Nurse practitioners say autonomy would improve rural Pa. health care

Joyce Knestrick can independently perform physical exams, diagnose health conditions, prescribe selected medications and make referrals as a nurse practitioner at a clinic in West Virginia.

But when she crosses the border into Pennsylvania, where she lives in Washington County, she needs a doctor’s supervision to do the same job.

Nurse practitioners, who receive advanced clinical training that emphasizes preventive care, are more specialized than registered nurses. Pennsylvania law requires that in order to practice, these nurses must collaborate with a physician providing input on patient care—a standard commonly called a collaborative agreement.

Knestrick, the former president of the American Association of Nurse Practitioners, compared the supervision requirement to a driver’s license, but only being allowed to operate a car if someone supervises.

For the past decade, lawmakers in both parties have tried to give more leeway to Pennsylvania’s roughly 20,000 nurses. Removing the restriction on physician supervision, they hope, could expand access to health care.

Bipartisan bills currently before the state House of Representatives and state Senate would have Pennsylvania join 27 other states — including three of its neighbors — that have given full authority to nurse practitioner practices so that they to be able to examine, diagnose and treat patients without the supervision of a doctor. And unlike many initiatives in Harrisburg, it has bipartisan appeal. Of the 50 members of the upper chamber, 32 have signed on as co-sponsors, including 17 Democrats and 15 Republicans.

The measure is also supported by a wide range of interest groups, from the state’s hospital association to the Commonwealth Foundation, a conservative free-market think tank.

But opposition from key lawmakers and the Pennsylvania Medical Society, a professional group representing doctors, appears to have stalled the legislation again.

And in the meantime, those shortages of health care providers remain.

“I understand that sometimes there are doctors who feel [practitioners] will be trespassing on their turf,” state Sen. Camera Bartolotta (R., Wash.), who has sponsored the nursing expansion, told Spotlight PA. But “this bill would no more replace a general practitioner than a heart surgeon.”

Studies have found that the availability of primary care physicians is associated with better health outcomes. But according to federal data compiled by the health research group KFF, 380,000 Pennsylvanians live in areas, many of them rural, where there is a shortage of these doctors.

In total, KFF estimates that the state needs at least 70 young professionals to meet this need. This is the 11th lowest need in the country.

Population studies show that rural communities tend to have large numbers of older residents who rely on Medicare and Medicaid, which reimburse health systems at lower rates. This can make it difficult for health care providers to make money in more remote areas, resulting in cutbacks and service closures. In an April report, the Center for Healthcare Quality and Payment Reform, a policy group, estimated that seven of Pennsylvania’s 41 rural hospitals, for example, are at imminent risk of closing.

Melany Chrash, a nurse practitioner in Fayette County, said preventive care and patient education are central to her job. She said full practice authority would give providers like her the flexibility to schedule appointments around patient needs and reach underserved areas. And if there’s a problem she can’t treat, Chrash said she has no problem referring patients to a specialist.

“It’s not going to change the way we practice,” she told Spotlight PA. “It would change the fact that we can be independent and run our practice as we see fit, and we’re not splitting our salaries with anyone else.”

Studies have reached mixed conclusions about the effect that expanding the authority of credentialed nurses would have on access to and quality of health care.

A 2023 research review found that nurse practitioners can provide better care for individuals dealing with multiple chronic conditions than a primary care physician because their training emphasizes “holistic health,” which includes social and psychological well-being.

Some studies have also suggested that states that give nurses more authority have lower health care costs. However, a 2023 working paper on nurse practitioners in Veterans Health System emergency rooms found that they did not improve care and used more resources.

Doctors who oppose the legislation point to the difference in training between them and nurse practitioners. Before setting up a private practice or signing a script, a board-certified physician has accumulated up to six more years of schooling and another 15,000 hours of training, they point out.

Kristen Sandel, an emergency physician in Berks County and president of the Pennsylvania Medical Society, defended the cooperative agreements. While everyone involved in a patient’s medical treatment has a role to play, “the people who have the most training and the people who have the most expertise are the ones who need to lead that team,” she told Spotlight PA.

Amid widespread cuts and closings in rural health care, the arguments of practitioners have won over a number of lawmakers.

The state Legislature has considered bills that would expand practitioner authority since at least 2013, according to a Spotlight PA analysis. In the decade that followed, those proposals received a dozen votes and committee votes, but never made it to the governor’s desk for a signature.

The version of the bill currently before the state Senate, sponsored by Bartolotta and Lisa Boscola (D., Lehigh), would give nurses full practice authority after fulfilling a three-year, 3,600-hour cooperative agreement requirement with a doctor.

“Most health initiatives introduced by lawmakers are expensive to implement, but changing the scope of practice laws costs taxpayers nothing,” said David Mitchell, a professor of health care economics at Ball State University, a state Senate committee earlier this year on behalf of the Commonwealth. Foundation.

Bartolotta noted that she has hardened her language over the years. At first, the proposal required a non-physician practitioner to receive only 30 hours of additional continuing education.

The changes in legislation, however, have so far not swayed doctors who oppose the measure. They have grown from their industry’s significant presence in Harrisburg and the support of key legislators.

The exact scope of lobbying in the Pennsylvania General Assembly is difficult to understand under state law. Lobbyists are not asked to mark which bills they support or oppose, and interest groups often juggle multiple priorities.

But since 2013, the Pennsylvania Medical Society alone has spent $6.6 million lobbying the General Assembly. In the same period, the nurse practitioner coalition spent $668,000. (Though during this period, the coalition has hired two prominent lobbying firms, including the recent hiring of former Republican state Sen. Joe Scarnati’s firm.)

Versions of the full practice authority bill first began moving through the state Senate in 2016, but did not make it through the state House. Former House Speaker Mike Turzai (R., Allegheny) was skeptical of the initiative, according to a source familiar with the Republican’s thinking, and the measure never received a vote in the lower chamber during his tenure.

After Turzai retired in 2020, new House leaders agreed to a measure that would create a six-year pilot program giving nurses full practice authority in designated federal health care shortage areas. . However, it passed late in the session and never received a vote in the state Senate.

Groups representing doctors and nurse practitioners pointed fingers at each other over that failed compromise. Bartolotta told Spotlight PA that she saw the pilot as a way to “make us sit back and be quiet.”

“We already had a pilot program,” she said. “Half the country was a pilot program.”

Then, in 2021, state Sen. Kim Ward (R., Westmoreland) took over as majority leader of her chamber. She had been one of the state Senate’s non-continuing votes against full practice authority for nurse practitioners, saying in 2017 that she worried about “unintended consequences.”

Since Ward ascended to the leadership, no full practice authority bill has passed the state Senate.

In a statement, Ward spokeswoman Erica Clayton Wright said the senator “continues to do her due diligence on this issue” and that Ward wants to ensure that “Pennsylvanians not only have access to health care, but also ensure that employees of health care providers who treat patients to be positioned to provide the high quality health care they were trained to provide.”

Clayton Wright added that “Ward’s leadership position has no bearing on the trajectory of this legislation.”

With new leadership at the Nurse Practitioner Coalition, the Pennsylvania Medical Society and the Legislature, Amanda Laskoskie, president of the Nurse Practitioner Coalition, said advocates hope to meet soon “with all parties involved to help resolve of patient access in the health care crisis.”

But getting doctors on board will require more work. Sandel agreed that more individuals needed access to care, but didn’t think expanding the scope of practice of nurse practitioners would help.

She pointed to a national analysis by the American Medical Association that found nurse practitioners are as scarce as other providers in underserved areas such as rural counties.

“We’ve looked at other states where they allow independent practice for nurse practitioners, the issue of access to care has not gone away,” Sandel told Spotlight PA.

She suggested that Pennsylvania encourage doctors to settle in rural and other underserved areas through targeted medical school debt forgiveness programs.

“The hope is that if we’re able to help doctors with their loan repayments and they practice in these areas, they’ll create a relationship with that community,” Sandel said.

90.5 WESA partners with Spotlight PA, a reader-funded collaborative newsroom producing responsible journalism for all of Pennsylvania. More on spotlightpa.org.