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Bill Would Let Nurses Prescribe Medicine on Their Own, Without Consulting Physicians

Measure could help ease shortage of primary care doctors, limit impact of federal healthcare reform.

By Andrew Kitchenman, NJ Spotlight

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.

Professional Profile

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.

Continue reading on NJSpotlight.com.

NJ Spotlight is an issue-driven news website that provides critical insight to New Jersey’s communities and businesses. It is non-partisan, independent, policy-centered and community-minded.

 

M.D.DeLisi,MD November 27, 2012 at 06:53 PM
To say this action will relieve the Primary Care PHYSICIAN shortage is just a lie. To believe an APN is the equivalent of a Board Certified Family Physician is comical. Six years of nurse training some how adds up to being equal to the 11 years that it takes to train a physician including the now reduced to 80 hour weeks gaining the experience of residency. A magical vision of educational efficiency by the nurses! All resulting in the arrogance of someone 2 years into her practice "who has never needed any help". I feel more confident in her practicing independently already.
SWMRN-APN November 27, 2012 at 07:22 PM
http://www.ncbi.nlm.nih.gov/pubmed/15846614 In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.
M.D.DeLisi,MD November 27, 2012 at 07:29 PM
"The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost." That is most of the cases involved self limited problems where no difference between optimum and sub optimum care would be revealed. It continues to fascinate me that our state will not license a physician fresh out of medical school but does license an APN fresh form the limited clinical experience afforded to them in there training frequently in a private doctors office not in a residency level training program.
SWMRN-APN November 27, 2012 at 11:34 PM
Well, I stuck to quoting directly, but I can paraphrase too.... All things being equal, the outcomes of care were the same and the patients liked the Advanced Practice Nurse more... who give more time and explanation during their visit. So, you say that the problems handled by APNs were essentially self limiting and probably didn’t need care anyway? I don't see anywhere in the article that said that APNs were equivalent to FP's. Or that removing the joint protocol requirement would solve the shortage of family practice/ primary care docs. It will help. And do you really think that most APNs got their experience in a private office? Really?
SWMRN-APN November 27, 2012 at 11:35 PM
and.....APNs, are not supervised by physicians in NJ. The Errors made are under the license of the APN only, unless the collaborating physician was brought in to the case and consulted. And on balance, APNs don’t get sued anywhere near as much as Docs. Why is that? My insurance company only wants ~ 2k a year for insurance. I guess we are a good risk. And we’re careful. No APN is going to try to prove that they have more training than a physician. But we can take care of the routine things. And not enough docs to take care of them all. And if we need help, we refer to the specialists, like the primary care and FP guys do all the time. And limited clinical experience? Yes, its not the same as a residency, and certainly not the same as in your day. But I bring 25 years of RN experience before I got my APN. I think it will help. And I was not unusual in my class. There were a few "new grads" but most had 10 or more years as an RN before they went back for their Masters and APN. This sounds so much like someone is afraid that there will be less money in the pool because there will be more competition. There will still be plenty of work to go around. And people need the care. Lets not limit it.

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