Hot debate in NC health care on freeing advanced practice nurses from doctors’ supervision

The legislative committee considering Medicaid expansion and access to health care in North Carolina took up the contentious issue of allowing nurses with advanced degrees diagnose illnesses and prescribe medicine without doctor supervision.

In a sometimes testy debate that lasted for more than three hours, doctors, nurses, and legislators went back and forth, referencing studies that appeared to draw conflicting conclusions whether advanced practice registered nurses who can work without doctors checking patient charts add more medical professionals to rural areas and whether their work leads to lower health care costs.

The freedom from supervision is something advanced practice nurses – which include nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists – have wanted for years.

A clear majority of the state’s 120 House members and half of the state’s 50 senators appear to want it, too. The SAVE Act, which would give APRNs the authority to practice that they’ve been seeking, has widespread, bipartisan support in both chambers. Both Rep. Carla Cunningham, a Charlotte Democrat, and Sen. Ralph Hise, a Republican representing six mountain counties, both argued vigorously for letting the nurse practitioners work without doctors’ supervision.

Doctors don’t want it.

Two doctors told the committee Tuesday that patients are safer when doctors, who spend years studying and training, are supervising nurses’ work.

Rep. Kristin Baker, a Cabarrus Republican and a psychiatrist, came to the meeting ready to challenge studies that showed benefits of giving nurses greater freedom to practice.

Groups as diverse as the John Locke Foundation and AARP back giving nurses practice authority.

“We have a regulatory reform issue that limits access to critical services and raises costs,” said the Locke Foundation’s Jordan Roberts.

Bills like the SAVE Act “are about access to care, patient choice and making the most of our scarce healthcare resources, “said Winifred V. Quinn of the AARP Public Policy Institute.  “They are not about a turf war between nurses and physicians. They are about patients and families.”

North Carolina is one of 10 states that requires nurse practitioners to have supervision agreements with doctors, according to the American Association of Nurse Practitioners. North Carolina is one of three states requiring supervision of certified midwives, according to the American College of Nurse Midwives.

Vincent Guilamo-Ramos, dean and vice chancellor for nursing affairs at the Duke University School of Nursing, said supervision of nurse practitioners in North Carolina often means doctors coming in to periodically review patient records. The doctor and nurse don’t have to work at the same place, he said.

In sorting conflicting information, he urged legislators look at overall trends in research, the strength of the research, and whether it is objective and independent.

“When you do that you see that the care outcomes are comparable and that it actually does save costs,” he said of giving nurses authority to practice without supervision agreements.

“The U.S. has the most expensive health-care delivery system in the world of any developed country and the worst outcomes in terms of mortality and morbidity,” Guilamo-Ramos said. “We need to move to something different that will ensure health equity and will improve outcomes.”