By Jim McLean – KHI News Service
The ways of the Kansas Legislature are a frustrating mystery to Merilyn Douglas.
The advanced practice registered nurse from Garden City is part of a group that is pushing for passage of a bill that would allow APRNs to practice independently from physicians. But that push has stalled.
The bill hasn’t received a hearing in either the House or Senate and it’s too late in the legislative session for any discussion to begin.
“This has happened to us three years in a row,” Douglas said. “It is frustrating. It challenges your faith in the legislative process.”
Current law requires that APRNs work under a so-called “collaborative practice agreement” with a supervising doctor. Douglas and other advanced practice nurses say those agreements needlessly restrict their ability to establish their own practices and provide primary care in underserved parts of the state.
“We’re a group of caring professionals who really believe that passing this bill would increase the number of health care providers for Kansans,” she said. “And it’s frustrating to work so hard and then to have one person – the chairperson of a committee – say ‘Well, I’m not ready to hear that bill yet.’”
Legislative leaders aren’t ready to consider the bill largely because Kansas doctors and their veteran lobbyist, Jerry Slaughter, don’t want them to. Slaughter said lawmakers don’t like refereeing scope-of-practice disputes. So, he suggested that they wait until doctors and nurses have first tried to negotiate a compromise.
“We approach every scope-of-practice issue that way,” said Slaughter, the executive director of the Kansas Medical Society. “We’re not singling nurses out for a different approach.”
Sen. Mary Pilcher-Cook, the chair of the Senate Public Health and Welfare Committee, and Rep. Dave Crum, the chair of the House Health and Human Services Committee, took Slaughter up on his suggestion.
“We’ve encouraged the two parties to get together and try to work out some language that they can agree to,” said Crum, an Augusta Republican. “Until that happens, I don’t think there’s going to be too much movement.”
The nurses say there’s nothing radical about what they’re proposing. Eighteen states and the District of Columbia allow APRNs to treat patients without having collaborative or supervisory agreements with doctors.
“There are multiple studies that have shown that nurse practitioners provide safe care,” said Mary Ellen Conlee, a lobbyist for the nurses.
One of the latest reports came from the Federal Trade Commission, which is attempting to increase competition in the health care marketplace. After considering the research on patient safety, the FTC is urging state policymakers to lift anti-competitive restrictions on APRNs. Practice restrictions not necessary to address “well-founded” health and safety concerns “can deny health care consumers the benefits of competition, without providing significant countervailing benefits,” the commission said.
Slaughter said though the medical society is willing to consider changes, the current law comes close to striking the right balance. It does not require that doctors supervise APRNs, only that they explicitly agree to collaborate when necessary.
“Our statutes are structured to protect patients,” he said. “They build in some safeguards so that the folks with the greatest training in terms of depth and breadth – that’s the physician community – are involved in patient care across the spectrum.”
That may be the intent of the collaboration requirement, but that’s often not reality, Conlee said. Some doctors charge fees for signing collaborative agreements and then have little or no interaction with the nurse over the course of the year, she said.
“They seem to be business agreements,” she said. “There is no supervision required in the agreement.”
Slaughter said the fact that some doctors aren’t abiding by the spirit of the law doesn’t mean that it should be scrapped.
“We don’t condone those sorts of arrangements that are just on paper only and don’t have meaningful collaboration,” he said. “That is contrary to the law.”
Ninety of Kansas’ 105 counties have been designed as federal health professions shortage areas.
Supporters of the expanded-practice bill, citing the FTC report, say that giving APRNs the freedom to establish their own practices would help alleviate the shortage of primary care providers in rural and underserved areas of the state.
But others said they see little evidence to support that claim.
“The idea that this will all of a sudden create a huge increase in the number of rural practitioners is incorrect,” said Dr. Josh Freeman, chair of the Department of Family Medicine at the University of Kansas Medical Center and an expert on rural health care.
“They’re going to be like doctors,” he predicted. “If they’re from Wichita or Kansas City and they live in the suburbs, they’re not all of a sudden going to pick up and move to Colby or to even smaller towns in Kansas.”
Selling the nurse practitioner legislation as a partial solution to the state’s rural health issues “is the wrong argument,” Freeman said.
“The right argument,” he said, is that they have the skills to practice independently and that allowing them to do so would generally increase the number of providers both in primary care and some specialty areas, including psychiatry.
Douglas said her story and those of other nurses she knows is evidence to the contrary. She obtained her advanced practice training in 1997 by taking classes offered by KU in Garden City.
“I was able to get my master’s degree and set up my practice in my home community where I wanted to be,” Douglas said. “I have since then facilitated several other nurse practitioners through the same program out here in southwest Kansas. Those students of mine now have practices in Liberal, Scott City, Protection and Haviland. Those are as rural as you can get.”
Slaughter said groups representing doctors and nurses will likely meet first in April to start negotiating a possible compromise bill that both sides could support in the 2015 legislative session.
“This is going to take several meetings,” he said. “It just takes that much time to understand these issues.”
Conlee said she’s had “some good discussions” with Slaughter and is guardedly optimistic that the talks can produce an agreement that would “allow the nurses to practice to their training.”