Pennsylvania physician leaders stated their case for keeping the health care team together Oct. 22 at a hearing before the House Professional Licensure Committee.
A standing-room only crowd, including at least two dozen members of the Pennsylvania Medical Society (PAMED), heard arguments on both sides of House Bill 765, legislation that would allow certified registered nurse practitioners (CRNPs) to practice independently in Pennsylvania. PAMED opposes the legislation.
PAMED members who were part of the panel included Karen Rizzo, MD (PAMED President at the time of the hearing, now immediate past president); Susan Kressly MD, president of the Pennsylvania Chapter of the American Academy of Pediatrics; Nicole Davis, MD, president of the Pennsylvania Academy of Family Physicians; and Mary Brigandi, DO, Reading Family Medicine Osteopathic program director. Christopher Olsen, DO, past president of the Pennsylvania osteopathic Medical Association and Ann Peton, MPH, director of the National Center for the Analysis of Healthcare Data (NCAHD) also testified as part of the panel.
Their testimony focused on five key areas:
1.Medical Education and Training
Dr. Rizzo talked about the vast difference in direct patient-care — more than 16,000 hours of supervised, clinical training for physicians and, in stark contrast, only 500-720 hours for CRNPs.
In her testimony, Dr. Davis took the Committee on the lengthy and comprehensive journey of becoming a physician.
“If we total these standardized exams, the average individual will need to successfully complete 12 standardized examinations before being allowed to independently practice medicine, with no less than eleven years of training following high school,” said Dr. Davis in her official testimony. “Put simply, the average medical student in her or his clinical years can expect to take a national standardized subject exam every six to eight weeks.”
During her testimony, Dr. Kressly gave real-life examples of situations where CRNPs, working collaboratively as part of the health care team, came to her and asked her to look at patients they were seeing. In one case, though to many it may have seemed like a case of run-of-the-mill constipation, she caught a case of infant botulism, and, in another case, she was able to diagnose diabetes due to an acetone smell. Both of these situations could’ve turned into much bigger problems if un- or mis-diagnosed.
Dr. Brigandi shed light on this issue from a different perspective, as she was a CRNP prior to going to medical school. “My clinical training in graduate school consisted of a six month internship in an office practice with another nurse practitioner,” she said in her official testimony. “I certainly realized that it was not enough training for me to even consider practicing independently.”
She told the Committee that after graduate school, she began working as a CRNP, and during that time, took care of many challenging medical patients with the guidance of the internal medicine physicians who she worked with side-by-side. “I was so grateful to have them there to collaborate with on many difficult and challenging patients in the practice,” she said. “But, in my years there, I felt a gap in my knowledge, one that I knew could not be fulfilled unless I went to medical school. I really felt that I was not giving my patients the overall best care because I did not have enough education at the time to do so.”
Once in medical school, she said she became aware very quickly of the depth and breadth of knowledge needed to become a physician. “It was very clear to me from the beginning how much more I needed to learn,” she said.
2.Access to Care
Dr. Rizzo clarified for the Committee that nothing in Pennsylvania law requires that CRNPs practice in the same geographic location as their collaborating physicians. “In the event that a CRNP is having difficulty finding a collaborating physician within reasonable distance to provide support, assistance, and oversight, PAMED would be very much willing to assist them and facilitate such important work,” she said.
She said that in states where CRNPs have gained the authority to diagnose and treat patients independently, neither access to care nor cost savings have substantially increased. This point was supported by data presented by Ms. Peton, director of NCAHD, who joined the panel to provide fact-based, independent insight. Since its creation in 2007, NCAHD has been conducting research on national health care workforce trends. When analyzing the practice patterns of states’ primary care workforces from 2008 to 2014, NCAHD found that independent practice for nurse practitioners has not led to improved access to care in rural areas.
A statewide poll, conducted in mid-September commissioned by PAMED and conducted by Susquehanna Polling, also suggests Pennsylvania patients, in general, travel relatively short distances to obtain care from a primary care physician and are able to access such care when they want to access it.
3.Quality and Cost of Patient Care
Dr. Rizzo said that proponents of HB 765 also argue that this legislation will result in reduced health care costs, higher patient satisfaction, and the same, if not better, outcomes when compared to physicians.
She then cited an extensive review of published research that determined that, in looking at 4,133 relevant studies, only 26 met minimum criteria for methodological quality. Authors of the review also determined that while nurses made independent decisions to perform certain tasks, the majority still required support or contact with physicians, and concluded that current evidence assessing the substitution of physicians by nurses is “substantially limited by methodological deficiencies.” They recommended more methodologically rigorous research on health outcomes and costs before changes in the way primary health care is delivered are implemented.
She also said that a number of published peer-reviewed studies and reports have also directly contradicted claims of cost savings and superior quality of care provided by CRNPs. For example, nurse practitioners have been found to order more diagnostic imaging tests than physicians, make more unnecessary and poorer quality referrals of patients to specialists, and are more likely to prescribe drugs to patients. Two of the nation’s largest professional liability programs for nurse practitioners strongly recommend that they actively consult and collaborate with physicians to mitigate risk and enhance quality of care and patient safety.
Dr. Olsen told the Committee that this bill could put the health and safety of Pennsylvania patients at risk, pointing out that while the bill removes physician involvement from the equation of patient care, it does not include commensurate increases in the education and training requirements for CRNPs.
4.How Collaboration Improves Access to Care
Dr. Rizzo told the Committee that, contrary to claims that this is just a “turf battle” for physicians and physicians want to hold nurses back, physicians support CRNPs and other non-physician providers practicing to the full extent of their training. “The collaborative agreement, which serves as a patient safety net to catch those instances that go beyond a CRNP’s scope, enhances rather than impedes the ability of CRNPs to deliver quality patient care,” she said in her testimony. “With the complexity our health care system ever increasing, patients need both physicians and nurse practitioners coordinating care and sharing information for the benefit of the patient.” She said that eliminating collaborative agreements and granting CRNPs a newfound authority to practice independently would only further enable and encourage provider isolation.
5.Working Together Toward a Solution
Dr. Rizzo told Committee members that simply increasing the number of physicians or expanding the role of non-physician practitioners will not solve our access to care problems in rural and underserved communities. Rather, policies and programs which specifically target those areas and directly address the barriers to practicing there have the most potential for success. Increased opportunities for educational loan forgiveness in exchange for service, the creation of additional primary care residency slots, further utilization and integration of telemedicine, and expansion of team-based care are just a few of the effective strategies that can help us meet our growing health care needs, and PAMED supports all of these initiatives.
“We will only succeed through collaboration, not further fragmentation,” said Dr. Rizzo. “The Pennsylvania Medical Society supports a physician-led, team-based approach to patient care, which emphasizes increased collaboration and integration among health care providers, rather than provider autonomy. Eliminating the ties that currently exist between NPs and physicians is contrary to these proven concepts and would only serve to further fragment patient care by eliminating the health care team’s most highly-trained member – the physician.”