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Doctors, nurses battle over roles in health care

Ohio becomes a focal point in a national debate.

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By Laura A. Bischoff, Staff Writers Updated 11:35 PM Saturday, March 6, 2010

SPRINGFIELD — Candy Rinehart schedules a patient at her practice every 20 minutes, seeing people from age 4 to 93 for everything from sinus infections and abdominal pain to diabetes.

Rinehart was a pioneer of sorts in Ohio when she opened her growing practice in 2004, and it’s still a rarity in the region. That’s because Rinehart is a certified family nurse practitioner, not a doctor.

Nurse-led practices are expected to become more common amid an aging population and a shortage of primary-care physicians. Patients nationwide already rely on advanced practice nurses (APNs) for 25 percent of primary care, according to Lori Herf, lobbyist for the Ohio Association of Advanced Practice Nurses.

But that shift has set off a sometimes testy debate between doctors and nurses over the limits on care that APNs like Rinehart can provide. Nurses frame the issue in terms of providing better access to primary care for patients, while doctors cite concerns about patient safety.

Intensifying the debate in recent months are two Ohio bills — one that would expand APNs’ ability to prescribe certain medications, and another that would create pilot programs to test a kind of family medicine that incentivizes preventive health care.

“The more nurse-led practices we have, the more we’ll be able to set it as a standard,” Rinehart said. “If it’s become a turf war, it’s not from the nurse practitioners’ aspect. We have to put out front what we’re capable of doing.”

Physicians go through four years of medical school followed by a residency that lasts three to six years, more extensive training than that required of nurses, said Tim Maglione, senior director for government relations at the Ohio State Medical Association.

In contrast, recognition as an APN in Ohio requires a registered nurse to hold a master’s degree in nursing and pass a national certification exam in their specialty area.

“To us, it’s about defining and distinguishing the professions,” Maglione said.

Defensive medicine?

As a certified nurse practitioner who owns and runs her own family practice in Springfield, Rinehart is required by law to have a collaborative contract with a physician.

Rinehart said she typically consults with Dr. Ashfaq Ahmed, a Springfield internist, once or perhaps twice a week, on average.

Rinehart said the arrangement has worked out well in Springfield. But she said she sometimes encounters difficulty when calling out of town to make referrals.

Across the nation, the American Medical Association has been lobbying state legislatures to block any bills that would expand the scope of practice for APNs.

“This is a big deal. It almost wouldn’t matter what the issue is right now — they’re going to fight it. It’s part of their national platform now,” Herf said.

Maglione said doctor groups are constantly fighting to keep a bright line between what physicians and others are trained to do.

“People like to say this is just a turf war between the doctors and nurses, or between the doctors and optometrists, or between the doctors and name-the-allied-professions. To us, it’s not. It’s about safety,” Maglione said.

Last year, the AMA tracked more than 300 bills in state legislatures that considered expanding practice scopes for nurses and other allied professionals.

“I suspect they (APNs) view those fights as steps toward independent practice authority,” said Ann Spicer, executive vice president of the Ohio Academy of Family Physicians.

In Ohio, the two sides have recently battled over two bills now pending in the Statehouse that would give more authority to APNs.

House Bill 198 until recently had been caught in a months-long crossfire between doctors and nurses over whether APNs should have the right to head up “patient-centered medical homes.” The health care model emphasizes preventive medicine in part by basing payments to doctors not just on fees for service when someone’s sick, but for how well they manage a patient’s chronic conditions and overall health.

The House of Representatives passed the bill on Wednesday.

Meanwhile, House Bill 206, which has yet to get a floor vote, would let some APNs prescribe some controlled substances in certain settings.

Ohio’s roughly 8,000 APNs, who typically specialize in areas such as obstetrics or anesthesiology, have the authority to write prescriptions and treat patients, but must collaborate with a licensed physician.

Shortages loom large in debate

Patients nationwide rely on APNs for 25 percent of the primary care service and for 600 million primary care visits each year, according to Herf. While there are serious doctor and nurse shortages, APNs are entering health care careers at nine times the rate of physicians, Herf said.

Ohio faces shortages in both nurses and family care physicians. According to a report by the Ohio Nurses Association, the state could be short 31,977 nurses by 2020 as more retire than can be replaced. The U.S. Department of Labor ranks nursing as the top growth occupation through 2012.

On top of that, the American Academy of Family Physicians estimates only 35 percent of physicians go into primary care while the rest opt for more lucrative specialty areas. Nationwide, 139,531 family physicians will be needed by 2020, it projects.

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House Bill 198

What it would do: Create pilot projects for a concept called patient-centered medical homes, a kind of family medicine that incentivizes preventive health care

What’s at issue: Advanced practice nurses wanted a definition of patient-centered medical homes in the bill that clearly stated that advanced practice nurses may lead PCMHs, setting off a fight with physician groups. The definition has been dropped from the current legislation.

Status: Passed unanimously by the House of Representatives on Wednesday, March 3. Now in Senate for further consideration.

House Bill 206

What it would do: Allow advance practice nurses to prescribe schedule II controlled substances if certain conditions are met, such as training and certification. It would prohibit them from writing these scripts in convenience care clinics.

What’s at issue: Advanced practice nurses already may prescribe schedule II controlled substances but only if a doctor writes the first prescription, the patient is terminally ill and only a 24-hour supply is written. Ohio APNs want more flexibility, as is allowed in 33 other states. Doctors want to limit the prescribing authority for schedule II drugs to only certain settings such as hospitals and nursing homes.

Status: Awaiting a House floor vote.

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