New Jersey’s advanced practice nurses would be able to prescribe medication on their own, without needing a formal agreement -- or joint protocol -- with a consulting physician, under a bill that's being introduced into the Legislature.
The measure (S-2354) would make it easier for advanced practice nurses, or APNs, to establish their own practices. It also would eliminate the difficulty of finding a doctor who's willing to sign a joint protocol.
Advanced practice nurses have taken an increasingly large role as primary care providers, one that is expected to grow as a result of the federal Affordable Care Act.
ACA will extend health insurance to a number of currently uninsured New Jerseyans and expand the Medicaid rolls. The first is likely to exacerbate the state's worrisome shortage of family care physicians. The second is likely to be even more problematic: Many doctors do not accept Medicaid recipients as patients.
Advanced practice nurses hold graduate degrees and are trained to diagnose and treat acute and chronic illnesses; take health histories; order and interpret lab tests and x-rays; and provide physical examinations, immunizations, and supportive counseling. They must pass an exam to receive state certification.
Regardless of those qualifications, however, many primary care physicians say they are concerned that enabling APNs to establish independent practices without collaborating doctors will affect the quality of patient care.
The Senate version of the bill was introduced by Sen. Joseph Vitale (D-Middlesex) on November 21. Assemblywoman Nancy F. Munoz (R-Morris, Somerset and Union) plans to introduce an Assembly version on December 3, according to Elizabeth Cairney, her chief of staff.
Advanced practice nurse Melissa Rubin said joint protocols with collaborating physicians are not needed.
“The problem is they never see your patients, they never see what’s going on with your patients,” Rubin said. She added that she has seen roughly 60 patients per week in two and a half years as an APN, but hasn’t had a situation where consulting with a doctor about medication was necessary.
Rubin works as an APN on a per-diem basis at Robert Wood Johnson University Hospital in New Brunswick and for other providers. She said encouraging more APNs to set up independent practices is crucial for the state.
“You’re allowing more patients to have access to care, not only access to care, you’re removing the barriers that clinicians like myself face when we treat the general public,” Rubin said.
The bill received a negative reception from officials with the New Jersey Academy of Family Physicians.
Claudine M. Leone, the academy’s government affairs director, said the bill is a step backward from the increasing emphasis on patient-centered medical homes. Under the PCMH model, healthcare providers collaborate closely to deliver care.
“Our philosophy has always been these are professionals we work with,” Leone said, along with physician assistants and other healthcare providers who aren’t doctors.
“They work as a team, just like in the PCMH model. The PCMH model doesn’t work if you don’t have a team that works together and it’s kind of going in the reverse direction of coordinated care, to have independent, primary care practices out there not coordinating care for patients, Leone added.
The joint protocol is an agreement between APNs and collaborating physicians that give nurses the authority to write prescriptions and require that the doctors are available for consultations. Under the protocols, which were established by a 1991 law regulating nurses, a collaborating physician must review the chart of at least one of the APN's patients each year.
Kathleen Burkhart, an APN who works for the U.S. Veterans Administration at its outpatient clinic in Piscataway, said APNs have been successfully prescribing medications and that the protocols are not necessary.
“The Affordable Care Act is really going to create a need for a lot more primary care providers,” but this could be hindered if doctors refuse to sign the protocols, Burkhart said. “I’m married to a physician and really understand their viewpoint, but the data speaks to the quality of care” provided by APNs.
Burkhart suggested that New Jersey could learn from the 16 states that already allow APNs to prescribe without joint protocols.
“There’s enough of a pie for everyone,” Burkhart said of the need for primary care providers.
Patricia Barnett, chief executive director of the New Jersey State Association of Nurses, said APNs tend to be conservative in the approach to writing prescriptions. She added that they lower medical malpractice rates.
“We’re very concerned that access is being addressed,” Barnett said, referring to the shortage of primary care providers. She cited a series of studies compiled by her organization that found that nurse practitioners provide care at a quality level that is at least equal to that of doctors. In addition, the cost to provide similar services through nurses is 20 percent to 35 percent less than through doctors, according to a federally administered survey.
Vitale also said the bill addressed a critical need for primary care providers. While acknowledging the concerns raised by family physicians, he questioned whether focusing on doctors rather than providing more opportunities for APNs will meet the primary care need.
“Is it a need for a family physician, or is it a need for a primary-care provider?” Vitale said. “Nurse practitioners can provide some of the same services.”
Under his bill, APNs with fewer than 24 months or 2,400 hours of licensed, active advanced nursing practice would still be required to have joint protocol with another provider to prescribe medication. The statement accompanying the bill said it’s consistent with a recommendation from the national nonprofit Institute of Medicine that barriers to APNs’ scope of practice be eliminated.
The proposal is drawing praise from other sources. Dr. Paul Katz, dean of Rowan University’s Cooper Medical School in Camden, said APNs are the only way the state will be address primary care needs, at least in the short term.
“I don’t think the physician community should be concerned about” potential competition from APNs, Katz said.
Grace Reilly, an APN at Southern Ocean Medical Center, said advanced practice nurses play a crucial role in providing care for uninsured and underinsured patients, including many residents who can’t afford name-brand medications.
But joint protocols can complicate this role, Reilly said. Pharmacies frequently contact the collaborating physician's offices and medical labs send test results to collaborating physicians, she said. Since these doctors never see the APN's patients, their offices are unfamiliar with the patients’ names.
“That information may just get tossed into the trash” or at least delayed, Reilly said. She is the past president of the nurses association’s statewide organization for APNs, the Forum of Nurses in Advanced Practice.
Reilly said the nurses are preparing to convince legislators that the bill is needed and that they anticipate a lobbying battle with doctors’ groups.