Higher mid-levels

Amid doctor shortage, state considers expanding nurse practitioners’ scope

Nurse Practitioner Surani Hayre-Kwan, left, and nurse practitioner student Kristina Crichton during an office visit with patient John Donaldson, a Guerneville resident who relies on Hayre-Kwan as his primary care physician.

Nurse Practitioner Surani Hayre-Kwan, left, and nurse practitioner student Kristina Crichton during an office visit with patient John Donaldson, a Guerneville resident who relies on Hayre-Kwan as his primary care physician.

Photo by Anne Wernikoff for CalMatters

About the article:
This is an abridged version of a story produced by Cal Matters, an independent public journalism venture covering California state politics and government.

Nurse practitioner Surani Hayre-Kwan sees longtime patients and first-timers. She manages chronic illnesses, diagnoses kids with colds and refers people to specialists.

She goes it alone or works with another nurse practitioner at the Russian River Health Clinic in Sonoma County. Sometimes a supervising physician is on-site, but often is a telephone call away.

“We don’t have enough physicians working in community clinics,” said Hayre-Kwan, who is also a nurse administrator for Sutter Health. “If there were no nurse practitioners, the clinic would have to close for the day because no one would be there to deliver care.”

As California experiences a growing shortage of primary care physicians, the Legislature is considering what backers believe could be a partial solution: allowing nurse practitioners who get additional training and certification to work independently. With that additional authority, these mid-level providers could treat patients without a “practice agreement” from a supervising physician outlining what they can do. It also would allow some nurse practitioners to open their own clinics without a doctor overseeing them.

If it does so, California would join 22 other states and the Veterans Administration. Researchers for the Bay Area Council Economic Institute have found it also would save the state millions of dollars a year.

But California’s powerful doctors’ lobby has fought the idea since it was first proposed five years ago—saying that expanding the role of nurse practitioners would dilute the quality of medical care patients receive, and create a two-tiered system of treatment.

In a letter to the Legislature, the California Medical Association raised concerns about the type of training and assessment required to determine independence. And the association points out that the bill does not require or ensure that nurse practitioners will set up or work in underserved or rural areas.

Instead, the organization, made up of physician members, said it supports continued efforts to graduate more physicians and give them incentives to treat patients in underserved areas.

By 2030, California is projected to be short some 8,000 primary care clinicians, including doctors, nurse practitioners and physician assistants, according to a report from the Future Health Workforce Commission and another from Health Force Center at UC San Francisco.

Californians are concerned. More than a third believe there are not enough primary care providers and specialists in their communities, according to a poll released Feb. 13 by the California Health Care Foundation. More than 80 percent of residents polled want the governor and Legislature to make alleviating the shortage of doctors, nurses and other health care providers a priority.

The state Assembly recently passed Assembly Bill 890, which would free many nurse practitioners from needing to operate under a supervising physician’s agreement. It also creates a path for nurse practitioners who want to work independently by opening their own practice. The bill, carried by Santa Rosa Democratic Assemblyman Jim Wood, is under consideration in the Senate.

A nurse practitioner is someone who has completed a master’s degree or a doctorate in nursing practice, as well as additional training. The majority work in primary care: According to the American Association of Nurse Practitioners, 75 percent do so.

Already at clinics in low-income neighborhoods or in rural areas, nurse practitioners often hold office hours on their own or have an arrangement with a supervising physician to be available by phone. In larger organizations, patients can choose to book with them directly and may get a quicker appointment than if they choose to wait for a physician.

If the bill becomes law, experts say it could help ease the shortage by allowing nurse practitioners to work in rural or inner-city areas and could attract out-of-state nurse practitioners who want to practice more freely.

Physicians are unconvinced. California Medical Association lobbyist Megan Allred told legislators at a hearing last year that the bill would impact safety and called for modifications to “ensure lay individuals are not interfering with the practice of medicine.”

Physicians note that nurse practitioners have not undergone the same intense, years-long training that doctors go through. Physicians for Patient Protection argues that the bill would put patient safety at risk because nurse practitioners complete only a sliver of the hours of clinical training, especially via online programs, compared to the medical school and residency requirements of physicians.

The American Academy of Emergency Medicine, another opponent of the full independence of nurse practitioners, also argues that their training is not equivalent to doctors.

“NPs cost less than physicians,” writes academy president David Farcy in a letter to members. “Hospitals and urgent care centers that are focused on profits are looking for cost-cutting options. Independent practice for NPs certainly fits that requirement.”

Wood stressed that his bill requires additional education and certification before nurse practitioners can assume more treatment authority, and even more training for those who want to set up their own clinic.

“There’s a lot of guardrails here,” Wood said. “This isn’t just every nurse practitioner who has ever graduated is going to be able to come in and do this.”

When states grant nurse practitioners “full scope” authority, they allow them to evaluate patients independently, order diagnostic tests, manage treatments and prescribe medication.

Patrick Kallerman, research director for the Bay Area Council Economic Institute, estimates that California would replicate the experience of other states in which expanding the authority of nurse practitioners has increased patient access and lowered costs, saving California about $400 million a year.

“In no way are we saying that nurse practitioners should replace doctors,” Kallerman said. “What we are saying is that we have this workforce of highly trained, highly qualified individuals and we should let them practice to the full extent of their training.”