Health Forward Foundation

Advanced Practice Registered Nurses Fight for Legislation to Improve Access to Care in Underserved Areas of Missouri

Nurses are vowing to continue next year with a political fight in Jefferson City over legislation that they and their allies say would increase access to medical care, particularly in underserved rural and inner-city areas of Missouri.

Two bills were proposed during this year’s session of the Missouri General Assembly that would have given nurses with advanced training greater authority to perform a variety of tasks, including prescribing medications, that currently can only be done by doctors or by the nurses under relatively close supervision of a doctor.

The identical measures, Senate Bill 679 and House Bill 1371, would have eased the supervisory restrictions and had support from various groups, including AARP. But the bills failed to advance after meeting stiff opposition from doctor groups.

“Their voices were just louder than ours this session, but we are gearing up for election season and we will be back next year,” said Jill Kliethermes, chief executive officer of the Missouri Nurses Association, describing the success of doctors in blocking the legislation.

Physicians, including state Sen. Rob Schaaf, a St. Joseph Republican, argued that nurses essentially were trying to become doctors without going to medical school and that their real motivation was to cherry pick business in metropolitan areas.

House and Senate sponsors could not move the legislation beyond committee hearings before the General Assembly adjourned in May. The bills would have rewritten portions of state law that deal with so-called “collaborative practice arrangements” between physicians and registered nurses.

Currently, a physician may give some prescription-writing authority to an “advance practice registered nurse,” or APRN working under their supervision. The new changes proposed by the nurses essentially would have freed them to write prescriptions or administer some anesthetics under “standing orders” from a doctor, which means they could perform the tasks on their own with certain protocols in place.

With the exception of a few who were certified before regulations were changed, advance practice nurses must have at least a master’s degree. According to the Missouri State Board of Nursing, there are about 89,000 registered nurses statewide and about 6,000 of them are certified for advanced practice.

Current law requires physicians to maintain oversight of advanced nurses practicing through “collaborative practice arrangements,” which must not exceed the nurse’s “scope of practice” and be consistent with the nurse’s “skill, training and competence.” Advanced nurses authorized to provide initial treatment for acute illness or injury must be within 30 miles of a supervising doctor or 50 miles if they are working in an area designated by the federal Health Resources and Services Administration to have shortages in primary care, dental services or mental health providers.

Physicians may not enter into collaborative practice arrangements with more than three advance practice nurses at any one time, and they must review at least 10 percent of the nurses’ charts every two weeks and at least 20 percent of the charts where nurses have prescribed medications.

The proposed legislations would have removed the entire section of the law that sets out the various “must-have” provisions in agreements between physicians and advance practice nurses.

The current regulations inhibit care in shortage areas, said Michael Johnston, an advanced practice nurse with a primary care clinic in Lexington.

For example, he said a mental health nurse practitioner he knows was having trouble setting up shop in Lafayette County because she couldn’t find a physician that was not already collaborating with the full complement of advance practice nurses.

Johnston said the 50-mile rule also had hampered his effectiveness when he works in an orthopedic clinic, since his collaborating physician lives outside that range. In today’s world of videoconferencing and telemedicine, he said, that requirement was outdated.

And he said physicians were too busy to thoroughly review charts as required by current law.

He said the collaborations advanced nurses have with doctors boiled down to the level of trust between physician and nurse.

“We know what we know,” Johnston said, “and we know what we don’t know, and we know when to ask for help.”

A county-by-county map included in the nursing board’s 2011 annual report showed clusters of advance practice nurses around Kansas City, St. Louis and other metropolitan areas.

Schaaf said the map showed that nurses were more interested in expanding their practices in lucrative urban markets more than expanding care in underserved rural areas.

“Follow the money,” he said. “It is just bogus that they make this rural argument.”

Dr. John Hagan, a Kansas City ophthalmologist and former president of the Metropolitan Medical Society of Greater Kansas City, agreed with that assessment.

If nurses want to fill a need in rural areas, he said, they should go to medical school.

It’s no different than aviation, he said. “If there is a shortage of commercial pilots, the answer is not to train stewardesses to fly the airplane. No one wants that.”

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