June 23, 2014 at 9:42 am

Michigan may let nurses do some of doctors' work

Shortage of physicians, expanded coverage spurs Senate plan sent to House

Nurse practitioners Michele Knappe, left, and Julie Zimmer go over a patient chart at Ingalls Family Care Center in Illinois. Under the bill awaiting Michigan House action, APRNs here would have authority to write prescriptions, order tests and more without physician approval, opening the door for the nurses to practice independently. (M. Spencer Green / AP)

As newly insured patients flood Michigan’s health system, legislation could make it possible for nurses with advanced education to take some of the workload off the increasingly short supply of primary care doctors.

The physician shortage is not just a state problem. A 2012 report by the Annals of Family Medicine projected that 52,000 new physicians would be needed nationwide by 2025, on top of the 209,000 working at the beginning of the decade.

The report concluded that the bulk of the doctors would be needed to meet the needs of a growing and aging population, but a significant portion — 8,000 physicians — would be needed at once with the expansion of insurance coverage under the Affordable Care Act.

Even before the full health care law rollout, Michigan numbers suggested unmet demand; a 2013 report from the Michigan Department of Community Health designated all but 12 of Michigan’s 83 counties “medically underserved areas.”

A measure passed by the Michigan Senate in November could make it possible for postgraduate-educated nurses to address more of that demand with less reliance on physicians. Senate Bill 2 would license advanced practice registered nurses (APRNs) under Michigan’s Public Health Code, expanding the scope of practice for a group that includes nurse practitioners, nurse midwives, nurse anesthetists and nurse specialists.

Under the bill awaiting House action, APRNs would have authority to write prescriptions, order tests and more without physician approval, opening the door for the nurses to practice independently. APRNs are already allowed to practice autonomously in 16 states and Washington, D.C. Connecticut was the most recent state to approve such legislation; Gov. Dannel Malloy has said he will sign a bill passed by the legislature last month.

“This is not a novel idea,” said Olivia McLaughlin, executive director of the Michigan Council of Nurse Practitioners. “We certainly want Michigan to be a part of that forward thinking in terms of how nurse practitioners can play such an important role in the health care environment for us here in Michigan.”

Michigan’s health code recognizes APRNs at the same level as undergrad-educated registered nurses, although APRNs hold master’s degrees or even doctorates. Michigan Nurses Association communications director Dawn Kettinger said there’s no reason for APRNs to wait to have their decisions “effectively rubber-stamped” by a physician, particularly in rural and other underserved areas.

“In places where there is no doctor, wouldn’t you rather have a nurse providing primary health care than no one at all?” Kettinger said.

Not everyone, however, is keen on the idea.

Dr. Kenneth Elmassian said there’s little incentive for nurses or doctors to work in rural areas, and expanding APRNs’ scope of practice wouldn’t change that. Elmassian is the immediate past president of the Michigan State Medical Society, which represents Michigan physicians. Elmassian said physicians and nurses should be working on strengthening their existing team relationships to better serve patients. He described SB 2 as “dangerous.”

“It’d be like flying a commercial aircraft without ground crew, without air traffic control, without the stewardess, without flight attendants,” he said. “It’s a team. That is the most efficient and safe model, and that’s what we need to build.”

As an anesthesiologist at McLaren Greater Lansing Hospital, Elmassian said there are daily nuances to his job that are “not necessarily picked up” by his nurse anesthetist. He said SB 2’s nurse advocates are really after the right to practice independently, an idea he thinks the general public would oppose.

“If we put this on a ballot initiative, people would not really like the direction in which health care is going when you remove physician supervision,” Elmassian said.

“People expect to be taken care of by a physician, and that’s not necessarily what they’re going to get.”

Daniel Gramlich is a nurse practitioner at Monroe’s Mercy Memorial Hospital. Hospital physicians at Mercy have delegated prescriptive authority to nurse practitioners under a collaborative agreement; Gramlich said his work would be “more cumbersome” otherwise. He said it’s part of an APRN’s job to know when to refer matters upward, and that even under SB 2, legal ramifications would still discourage APRNs from abusing their expanded powers.

“With our Michigan Public Health Code, we’re responsible to our own limitations in our own practice,” Gramlich said. “I don’t think nurse practitioners are going to be out there doing surgery or anything outside the scope of their practice, because they’re liable for that patient.”

Elmassian said educating more physicians and giving them incentives to locate in rural areas would be the ideal solution to the doctor shortage.

But the tide already may have turned in another direction, thanks in part to an initiative funded by the Affordable Care Act called the Advanced Nursing Education Expansion Program. The $30 million program, intended to facilitate the training of more new APRNs, awarded grants in 2010 for 26 schools to provide stipends to their APRN students. Michigan State University received $1.4 million from the program, and has since offered its nurse practitioner students a $22,000 annual stipend for up to two years.

Teresa Wehrwein, associate dean of MSU’s nursing school, said the stipend can be a boon to students who usually have to split their time between school and part-time nursing work.

She describes the federal funding as “very successful,” resulting in a record graduating class of 46 nurse practitioners this year. Wehrwein said many of them have already been providing for the Michigan communities of most concern under the health care rollout.

“We have been able to see, in the clinical experience we’ve been providing for these students, that they have been taking care of underserved populations,” Wehrwein said. “They have been taking care of populations in rural communities, people of color, individuals who are in need of care — very much like those 300,000 people that have just come into the system.”

For those 46 MSU graduates and APRNs across Michigan, the question of scope of practice is in a state of limbo.

After its November passage in the Senate, SB 2 was referred to the House Committee On Health Policy, where it has remained. Lobbying groups for both physicians and nurses have waged a protracted battle in Lansing, but McLaughlin said she’s optimistic the bill will become law by next year, if not sooner.

“We do have, quite frankly, the Affordable Care Act and the momentum there behind us,” she said.

But with the long lag time in the Legislature, Wehrwein said she’s becoming less confident that APRNs will get their victory.

“There’s always a clock in the legislative process,” she said. “Things can be ignored to death, if you will.”

Patrick Dunn is an Ann Arbor-based freelance writer.
This story is part of a collaboration with Kaiser Health News, an editorially independent program of the www.kff.org/.