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Missouri Legislature refuses to loosen reins on nurse practitioners

This article first appeared in the St. Louis Beacon, May 11, 2012 - When a tornado wiped out part of Joplin a year ago this month, an appeal went out immediately to medical workers to help the survivors. But many nurse practitioners couldn't respond because Missouri law forbids them from providing medical services beyond a 30-to-50 mile radius of their collaborating physician.

The Missouri Nurses Association used that example as one of many to try to make a case for state lawmakers to enact HB1371, introduced by Rep. Ray Weter, R-Nixa, and co-sponsored by Rep. Jeanne Kirkton, D-Webster Groves. The bill would have eased many rules involving collaborative practice arrangements between doctors and NPs.

"It's unfortunate that this legislation didn't go anywhere," says Jill Kliethermes, chief executive officer of the Missouri Nurses Association. She notes that the issue goes far beyond NPs serving during catastrophes like the one in Joplin.

"It's a matter of giving people access to routine medical care," she says. "There are plenty of patients in rural Missouri needing that access, but don't have it because no doctors are available and nurse practitioners are not allowed to step in to fill the gap. Restrictions in Missouri continue to prevent them from practicing to the fullest extent of their education and competency."

In addition, she thinks it's a bad idea to require NPs in Missouri to, in effect, prove themselves again if the collaborating doctor dies or moves away suddenly.

Once finding another collaborating physician, the NP must practice with that doctor for 30 days. "This means you could be a nurse practitioner with 20 years of experience, but you'd have to leave your clinic and work with that doctor before you can go back to work at your own clinic and do what you've been doing for two decades."

Missouri has more than 6,000 advanced practice nurses, about 3,500 of them being NPs. While Missouri rules require a doctor to review the work of NPs, there is a nationwide movement to broaden the scope of practice of NPs to include diagnosing illnesses and initiating therapy without a physician's involvement.

Rep. Kirkton says many physicians object to this movement. She says the issue boils down to a "battle over control, scope of practice, perceived competition and money. Opponents argue that nurses are practicing medicine, and if they wanted to be doctors, they should go to medical school. "

But Kirkton argues that the issue is less about nurses wanting to be physicians than about allowing these specialized nurses to perform work in keeping with their qualifications and training. That could be a plus in underserved areas and during emergencies, she said. "The tornado in Joplin is a good example of why the 50-mile geographical radius limitation on nurses in collaborative practice doesn’t make sense. The arguments frequently veer away from the logic to the emotional."

Loretta Colvin is an NP who grew up in Columbia and returned here from Maryland to be closer to her parents and other family members. She works at the Clayton Sleep Institute after doing similar work in Maryland. Because she is not in private practice, some of the rules governing NPs don't affect her. Yet she is surprised by the differences between NP laws in Missouri and Maryland.

She points to the Bootheel as an example of where the NP rules work against the delivery of health care. Because doctors are in short supply in the Bootheel, she says it might be more difficult for some NPs to set up clinics and find physician collaborators. She says that Maryland has done away with such collaborative practice agreements, and that NPs in Missouri are urging state lawmakers to do the same.

She noted the differences in prescribing limitations on Missouri NPs. "In Maryland, I was able to prescribe medications (for controlled substances). When I moved here, I had the same degrees, the same background but that authority was taken away from me. I could not prescribe medicine (controlled substances) to help a person sleep."

Another Missouri rule that Colvin says is outdated is the one requiring that a doctor not be allowed to collaborate with more than three full-time NPs at once. She says that can be a problem for a physician who might want to employ more than three NPs in a rural clinic where there are no other doctors.

Update: But the Missouri State Medical Association strongly opposes expanding the independent authority of advanced practice registered nurses. In a statement, it says the rural-practice issue is irrelevant because NPs are choosing urban practices over rural ones. It adds that APRNs have as few as 500 and up to 1,500 hours of clinical training. In contrast, it says, primary care physicians have more than 15,000 hours of clinical training.

"APRNs are not prepared for the responsibilities of practicing as an independent, primary care practitioner," the association says. "MSMA believes patient care is best managed by a physician led, team approach. Granting APRNs independent practice and prescribing does nothing to improve the quality, quantity, distribution or efficiency of care for Missouri residents. MSMA and other physician groups speak in opposition to independent practice of APRNs and in support of collaborative practice and narcotic prescribing."end update

The association's view is in sharp contrast to ongoing efforts by the Institute of Medicine and others to expand the scope of practice so that advanced practice registered nurses, such as NPs, take on more of the primary care responsibility, particularly in underserved areas.

In addition, a recent study commissioned by the Missouri Foundation for Health, points to significant health care savings and practical reasons for turning to both NPs and physician assistants to handle more health care in the state.

Titled Bending the Health Care Cost Curve in Missouri, the study notes that one in five people already lacks access to primary health care and that the demand for care will increase if the Supreme Court upholds that Affordable Care Act.

"With fewer medical students electing to enter primary care, the future suggests there may be even fewer primary care physicians available," the study says. It says that expanding the number of PAs and NPs is one strategy for addressing the unmet need for primary care.

It notes that PAs and NPs are often unable to provide some services when not under the direct supervision of a physician. Expanding the scope of practice for these health workers would "improve access to primary care and reduce the overall costs while continuing to provide high quality care."

The study estimated that this change would reduce health care costs in Missouri by $1.6 billion in 10 years.

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.