Bill pushes nurse practitioners as solution to primary care shortage

(The Sentinel) Lorraine Bock was a nurse practitioner for 20 years, the bulk of which she served as the head of Bock Family Healthcare off West Trindle Road in Middlesex Township.

Last Thursday, however, Bock closed her family practice because of the costs and requirements associated with being a nurse practitioner in the family care field.

“It’s truly an economic issue,” said Bock, who is president of the Pennsylvania Coalition of Nurse Practitioners and now works in the state’s Legislative Health Services. “But it’s not just a Lorraine Bock issue. No single (nurse practitioner) provider can survive in the environment that exists now.”

A new state Senate bill introduced by Sen. Pat Vance, R-31, aims to change the mandates that limit what nurse practitioners can do in Pennsylvania. The bill’s purpose evolved from the need for more primary care providers , especially as the Affordable Care Act sets up more people being insured but fewer places for them to go for preventative medical attention.

“The key point is that we are facing a shortage of primary care providers, (a large group of which) who are going to retire in the next couple of years,” Vance said.

John Denny of consulting firm Denny Civic Solutions is working with the coalition to get word out about the campaign for the state legislation. He said nurse practitioners are, so far in the state, an untapped solution to the problem.

“The nurse practitioner sector is 8,500 strong,” Denny said. “There are about 5,000 primary care physicians practicing in Pennsylvania. About a quarter to a third of them are leaving practices in two short years.”

Denny said nurse practitioners are one of the fastest growing segments in the health care sector, where fewer physicians graduate in the family care field — more are opting to go into specialized fields that pay more.

Vance said when legislation passed in Massachusetts that is similar to the Affordable Care Act, the biggest problem the state faced was a shortage of primary care providers to take on the increase of residents who had insurance cards. She said if nurse practitioners are added to the mix, the state and the country can do more to handle preventative health.

“I believe preventative care is not something we do enough of,” Vance said.

Vance said she isn’t sure when the bill would move forward in the Senate, though it already has 18 bipartisan co-sponsors.

Similar “full practice authority” legislation has already been passed in 18 other states.

Health care field

The vote can’t come soon enough for area nurse practitioners.

Though Bock is leaving the profession, she was the preceptor, or clinical mentor, for Donna Bertone, who worked in Bock’s practice after graduating in May. Her work at the practice will allow her to apply for certification.

Bertone said she has already encountered many challenges to simply find work. Bertone lives in Sunbury in Northumberland County and notes Carlisle was one of the closest places she could find.

“That’s how hard it is to find a preceptor,” Bertone said.

Bertone isn’t the only one. Bock has been the preceptor for other studying nurse practitioners from as far away as Cincinnati.

Bock explained physician laws require a physician to only collaborate with four nurse practitioners at a time, and a nurse practitioner is required to collaborate with two physicians — a main physician designated to keep an eye on the nurse practitioner and a secondary back-up.

Because both physicians are limited to how many collaborative agreements they can have — and because many physicians are now under contract with major health systems that have additional limitations on with whom they can have an agreement — Bock said finding one that has an opening is difficult.

There is also the matter of paying those physicians. Bock said in her personal experience at her practice, the secondary physician did not ask for payment, but there are common cases where both physicians require payment to be part of a collaborative agreement with a nurse practitioner. That’s an additional hardship for nurse practitioners, who by law, get only 85 percent reimbursement compared to physicians’ complete reimbursement from insurance, Bock said.

“I might need to talk to him only two or three times a year, and I don’t refer patients to the physician — I’ll send them directly to a specialist,” Bock said, explaining why the payment directive is mostly unnecessary.

The full practice authority legislation would also affect two other current challenges nurse practitioners face. The legislation also takes aim at insurance companies, many of which do not recognize nurse practitioners as legitimate medical professionals in certain fields. Nurse practitioners have already gained ground in the field of primary care but not in other fields, such as cardiology.

Nurse practitioners, currently, are also not allowed to have medical or staff privileges at hospitals. This can be difficult especially if a nurse practitioner is the primary care provider for a patient who goes to the hospital. Bock said without the privilege, the nurse practitioner could not check on the patient or exchange notes without hospital approval.

Quality of care

Though Vance, a former nurse, and area nurse practitioner advocates are pushing for the legislation, there are other groups — especially physician groups — who are against the move. Those groups cite quality of care as a foremost reason, which was the main factor used when initially drawing up the restrictions and limitations on nurse practitioners in the state.

However, that has never been an issue for Crystal Smiley of Carlisle.

Bock was Smiley’s primary care provider for about 20 years, when Bock owned her own family practice and when she was in a physician’s practice. For Smiley, who has had both physicians and a nurse practitioner as her primary care provider, the choice is simple for her.

“She knows who I am without looking at my sheet, and she treats my family,” Smiley said. “I can also get in to see her within 24 hours.”

Bertone has worked under both nurse practitioners and physicians, and though she’s studying to be the former, she said she can tell the difference in the medical approach of both.

“(Nurse practitioners) want a holistic experience,” Bertone said. “I’ve seen physicians spend about 15 minutes with a patient, but the nurse practitioner will spend a half hour or more.”

Bertone explained nurse practitioners can go more in depth with help. Instead of simply telling someone to lose weight, a nurse practitioner will provide specific details and options instead of just sending them to a nutritionist or specialist.

Bock said that in terms of education, nurse practitioners do not spend as much time as physicians getting their degrees, but nurse practitioners are required to graduate with a master’s degree or doctorate in order to practice. In addition, nurses, upon graduating the nursing school programs, must have at least two years of experience in the field before studying to become a nurse practitioner.

That is something Bertone thinks is enough, especially as places like her hometown face economic challenges that make receiving affordable and preventative health care difficult. Sunbury, like Perry County, is one of the places labeled by the state as only having about one physician per 2,500 residents.

“There are no (family) doctors for miles,” Bertone said. “So many people have lost their jobs up there. We have a high unemployment rate, and we have people with a high school and maybe associate’s degree if they’re lucky. Most just have part-time jobs … and sometimes two. What we do have up there is clinics … and they don’t pay much.”