In February, Pennsylvania State Sen. Camera Bartolotta (R., Washington) reintroduced a bill to loosen requirements for physician oversight of nurse practitioners who offer primary care. The first version passed the Senate in 2017 but then stalled in the House. While its proponents argue the change would expand high-quality primary care, especially in underserved parts of Pennsylvania, others object that the current rules around nurse practitioner-physician partnerships are in the best interest of patients.

The Inquirer turned to two health-care researchers and the president of the Pennsylvania chapter of the American College of Physicians to debate: Is it time for Pennsylvania to pass Senate Bill 25 and expand nurse practitioner practice?

Yes: NPs can help solve our primary care shortage.

By Kihwan Bae and Edward Timmons

The COVID-19 pandemic has starkly revealed the shortage of physicians and rigidity of health care in the United States. One silver lining has been the series of emergency reforms that expanded the pool of health-care workers in dozens of states, allowing more health-care professionals — including nurse practitioners — to serve patients to the full extent of their education and training. Pennsylvania legislators are considering SB 25, which would permanently provide nurse practitioners with three years of experience this same privilege.

Current state law requires nurse practitioners — registered nurses who have obtained postgraduate education and passed a national certification exam — to collaborate with physicians in offering primary care, preventing them from providing care independently. It’s not this way everywhere. To meet a growing demand for primary care, 23 states and the District of Columbia allow nurse practitioners to fully practice without physician supervision or collaboration.

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Given the large number of medically underserved areas in the state, granting full practice authority to these providers would significantly improve access to primary care. And there’s great need. Pennsylvania ranks in the top fifth of states for its number of medically underserved areas. The commonwealth also has the eighth-highest percentage of seniors, who sometimes require easier access to providers.

Opponents of the idea, like the Pennsylvania Medical Society, put forth arguments that nurse practitioners lack the training to provide independent medical care. But why were nurse practitioners trusted to provide additional care during the pandemic if they are not sufficiently trained?

If anything, SB 25 arguably doesn’t go far enough. Fourteen states allow nurse practitioners the ability to practice independently immediately after obtaining a license. Three additional years of experience seems like an unnecessary burden.

We only have so many physicians, and as we’ve learned since 2020, it’s hard to increase access to health care without expanding the role of other health-care workers. In a crisis, policymakers were quick to respond. Eight states temporarily suspended the requirement that nurse practitioners work collaboratively with physicians. Pennsylvania’s approach was more of a half-measure. It temporarily waived some restrictions on nurse practitioners, like allowing them to practice outside of their primary specialization, but did not remove the key barrier of a practice agreement with a physician.

It may take time to fully examine the effects of the policy, but an early study found that temporary waivers reduced the number of COVID-19 deaths. California and Massachusetts have made their temporary exemptions for nurse practitioners permanent.

“Research finds that independent nurse practitioner practice increases the frequency of routine checkups and reduces mental health-related mortality rates.”

Kihwan Bae and Edward Timmons

Even if we set the pandemic aside, a large body of evidence from states that allow nurse practitioners to work independently shows that it improves access to primary care without compromising the quality of care. Recent research finds that independent nurse practitioner practice increases the frequency of routine checkups and reduces mental health-related mortality rates. There are also implications for consumers’ wallets. Restrictions on nurse practitioner practice increase prices for primary care service.

Demographics and a significant rural population will continue to present challenges in Pennsylvania even after COVID-19 is in the rearview mirror. Policymakers should not worry so much about who is providing care and instead focus on actual outcomes. Research continues to show that nurse practitioners provide high-quality care.

Pennsylvania would not be going out on a limb by letting nurse practitioners work independently. Instead, the commonwealth would be catching up to a growing number of states that have already unlocked the potential of their highly trained nurse practitioners.

Kihwan Bae is a research fellow and Edward Timmons is director of the Knee Center for the Study of Occupational Regulation at St. Francis University in Loretto, Pa.

No: Collaboration between NPs and doctors is still best practice.

By Lawrence Ward

The looming threat of physician shortages is particularly difficult for rural and other underserved areas. Certified registered nurse practitioners (CRNPs) represented by the Pennsylvania Coalition of Nurse Practitioners have long lobbied the Pennsylvania General Assembly to pass legislation such as SB 25. This bill would relax regulatory standards by granting them full practice authority and removing the requirement to work under the supervision of a collaborative physician. The Pennsylvania chapter of the American College of Physicians, along with a coalition of physician associations, oppose this legislation, not out of lack of respect for CRNPs and the work they do, but because maintaining standards of care for our patients and communities will always be our first priority.

Physicians and CRNPs complete training with different levels of knowledge, skills, and abilities that, while not equivalent, are complementary. Both are valued members of the multidisciplinary health-care team and share goals of providing high-quality, patient-centered care and improving the health of those they serve. For context, in Pennsylvania, CRNPs already practice to the full extent of their education and training. Specifically, they can do much of the same clinical work as physicians, including prescribe medications, diagnose and treat acute health problems, manage chronic conditions such as diabetes, order blood tests and imaging studies, and provide well-child care.

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Pennsylvania’s current regulations require that CRNPs partner with a physician who is available to them when they provide care to patients. This is intended as a safety net measure in the event that a higher level of intervention is necessary, such as in cases with a diagnostic dilemma or a severely ill patient in the office. In our experience, practicing CRNPs are generally in favor of this collaboration, especially those still at the early part of their careers and without extensive clinical experience.

A basis of the argument in seeking independent authority is that, if granted, CRNPs will increasingly practice in underserved areas, where finding a collaborative physician can be challenging. Research indicates that even in states where CRNPs can practice without physician involvement, they tend to practice in the same areas as physicians rather than filling gaps in underserved areas. SB 25 would make dramatic changes in the delivery of both primary and subspecialty medical care across the entire commonwealth, not just in underserved areas, and without evidence that it would improve access to care or the overall health care for Pennsylvanians.

“Even in states where CRNPs can practice without physician involvement, they tend to practice in the same areas as physicians rather than filling gaps in underserved areas.”

Lawrence Ward

Thankfully, there is a good way to move forward. Last year, after extensive negotiation between multiple state medical societies and PCNP, State Rep. David Hickernell (R., Lancaster) crafted amendments to HB 100 that would allow CRNP’s full practice authority in the nation’s first pilot program to evaluate independent CRNP-led care, specifically in underserved areas. Importantly, this would also provide valuable data for the legislature to inform future policy decisions regarding the potential expansion of this authority in the commonwealth.

While the amended HB 100 bill was overwhelmingly approved 201-1 by the House last October, it has not yet been approved in the Senate. Meanwhile, SB 25 has been reintroduced, which returns the debate to a divisive proposal that will not provide the highest-quality care to patients. We believe that a collaborative relationship between CRNPs and physicians will best serve everyone involved and that returning to the agreement forged between multiple organizations working with the General Assembly would be the best solution. For these reasons, we urge lawmakers to reject SB 25.

Lawrence Ward is a general internist and president of the Pennsylvania chapter of the American College of Physicians.