Cumberland Times-News

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December 15, 2013

Nurse practitioners seek more autonomy

CUMBERLAND — Nurse practitioners in Western Maryland and across the state are pushing changes in laws and regulations that limit their ability to practice independently as primary care providers.

The nurses are also seeking more standardization of regulations on nurse practitioners both in the state and nationally.

Among the barriers is that verbal orders are allowed for certain prescriptions and other patient needs, but many written orders require that a physician sign off on the request, said Cathy Chapman, a nurse practitioner. The concerns have a direct impact on patient care, Chapman said.

“I won’t be able to sign for a walker ... it’s a huge barrier to practice,” Chapman said.

Chapman is the Mountain District director of Nurse Practitioner Association of Maryland. Nurse practitioners are increasingly the front line of care for may patients.

Forty seven percent of primary care is now provided by nurse practitioners, Chapman said. In Cumberland, there are three practices run by nurse practitioners. With many primary care doctors leaving the area, access to health care is dependant on the availability of nurse practitioners, Chapman said.

Each nurse practitioner in Maryland must have a letter of attestation signed by a physician. The restriction makes little sense, according to Chapman, since for instance, the doctor writing the letter may have little or no experience with general practice. Some specialists write the letters for nurses who are not practicing in a specialized area. Nurse practitioners already meet tight educational and certifying requirements, she said.

Terry Harvey, also a nurse practitioner, echoed many of Chapman’s comments.

Chapman has her own practice in Cumberland. Harvey practices at Hahn & Nelson Family Medicine. Seventeen states and the District of Columbia have few limits on practice by nurse practitioners, while 12 states have very tight limits. Maryland is one of 21 states in between, with some significant restrictions on nurse practitioners.

Sen. George Edwards said he is sympathetic to the nurses’ plight and said he thinks the trend of having more nurse practitioners will continue to grow.

“I think we would be supportive (of less restrictions) ... it could bring more care to our area of the state,” Edwards said.

Insurance issues are another problem. While many companies allow nurse practitioners to write prescriptions, others will not allow them to order diabetic supplies for their patients, Chapman said.

“The insurance companies have too  much power,” Harvey said. For instance, they require use of older generics even in cases where the practitioner knows the patient won’t be able to tolerate the drugs. Then, even when the patient does have problems with the medicine, the insurance company will balk at paying for a more pricey drug, Harvey said.

On another front, some electric companies will not allow a nurse practitioner to certify that a patient needs electric service for medical reasons in cases where the person is in danger of having their power shut off, which could jeopardize medical equipment they have in their homes.

While Maryland is not among the states with the tightest restrictions on nurse practitioners, there are many states with more liberal policies.

While there have been issues in the past between nurse practitioners and physicians, they increasingly cooperate, Chapman said. There is no difference in care outcomes between individuals treated by a physician and those treated by a nurse practitioner for primary care, Chapman said.

Another problem is the state’s Primary Adult Care program, Harvey sad.

“It’s a poor system,” with a huge amount of paperwork, Harvey said. The program is for those over the age of 19 with limited income.

Delegate Kevin Kelly asked Chapman to keep legislators apprised of issues and bills that might affect them.

Chapman was speaking to legislators earlier this week asking for their support as they work for changes to expand their ability to directly care for patients and make decisions regarding their health care. Her comments came during the District 1 delegation’s pre-General Assembly public meeting at Allegany College of Maryland on Dec. 9. The General Assembly session begins Jan. 8 in Annapolis.

Matthew Bieniek can be contacted at mbieniek@times-news.com.

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