Controversial Proposal Advances to Ease Restrictions on APN Practice

Lilo H. Stainton | June 5, 2019 | Health Care
Senate committee approves bill allowing specially trained nurses to write prescriptions for medications and devices

Credit: Twenty20
Nurse practitioner
After nearly a decade of lobbying, advocates are celebrating a vote by New Jersey lawmakers to expand the power of specially trained nurses and enable them to prescribe medications without formal oversight by a physician.

The Senate health committee approved a bill to eliminate what’s known as a joint protocol — the written agreement with a doctor that now allows so-called Advance Practice Nurses to prescribe in the Garden State — with near-unanimous support Monday, following several hours of passionate testimony for and against the controversial legislation. The measure has yet to have a hearing in the Assembly and must clear several other hurdles before it can become law.

Supporters have insisted for years that ending this formal physician oversight is essential, since it will allow APNs to do more to address a growing need for healthcare providers. Many APNs said they are often the only clinicians willing to care for the patients they do, including those struggling with complex mental and medical issues — but limited insurance. The arrangement adds needless cost and complication to their jobs, they say.

“The joint protocol is unnecessary, it is burdensome and it impedes access to care,” said Carolyn Tore, a nursing policy consultant who previously worked with the New Jersey State Nurses Association.

Physician groups cite safety concerns

But opponents, including several physician groups, say eliminating the oversight would create safety concerns for patients, noting that most APNs don’t have the same level of training as physicians. And representatives of the Medical Society of New Jersey said the legislation would move New Jersey in the “wrong direction,” away from team-based collaboration, something APNs dispute.

“The current laws and regulations are ensuring patient safety is the priority in our state,” said Dr. Christina Chen, who heads the New Jersey State Society of Anesthesiologists. “These safeguards would go away under this legislation.”

First recognized in 1991, there are now nearly 10,000 licensed APNs in New Jersey, a group that includes mostly nurse practitioners, who focus on primary care, as well as psychiatric and other clinical nurse specialists. Many new outpatient clinics, including those embedded in some pharmacy chains, depend heavily on APNs.

These providers receive graduate-level education and training that enables them to diagnose and treat illnesses, interpret lab tests and X-rays, and provide counseling, among other things. They also can lead their own practice and must have their own malpractice insurance. But, under existing law, when it comes to prescriptions, they need to have a consulting agreement with a physician on file.

Advocates suggest that enabling APNs to do more will help address a growing clinical provider shortage in New Jersey and nationwide, at a time when the need is expanding thanks to an aging population with more chronic health issues. According to the Robert Graham Center, a national nonprofit that studies healthcare workforce issues, the Garden State could need to add more than 1,000 primary-care providers by 2030, just to maintain the current level of care.

Little oversight, substantial cost

Under current law, APNs must sign annual agreements with a “collaborating physician” to prescribe medications or order medical devices. The doctor does not to need to be on site, nor do they need to be consulted on a patient’s case. In fact, the statute only requires them to review one patient case per year.

For that responsibility, physicians — who are not required to share the APNs’ focus area — can charge nurses tens of thousands of dollars a year; on average, APNs pay $500 a month for the arrangement. Nurses testified Monday about the financial burden this adds to their practice, and the struggle involved with finding a doctor who will agree to support them.

“If an APN loses their physician collaborator, they are no longer allowed to prescribe medications or medical devices, which limits their ability to adequately care for their patients,” said Kate Gillespie, a nurse with Virtua Health and president of the New Jersey State Nurses Association, which represents more than 100,000 registered nurses and APNs. “Finding a collaborator can be incredibly difficult and often has a costly price tag. This is another barrier to the APN providing care.”

“APNs practice throughout the state and are especially critical in rural and urban areas where there is a shortage of physicians,” Gillespie added.

Other nurses noted that, by nature, APNs work collaboratively with a wide range of other providers — something they promised would not change if the bill is enacted.

Similar steps taken in other states

Some APNs choose not to become prescribers — and therefore do not need joint protocols. This includes many hospital nurses, who depend instead on other clinical staff. And APN nurse anesthetists are governed by slightly different regulations, which require they sign a joint protocol agreement with a licensed anesthesiologist, who must be in the building when the APN’s patient is in surgery.

At least two-dozen states, including Connecticut, Maryland and New York have eliminated many APN practice restrictions; lawmakers in Pennsylvania are also considering similar legislation. But physicians have continued to protest the changes and, in New Jersey, the measure had failed to reach a vote until Monday.

Under the bill (S-1961) — sponsored by Sen. Joseph Vitale Jr. (D-Middlesex), the health committee chair, who first introduced the measure in 2012 — the state would eliminate the need for joint protocols only among experienced APNs, enabling them to prescribe or order medical devices on their own. APNs would still need to study pharmacology and have hands-on experience before they could be fully licensed.

The measure would still require APNs who have less than two years on the job, or under 2,400 hours of experience, to establish a joint protocol with a collaborating physician, or a more experienced APN. A number of nurses said this compromise made sense, to ensure the APNs have adequate guidance early on.

“This legislation does not change (APNs’) scope of practice. It simply removes a barrier,” said Assemblywoman Nancy Munoz (R-Union), a nurse who has long championed the measure. “It’s time to end this professional chauvinism,” she added.