Ohio Academy of Family Physicians Past President Brian Bachelder, MD, authored an editorial published in the February 9 issue of the Akron Beacon Journal. The editorial focuses on how physician-led teams ensure patient safety and clearly enumerates the reasons that physicians’ organizations oppose House Bill 216 (HB 216), a proposal to allow advanced practice registered nurses (APRNs) to practice independently without physician collaboration agreements.
The text of the editorial is as follows:
The Akron Beacon Journal’s January 29 editorial “Take Advantage of Advanced Practice Nurses” ignores key facts about how these nurses (including nurse practitioners, nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists) actually work in Ohio. APRNs do play a critical role as part of a health care team. Having said that, HB 216 is an unnecessary overreach. Many provisions of the bill are unnecessary or potentially harmful.
The editorial says the bill would be a “major step toward addressing a shortage of primary care physicians, especially in rural areas.” In fact, just 13% of APRNs in Ohio have chosen primary care as their main practice area. Advanced practice nurses could easily practice in rural areas under current law, but most just don’t.
As the editorial pointed out, APRNs are required to have an agreement with a collaborating physician, but that doctor need not practice nearby. This actually makes it easier for an APRN to practice in a rural area where there might not be a local doctor. Nevertheless, most choose to practice in one of Ohio’s major cities. Also, there are no incentives in the bill for APRNs to practice in rural areas.
Is the collaboration requirement so onerous? It simply requires that the physician be available to communicate with the nurse when necessary. The communication can be in person, on the phone, or via a computer link. It assures patients that when a complex situation arises, they will have the benefit of a physician’s experience and training.
By eliminating all physician collaboration requirements in the law, the bill dismisses more than a decade of diverse education and direct clinical care physicians bring to the team.
The team-based approach to patient care, where physicians collaborate with other health care professionals, is preferred by medical professionals and insurers because it is effective and efficient. According to a 2012 study by the American Medical Association, patients also favor a collaborative approach and prefer that a physician be included in that team model.
The argument for HB 216 is based on a 2015 Rand Corporation study sponsored by the state APRN organization. However, the results of this study were less certain than the organization alleges.
The study considers that laws changing the scope of practice might lower health care spending or lead to fewer emergency room visits, but says, “There is not enough evidence to know definitively.” In fact, studies exist showing that APRNs may even increase health care costs due to increased numbers of unnecessary tests, imaging, and specialist referrals.
And let’s be clear: Though the editorial says “nothing in the bill would affect … scope of practice,” that’s not quite right. The major change would allow APRNs to prescribe Schedule II drugs, including addictive pain medications in virtually any setting and without physician collaboration.
This is a step in the wrong direction given Ohio’s crisis with pain pill addiction. Many primary care physicians choose not to prescribe opioid medications, yet the bill expands that authority for APRNs who have less training and clinical experience.
The medical community has proposed a solution to the complex drug formulary that currently governs what APRNs can prescribe. That plan would allow APRNs to prescribe medications with limited exceptions. Those would be determined by a panel of APRNs, physicians, and pharmacists. This panel of medical experts would decide whether the addictive, dangerous drugs that have contributed to Ohio’s opiate crisis need more rigorous prescribing authority.
There are concerning changes in HB 216 when it comes to the operating room. The bill would allow a nurse anesthetist to order medications for the patient pre- and post-operation for another to administer, taking the physician out of the loop on what is happening with the patient. When complications arise, a trained physician is better prepared to make the split-second decisions that best protect the patient.
As further evidence that current law is working, consider that a 2015 Ohio Board of Nursing report reveals that out of the more than 13,000 APRNs who responded to a workforce survey, just 21 (that’s 0.001%) indicated they were unemployed due to difficulty finding a job. This is despite the fact that the number of APRNs in Ohio has increased by more than 4,000 since 2011.
So yes, HB 216 is an overreach. APRNs have a valuable role in patient care, but the education and training of physicians and APRNs are substantially different. Simply stated, physicians and APRNs are not interchangeable health care professionals. Patients deserve the treatment model that provides the best access to the safest care.
Dr. Bachelder is president-elect of the Ohio State Medical Association, past president of the OAFP, and is a practicing physician in Akron, OH.
Visit the APRN independent practice legislation page of the OAFP website for more information and resources.