Connecticut Becomes 18th State to Allow NP Independence

May 01, 2014

In the face of physician opposition, Connecticut lawmakers have passed a bill allowing nurse practitioners (NPs) and other advanced practice registered nurses (APRNs) to work independently after a 3-year collaboration with a physician there.

The Connecticut House okayed the measure 110 to 34 Monday after state Senate approval earlier in April.

Governor Dannel Malloy has promised to sign the bill, effectively making Connecticut the eighteenth state, in addition to Washington, DC, where NPs can practice without physician supervision or a collaborative relationship. In addition to Connecticut, those states granting full independence to NPs are Alaska, Arizona, Colorado, Hawaii, Idaho, Iowa, Maine, Montana, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, Vermont, Washington, and Wyoming, according to the American Association of Nurse Practitioners (AANP).

Connecticut lawmakers passed a bill last month putting NPs on the independence map. Connecticut Gov. Dannel Malloy has promised to sign the bill.

The AANP defines full independence as the ability of NPs to "evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments — including prescribe medications — under the exclusive licensure authority of the state board of nursing." In other words, nothing is contingent on a relationship with another healthcare professional.

The Connecticut legislation applies to all APRNs, including certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists in addition to NPs. However, not every state granting independent practice to NPs has done the same for other APRNs, according to Tay Kopanos, DNP, an NP and the AANP's vice president of state government affairs.

Heavyweight organizations such as the Institute of Medicine and the National Governors Association have recommended practice independence for these clinicians, given a nationwide shortage of primary care providers and an influx of newly insured patients under the Affordable Care Act. However, organized medicine, as well as many individual physicians, opposes free rein for NPs and other APRNs, saying these clinicians should work as members of physician-lead teams because of their relative lack of training.

Collaboration Occurs Without a License Requirement, Says AANP

The Connecticut legislation notwithstanding, the NP liberation movement is not without its setbacks. Last week, a Nebraska bill that would grant NPs full independence was vetoed by Governor Dave Heineman, who said the measure did not require enough supervised practice beforehand. In his veto letter, Heineman quoted the state's chief medical officer as saying that "recent graduates of [NP] programs...lack sufficient clinical experience to practice independently."

The Nebraska Medical Association and other medical societies had opposed the bill.

The Connecticut State Medical Society (CSMS) waged an unsuccessful campaign against the APRN bill in its state. "It is fundamentally an issue of patient safety and healthcare transparency," said CSMS President Michael Saffir, MD, in a news release on April 28. Studies show that the team-based model, in which APRNs and physicians work together, is the most effective approach to patient care, Dr. Saffir said. "This bill moves in the opposite direction by removing collaboration and fragmenting the care team."

The CSMS also argued that the bill did nothing to ensure that patients clearly understand that an APRN who happens to treat them is not a physician.

The AANP's Dr. Kopanos told Medscape Medical News that NPs can and do team up with physicians without states having to impose collaboration on her profession as a license requirement. "In states such as Washington, Vermont, and Colorado, where NPs can practice to the full extent of their license, they have models of team care that are emulated across the country," she said.

State laws that deny independent practice to NPs, she said, keep people "from getting full and direct access to health care," especially in states with rural and underserved populations.

The worry expressed by Connecticut physicians that patients might mistake NPs for physicians is "misplaced," said Dr. Kopanos. "We have not found that to be an issue in actual practice."

"From a business and economic standpoint, we want patients to know they were seen by a NP," she said, noting that NPs have outscored physicians on patient satisfaction.

"NPs chose to be NPs. It's something to be proud of."

Op-Ed Piece in the New York Times Fans Flames of Debate

On April 29, the New York Times published an op-ed piece by cardiologist Sandeep Jauhar, MD, arguing that NP independence laws "underestimate the clinical importance of physicians' expertise and overestimate the cost-effectiveness of [NPs]."

In the piece, titled "Nurses Are Not Doctors," Dr. Jauhar pointed to a study published in Effective Clinical Practice in 1999 reporting that patients assigned to NPs underwent more diagnostic imaging than those under a physician's care (the difference was statistically significant, which was not the case for many other NP–physician comparisons).

Dr. Jauhar, who directs a congestive heart failure program at Long Island Jewish Medical Center in New Hyde Park, New York, said NPs may have ordered more diagnostic imaging, which is a big driver of healthcare costs, because of their lack of training.

Dr. Jauhar also decried a newly enacted law in his home state that will allow NPs with more than 3600 hours of training to treat patients without a written practice agreement with a physician, beginning in 2015.

"Medical school graduates, after 2 years of classroom instruction and 2 years of clinical training, are not considered fit to practice medicine independently," Dr. Jauhar writes. "Yet in New York State next year, nurse practitioners with perhaps even less experience will be allowed to do so."

In response, Dr. Kopanos told Medscape Medical News that the new law does not put New York on the list of states in which NPs enjoy full independence. Despite doing away with the written practice agreement with physicians, the law still will require NPs to collaborate with physicians or hospitals as a license requirement and explain in writing how they will do so, according to an explanation of the law posted on the Web site of the New York State Senate. Dr. Kopanos said her association is waiting to see how New York implements the law, which she describes as a "step forward."

Dr. Kopanos took issue with Dr. Jauhar's extrapolations from the 1999 article in Effective Clinical Practice. She noted a design limitation identified by the authors themselves: Diagnostic imaging for NP patients could have been ordered by physicians as well as NPs, yet the study did not break that out. She also surmised that NPs might have indeed ordered more diagnostic imaging because they more closely adhered to national screening guidelines for certain classes of patients than physicians.

The lone 1999 study, she added, must be considered alongside 4 decades of outcomes research showing that NPs provide safe, high-quality care.

Dr. Kopanos reiterated that independence for NPs does not translate into enmity with physicians.

"We need to move past these conversations," she said, "which set one profession against another."

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