Ky. Voices: Improve access to health care, expand nurse practitioners' role

Give nurse practitioners expanded role

March 21, 2013 

  • About the authors: Julianne Z. Ewen of Lexington is an advanced practice registered nurse and Dr. Kylend Kiser is a family physician in Glasgow.

As health-care providers working in every corner of Kentucky, we see the patients behind the state's dire health statistics. Nationally, our state ranks among the very worst in cancer deaths, heart disease, strokes and high blood pressure. We also rank near the bottom — 36th — in the number of primary care physicians practicing in our state.

That's a bad combination, because good health is directly correlated to access to care.

And Kentucky indeed faces an acute primary care shortage. Right now, a nurse practitioner or nurse midwife is the only full-time primary care provider in many of the state's 87 medically underserved areas.

Clearly, we should be doing everything we can to expand and improve access to health care. Instead, a bureaucratic requirement is aggravating the shortage.

In order to write prescriptions for routine, non-narcotic medications for treating such health conditions as diabetes and high blood pressure, nurse practitioners must have a signed agreement with a physician. It's a piece of paper — signed just once — that sits in a file in a drawer and does nothing to enhance safety or quality. The agreement doesn't require the physician to see our patients, consult with us or be liable for patient care.

The problem? Without that signed piece of paper, we cannot prescribe the most basic medications, leaving patients without the care they need. Furthermore, the large fees charged by many physicians for these agreements, combined with the fear of the physician moving, retiring, dying or withdrawing the agreement, keeps many nurse practitioners and nurse midwives from establishing their own practices. And, as noted above, in some areas there simply are no physicians, period.

Senate Bill 51, legislation which would remove the requirement for the prescribing agreement for non-narcotic drugs, was filed by Sen. Paul Hornback on Jan. 11. It has never been given a hearing. The bill language has now been amended to Senate Bill 43 and could become law with a single vote taken by the full Senate.

We urge readers to ask their senator to call SB 43 for a vote. It will remove this paperwork requirement and improve Kentuckians' access to needed health care.

In a state plagued with poor health and meager resources, it makes no sense to maintain this bureaucratic requirement. When even urban dwellers sometimes have to wait weeks to get a medical appointment, let alone residents in rural areas, this obstacle to care is simply not justifiable.

Consider the facts:

• Nurse practitioners and nurse midwives have an unblemished, 17-year track record of appropriate prescribing in Kentucky.

• NPs have never been required to work under a physician's supervision in Kentucky. The same is true in 21 other states and the District of Columbia.

• Seventeen states and D.C. allow full prescribing authority for non-scheduled medications — in other words, they do not require a signed agreement with a physician. That is also true for nurse practitioners working in the military.

• The care NPs provide is patient-centered — listening, educating and focusing on prevention — leading to very high patient satisfaction and outcomes equivalent to that of physicians. Studies spanning nearly 50 years have consistently shown that the quality of care provided by nurse practitioners is equal to that of primary care physicians.

• Nurse practitioners are filling the care gap. In the last two years, Kentucky has seen a 25 percent increase in the number of nurse practitioners, while the number of new primary care physicians is declining. More to the point, more than two-thirds of NPs are both trained in and actively practice in primary care — versus just 8 percent of medical-school seniors who entered family medicine in 2011, according to the Association of American Medical Colleges.

• According to the National Center for Rural Health Works, one primary care clinic in a rural community generates $1 million in wages and creates 23 jobs annually, an economic impact not to be ignored.

The Federal Trade Commission, the National Governors Association, the Institute of Medicine, The Kaiser Foundation, the AARP, the American College of Surgeons and many Kentucky physicians believe that modernizing the practice laws for nurse practitioners — including eliminating the prescribing agreement requirement — will improve access to primary care services, lower costs and increase consumer options.

This is not about doctors. This is not about nurse practitioners. This is about meeting the needs of patients everywhere in Kentucky.


Julianne Z. Ewen of Lexington is an advanced practice registered nurse and Dr. Kylend Kiser is a family physician in Glasgow.

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