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Nurses Covering More Health Care

FRANKFORT, Ky. - Each year, Wendy Fletcher says she and two partners see more than 5,000 patients at their practice in Morehead, Ky.

They are not doctors, but rather registered nurse practitioners who say they are able to increase access to health care and make it more affordable.

"None of us are trying to play doctor," she said.

"If we'd wanted to be doctors, we would have gone to medical school," added nurse practitioner Melinda Staten of Louisville.

The Kentucky Medical Association claims otherwise and is fighting proposed legislation that would lift some limits on the ability of about 3,700 nurse practitioners in Kentucky to prescribe medication and perform other, mostly routine tasks such as signing a child's immunization certificate or certifying the need for employee sick leave.

Greg Cooper, a former Kentucky Medical Association president and family physician from Cynthiana, Ky., who testified against the Kentucky bill, said he objects to what he said "is this constant push by nurse practitioners to be physicians."

"It's a little bit frustrating, the way this has evolved," he said. "The family physician is the foundation of health care."

That argument has been echoed nationally by the American Medical Association, which issued a report last fall critical of the training that nurse practitioners receive.

Dealing with doctor shortage

As the debate over health care legislation continues in Washington, advocates for nurse practitioners say it is these primary care nurses who will make up for the shortage of primary care physicians and at the same time keep costs down.

According to the American Nurses Association, as of November, the median expected salary for a typical nurse practitioner in the United States was $83,293, while the median expected salary for a typical family practice physician was $160,586.

Rebecca Patton, president of the American Nurses Association, said that each year state legislatures are seeing bills proposed that seek to increase the capabilities of nurse practitioners and in many cases eliminate a level of supervision from physicians.

Among recent examples she cited:

- In January, Ohio's Democratic Gov. Ted Strickland signed a bill that did away with the need for nurse practitioners moving to Ohio to repeat training with an Ohio physician as long as they have had prescribing privileges in another state at least one of the prior three years.

- In July 2009, Hawaii enacted a bill that gave nurse practitioners there broader prescription authority that includes controlled substances.

In addition, the association cited several additional states that have bills pending that would either broaden or restrict prescription writing ability for nurse practitioners, including bills in Alabama, Colorado, Washington and West Virginia. And Alabama, Connecticut, Mississippi, Nebraska and New York have bills pending related to removing requirements for physician supervision or collaboration agreements.

'Don't see a big difference'

Nurse practitioners are "gaining traction because people are seeing how cost-effective they are," Patton said. "The primary care physician shortage is going to drive it."

Judi James, 56, who lives in Morehead, Ky., says she gets her basic medical care from a nurse practitioner and has no qualms about going to see a nurse rather than a doctor.

"I really just don't see a big difference," James said. "The nurses are the ones who take care of you anyway, not always the doctor. If I need a specialist, she'll send me there."

Each state sets up regulations for nurse practitioners. In Kentucky, for example, nurse practitioners are able to practice independently without being supervised by a physician. But in order to prescribe medicine they must obtain a signed agreement from a physician, even though that physician may not work directly with or consult with the nurse.

The Kentucky bill would allow nurses to forgo the agreement when it comes to certain medications, such as antibiotics and blood-pressure medication. Prescribing controlled drugs, such as narcotic painkillers and sedatives, would still require the physician agreement.

The Kentucky bill passed out of committee and could come to the full house for consideration as soon as Monday, said its sponsor, Rep. Mary Lou Marzian, a Louisville Democrat. Marzian said she's not sure the bill can make it through the Senate.

Twelve states, including Alaska, New Mexico, Montana, Wisconsin and Wyoming, and the District of Columbia allow nurse practitioners to prescribe independently, including controlled substances, according to the American Nurses Association. In 29 states, laws require physician collaboration for prescribing controlled substances.

Some states have limits on which controlled substances can be prescribed by nurse practitioners. Laws in Florida and Alabama prohibit nurse practitioners from prescribing any controlled substances.

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