appropriate standard of care because they don’t even know what the standard of care for practicing medicine is… and in court and before lawmakers they argue they are practicing nursing, not medicine, and so these laws should not apply to them. Why would they fight being treated like medical professionals? Money. Hospitals are on board for this allowing NPs to work as hospitalists with ZERO INPATIENT TRAINING because they pay them less than physicians and they order more tests, generating more revenue for hospitals. They aren’t sued as often because in most cases, the supervising physician is sued for their mistakes.
    No one is suggesting that NPs shouldn’t practice medicine but they should only do it under real supervision (not meaningless paper agreements) with real doctors who have proper training to adequately diagnose and treat disease and patients have a right to be well informed about who is caring for them.
    The unsupervised and unlicensed practice of medicine by NPs is hurting patients and it’s causing a tremendous burden on the real unsung heroes, bedside nurses.

    • Anonymous

      Ms. Ahmed, I would challenge you to list the states that allow the fully unsupervised practice of advanced nursing because your article inaccurately states that only 13 do not but it’s really 26 that do not. What is your motive?

  • Anonymous

    Why is my comment in opposition of unsupervised nursing practice being censored? From your About us page: “CommonWealth is journalism at its best: in-depth, balanced, and independent. It is also the type of journalism that’s badly needed today as the economic model that fuels most news media is running out of gas.”

    So why is a dissenting opinion being censored? Seems like something other than balanced, in-depth journalism to me.

  • Sarah A

    I think nurses have such an important role in patient care. Nursing is facing a national shortage and as patient advocates, I don’t understand why nursing societies aren’t pushing for more nurses to do actual “nursing” and join the call for more primary care residency spots for unmatched doctors to complete training to fill the doctor shortage.

  • Anonymous

    This article states “the cost of a patient’s office visit can be 25-35% lower” than with a physician but there again, not exactly the whole story. Patients don’t see that savings at all because they pay the same copay regardless of who they see. However, the insurance companies reimburse the NPs at a rate of 85% of the rate of physicians and this savings is not passed on to the patient. NPs in Oregon fought for “pay parity” (despite training disparity), and won – so they get reimbursed at 100% the same as a medical doctor. Furthermore, NPs have been shown to order more test, prescribe more medications, and send more referrals – all of which cost the patient more in co-pays and deductibles. If the NP works for a hospital, the hospital benefits financially because they pay NPs less and the NPs in turn order more tests and referrals they can charge for. What benefit is there for the patient then in seeing a provider with less training?

    Order more imaging (xrays, MRI, etc):
    https://www.ncbi.nlm.nih.gov/pubmed/25419763

    More referrals to other providers:
    https://www.ncbi.nlm.nih.gov/pubmed/25419763

    Perform twice as many unnecessary skin biopsies:
    https://www.ncbi.nlm.nih.gov/pubmed/25806897

    Prescribe more antibiotics (which can lead to creation of “superbugs”)
    https://www.ncbi.nlm.nih.gov/pubmed/27704022

    Prescribe more opioids in the states that have databases and have looked at this data:
    http://www.unionleader.com/Doctors-arent-top-opioid-prescribers-in-NH
    http://c-hit.org/2015/02/19/connecticut-nurse-among-highest-prescribers-in-u-s/

    I could go on but the point is, patients and society spend more on NPs and this article is very misleading.

  • Anonymous

    Practicing medicine is a privilege, not a right. Insinuating that supervised practice is in any way similar to slavery is both ignorant and offensive.

  • Anonymous

    Also not mentioned in this article is the recent shortening in the duration of NP training and shift to an online format. A Doctorate in Nursing Practice can now be earned 100% online in as little as 15 month and that is actually shorter than the time it used to take to earn a Masters in Nursing practice (3 years in a brick and mortar university). If you aren’t a nurse? No problem, you can earn the RN online in as little as 12 months and then the DNP in as little as 15 months. That’s both a bachelor’s and a doctoral degree through places like the University of Phoenix in less than 3 years and 100% online. Surely this author does not contend that this type of education is in any way equivalent to that of a medical doctor?

    https://nursejournal.org/dnp-programs/bsn-to-dnp/
    https://academicpartnerships.uta.edu/programs/doctor-of-nursing-practice.aspx

  • Anonymous

    NPs are only required to have 500 hours of clinical experience. What’s more, not only do DNP students not go to a classroom for their coursework, the often out of state online universities never visit the student’s state and students are often left to find their own preceptors for this part of their training. Furthermore, there is no verification that their clinical experiences were with the appropriate preceptors, were of the appropriate duration, that they ever touched the patients (vs just “shadowing”) or that they ever happened at all because they rely on an honor system.

    NP students discussing rampant cheating in online programs at one popular nursing site (I googled “NP students cheating in online courses” and there is a wealth of information on the topic):
    http://allnurses.com/student-nurse-practitioner/cheating-in-an-973972.html
    https://www.nurse.com/blog/2015/07/23/ethically-speaking-online-education-cheating/

    Rest assured, when your medical doctor took exams, he or she did so in a classroom with an empty seat between them all, a human proctor, and computers that randomized the test questions. For the licensing and board exam, he or she too them at a testing center where they provided a picture ID, were fingerprinted (not joking), and had to pull their pants legs up and socks down while being checked with a metal detector.

  • Anonymous

    I know the author mentioned a physician shortage, but did she mention there is also a RN shortage? RNs who work tirelessly at our patients’ bedsides are understaffed and overworked and despite this, NP organizations are tirelessly claiming they should be allowed to practice medicine unsupervised because they are there to fill the “physician shortage” and leaving the bedside in large numbers. Meanwhile, ~8,000 medical students did not have residency spots this year. Lawmakers have pushed for more medical school spots but they have not increased funding for residency spots since 1996. These medical students were among just 5% of candidates accepted to medical school. They are smart, deserving, and the right men and women for the job yet they cannot (and should not) work unsupervised as physicians without residency training. Residency training adds another 20,000+ hours of clinical training to the already 3000+ hours a medical student has completed. Should an NP with even less training really be practicing medicine unsupervised?

    https://www.theatlantic.com/health/archive/2016/02/nursing-shortage/459741/

  • Anonymous

    The author states, “According to a recent Gallup poll, nurses are the most trusted professionals in the United States and nurse practitioners are well recognized for delivering high quality, cost effective healthcare.”

    This Gallup poll actually asked about nurses, not nurse practitioners. There is a significant difference between practicing nursing and practicing medicine.

    Is this article an opinion piece or a work of fiction?

  • Anonymous

    This article states “the cost of a patient’s office visit can be 25-35% lower” with an NP than with a physician — that is misleading. Patients don’t see that savings because they pay the same copay regardless of who they see. The insurance companies reimburse the NPs at a rate of 85% of the rate of physicians and this savings is not passed on to the patient. NPs in Oregon fought for “pay parity” (despite training disparity), and won – so they are reimbursed at 100% the rate of a doctor. Furthermore, NPs have been shown to order more test, prescribe more medications, and send more referrals – all of which cost the patient more in co-pays and deductibles. What benefit is there for the patient for seeing a provider with less training?
    NPs order more imaging (xrays, MRI, etc): https://www.ncbi.nlm.nih.gov/pubmed/25419763
    NPs make more referrals to other providers: https://www.ncbi.nlm.nih.gov/pubmed/25419763
    NPs perform twice as many unnecessary skin biopsies: https://www.ncbi.nlm.nih.gov/pubmed/25806897
    NPs prescribe more antibiotics (which can lead to “superbugs”): https://www.ncbi.nlm.nih.gov/pubmed/27704022
    NPs prescribe more opioids in the states that have looked at this data:
    http://c-hit.org/2015/02/19/connecticut-nurse-among-highest-prescribers-in-u-s/
    http://www.unionleader.com/Doctors-arent-top-opioid-prescribers-in-NH

    I could go on but the point is, patients and society spend more on NPs. If the NP works for a hospital, the hospital potentially benefits financially because they pay NPs less and the NPs in turn order more tests and referrals they can charge for.

  • Anonymous

    I know the author insinuated there is a physician shortage, but did she mention there is also a RN shortage? RNs who work tirelessly at our patients’ bedsides are understaffed and overworked and despite this, NP organizations are tirelessly claiming they should be allowed to practice medicine unsupervised because they are there to fill the “physician shortage” and leaving the bedside in large numbers. Meanwhile, ~8,000 medical students did not have residency spots this year. Lawmakers have pushed for more medical school spots but they have not increased funding for residency spots since 1996. These medical students were among just 5% of candidates accepted to medical school. They are smart, deserving, and the right men and women for the job yet they cannot (and should not) work unsupervised as physicians without residency training. Residency training adds another 15,000+ hours of clinical training to the already 3000+ hours a medical student has completed. Should an NP with just 500 hours of training really be practicing medicine unsupervised?
    https://www.theatlantic.com/health/archive/2016/02/nursing-shortage/459741/

  • Anonymous

    The issue of the safety of unsupervised practice of medicine by nurses is before the legislature in MA now, and the lies and misrepresentations Ms. Ahmed has published here she has also been presenting to your politicians as she is an NP herself and an active lobbyist. This article should be retracted and the half truths and blatant lies corrected.

  • Volleyball rules

    The practice of nursing and the practice of medicine are two different things. I am very proud of the nurses I work along side with. They offer the eyes and ears I need to manage several patients. They give them the meds I prescribe. Basically we work as a team to get things done. However, do I want them independently caring for my family like an MD/DO but without a background from an MD/DO program. Absolutely not. It’s not a “better than you attitude”. It’s a we trained for two different marathons. One is a sprinter and one is a long distance runner. Just because they both run doesn’t mean they can be interchanged.

  • Christina Lang

    There are NO chains. They know what to do if they want to practice like a physician. Go to Medical school. No short cuts in life.