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HARRISBURG — As a nurse practitioner at a West Virginia clinic, Joyce Nestric can independently perform physical exams, diagnose health conditions, prescribe certain medications and make referrals.
But once she crosses the state line, where she lives in Washington County, Pennsylvania, she needs medical supervision to do the same work.
Nurse practitioners, who receive advanced clinical training with an emphasis on preventive care, are more specialized than registered nurses. Pennsylvania law requires that nurse practitioners work in partnership with physicians who advise them on patient care, a standard commonly known as a collaborative agreement.
Knestrick, a former president of the American Nurses Association, likened the supervision requirement to having a driver’s license but not being able to drive a car without supervision.
For the past decade, lawmakers from both parties have tried to give more autonomy to Pennsylvania’s roughly 20,000 nurse practitioners, hoping removing restrictions on physician oversight would expand access to care.
A bipartisan bill currently working its way through the state House and Senate would help Pennsylvania join 27 other states (including three neighboring states) that give nurse practitioners full practice authority to examine, diagnose and treat patients without a doctor’s supervision. And unlike many of the efforts in Harrisburg, this bill has bipartisan appeal: Thirty-two of the 50 senators have signed on as co-sponsors, including 17 Democrats and 15 Republicans.
The measure also has support from a wide range of interest groups, from the state’s hospital association to the Commonwealth Foundation, a conservative free-market think tank.
But the bill appears to have stalled again due to opposition from key lawmakers and the Pennsylvania Medical Association, a professional group representing doctors.
And meanwhile, the shortage of health care workers remains.
“I understand that some physicians feel that (private practice physicians) are encroaching on their territory,” Sen. Camera Bartolotta, a Republican from Washington County who sponsored the nursing expansion bill, told Spotlight PA, but “this bill does not replace physicians, any more than a general practitioner would replace a cardiac surgeon.”
Studies have shown that having a primary care physician is linked to better health outcomes, but federal data collected by the health research group KFF shows that 380,000 Pennsylvanians live in areas where there is a shortage of primary care physicians, many of them rural areas.
KFF estimates that at least 70 new professionals are needed statewide to meet this demand, the 11th-lowest demand in the country.
Census data show that rural communities tend to have larger numbers of seniors who rely on Medicare and Medicaid, which pay lower rates for their health care. That makes it harder for providers to make a profit in remote areas, which could lead to them cutting services or closing. In an April report, the Center for Healthcare Quality and Payment Reform, a policy group, estimated that seven of Pennsylvania’s 41 rural hospitals are at risk of closing, for example.
Melanie Klash, a nurse practitioner in Fayette County, said preventive care and patient education are at the core of her job. She said full practice authority would allow providers like her to plan appointments around patients’ needs and reach underserved areas. Klash also said she has no problem referring patients to specialists if there’s a problem she can’t handle herself.
“It won’t change the way we practice,” she told Spotlight PA. “What will change is the fact that we can be independent and run our practice how we see fit, and we won’t have to share our salary with anyone else.”
Studies have come to mixed conclusions about how expanding the authority of licensed nurses will affect access to and quality of care.
A 2023 research review found that nurses can provide better care than primary care physicians for patients with multiple chronic conditions because their training focuses on “holistic health,” including social and psychological health.
Some studies also suggest that states that empower nurses have lower health care costs. But a 2023 working paper on nurses in emergency rooms at the VA found that nurses aren’t improving quality of care and are using more resources.
Doctors who oppose the bill highlight the difference between their training and that of nurses, pointing out that licensed doctors undergo up to six more years of schooling and 15,000 hours of training before they can go into private practice or sign prescriptions.
Kristen Sandell, an emergency physician in Berks County and president of the Pennsylvania Medical Association, defended the collaborative agreement. Everyone involved in a patient’s care has a role, but “the people with the most training and the most expertise should lead that team,” she told Spotlight PA.
The call for action by health care workers has been supported by many lawmakers amid widespread cuts and closures in rural health care.
According to a Spotlight PA analysis, state lawmakers have been considering bills to expand physician authority since at least 2013. In the decade since, those proposals have been voted on in full or committee about a dozen times but never made it to the governor’s desk for his signature.
A bill currently before the state Senate, sponsored by Rep. Bartolotta and Rep. Lisa Boscola (D-Lehigh County), would give nurses full practice authority if they meet a three-year, 3,600-hour collaborative contract requirement with a physician.
“Most of the health care policies proposed by lawmakers would be costly to implement, but changes to scope of practice laws would come at no cost to taxpayers,” David Mitchell, a professor of health economics at Ball State University, told a state Senate committee earlier this year on behalf of the Commonwealth Foundation.
Bartolotta noted that the language has been tightened over the past few years. Originally, the proposal required non-physician practitioners to take just 30 additional hours of continuing education.
But the changes to the bill have so far not swayed physician opponents, who are bolstered by the medical profession’s large presence in Harrisburg and the support of some of its most powerful lawmakers.
The precise scope of lobbying in the Pennsylvania General Assembly is difficult to gauge under state law: lobbyists are not required to specify which bills they support or oppose, and interest groups often juggle multiple priorities at the same time.
But since 2013, the Pennsylvania Medical Association alone has spent $6.6 million lobbying the state legislature, while the Nurses United spent $668,000 during the same period (though the union did hire two well-known lobbying firms during that same period, including one recently hired by former top Republican state senator Joe Scarnati).
A full medical authorization bill began moving through the state Senate in 2016 but failed to pass the state House. Former Republican House Speaker Mike Turzai of Bradford Woods was skeptical of the bill, a source familiar with his thinking said, and the bill never came up for a vote in the House during his tenure.
After Turzai retired in 2020, new House leadership agreed to a bill that would create a six-year pilot program to give nurses full practice authority in federally designated medical shortage areas. But the bill passed late in the session and never received a vote in the state Senate.
Groups representing doctors and nurses have blamed each other over the failed compromise, with Mr Bartolotta telling Spotlight PA he saw the pilot scheme as a way to “make us sit back and shut up”.
“We already had pilot programs,” she said. “Half the country was in pilot programs.”
And in 2021, state Sen. Kim Ward, a Hempfield Republican, became majority leader in the state Assembly. She was one of the few members of the state Senate who had consistently voted against full practice authority for nurses, saying in 2017 that she was concerned about “unintended consequences.”
A full medical authority bill has not passed the state Senate since Ward took over as leader.
Ward’s spokeswoman, Erica Clayton Wright, said in a statement that the senator “continues to pay close attention to this matter” and “want to ensure that not only are Pennsylvanians able to access health care, but that the health care workers who treat them are able to provide the quality care they are trained to provide.”
Clayton Wright added that Ward’s “leadership position has no impact on the path of this bill.”
With new leadership in the Nurses United, Pennsylvania Medical Association and the Legislature, Nurses United President Amanda Laskoski said advocates hope to meet soon “with all relevant stakeholders to resolve the crisis in patient access to care.”
But more work needs to be done to get doctors on board. Sandel agreed that more people need access to health care, but he didn’t think expanding nurses’ scope of practice would help.
She pointed to a national analysis by the American Medical Association that found that in medically underserved areas, such as rural counties, nurses are in as short supply as other health care providers.
“We’ve looked at other states that allow nurse practitioners to practice independently, but that doesn’t solve the access to care issue,” Sandell told Spotlight PA.
She suggested Pennsylvania encourage doctors to practice in rural and other underserved areas through a targeted medical school debt forgiveness program.
“The hope is that we can help doctors repay their loans and, as they practice in these communities, they’ll build connections to those communities,” Sandell said.
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