A Greater Role for Nurse Practitioners

nurse_practitionerby James A. Bacon

While Medicaid expansion may have been dead on arrival at the General Assembly this year, the Senate Education and Health Committee has been thinking of other ways to improve medical access for Virginia’s poor. One solution is to loosen the regulatory restrictions that limit the ability of nurse practitioners to handle routine medical cases without a physician’s supervision. Three bills passed by the committee would improve medical access by expanding the role for nurse practitioners.

Reports the Richmond Times-Dispatch:

  •  SB 369 would establish a pilot program in which nurse practitioners would practice without direct supervision of a physician in clinics in medically under-served or high-unemployment areas. The nurses would collaborate with physicians via tele-medicine, and would have authority to issue prescriptions.
  • SB 264 would allow a nurse practitioner to provide care for up to 120 days in the event that the physician overseeing the patient care team dies, retires, becomes disabled or no longer has a license.
  • SB 463 would authorize nurse practitioners certified as nurse midwives to practice without the requirement for collaboration and consultation with a patient care team physician.

By themselves, these measures will not solve the plight of Virginia’s uninsured population, which Medicaid expansion is meant to address, but they are a step in the right direction. Combined with other measures such as the rollback of Certificate of Public Need regulations and the expansion of primary-care clinics, Virginia can do a lot to ensure better access for the poor and near-poor without exposing taxpayers to the massive fiscal risk of expanding Medicaid.

Advocates of Medicaid expansion tend to overlook a critical point: Having access to health insurance is not the same as having access to primary care services. Because Medicaid tends to pay health care providers less than it costs them to provide a service, Medicaid patients are money losers. As a consequence, many primary-care physicians, who tend to be over stretched as it is, refuse to take Medicaid patients. The looming physician shortage makes it increasingly difficult for Medicaid patients to find a primary-care physician, which is why so many end up in the emergency room.

The U.S. health care system is an extraordinarily complicated organism, and its problems cannot be fixed by throwing money at it. By taking up the if-you-don’t-like-Medicaid-expansion-what’s-the-alternative challenge, Virginia can build a health care system that works better for all. These three bills are excellent examples of the kind of thinking we need. If Republicans win the White House in 2016 and succeed in their dream of dismantling Obamacare, we’ll be darn glad we chose this path.

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22 responses to “A Greater Role for Nurse Practitioners”

  1. Sounds like a great way to actually help the poor. Good primary care services will reduce the need to treat more serious (and expensive) illnesses and conditions down the line.
    Question? What about PA’s (physician’s assistants). How would they fall under this plan?

  2. TooManyTaxes Avatar

    Anthem BC/BS Federal Employee program pays the same reimbursement for a physician’s assistant that it does for the physician – at least for a post-operative check-up. Same co-pay also (in this case, the higher amount for a specialist.)

    1. LarrytheG Avatar

      yep – but if you don’t have insurance – how does that help?

  3. LarrytheG Avatar

    I didn’t catch how they were going to be paid…

    also – if you really want to leverage scarce resources – you’d have electronic medical records so any person can see any nurse practitioner.

    of course that would take money also.

    oh wait! there was money to pay for this in the expansion…

    once again Conservatives talk about concepts but fail to get to reality.

  4. Blackbird Fly Avatar
    Blackbird Fly

    I would be in favor of SB369 as long as it only granted midlevels independence in truly medically underserved areas. Midlevels successfully lobbied for independent practice in AZ and CO on the premise that they would practice in underserved areas and fill voids. However, in reality all they did was set up shop in the profitable areas where doctors already were (the maps of MD/DOs and NPs overlapped perfectly). What those states are finding is that NPs do not end up saving money, but are more costly. This is because they tend to practice very defensively, they order a lot more tests than physicians do because their training often leaves them less confident in their clinical impression.

    Physicians out of residency have at minimum 14,000 clinical hours, whereas NP’s get out of school with ~500 hours. Do we really want NPs right out of school with only ~500 hours of making medical decisions (under the supervision of an MD/DO) to immediately go out to rural areas and start practicing without physician supervision? As it stands a physician already oversees up to 6 midlevels–why the need for independent practice? It’s not like they are micromanaged as it is. What they want is $ for $ pay that the primary care physicians get. You’ll see that this will be a money loser and will yield subpar care for underserved (vulnerable) populations. What our state needs to be doing is supporting more residency positions with an emphasis on rural sites (the number 1 predictor of where a physician will practice is where they did residency).

    Get this, Virginia exports about 40% of the medical students it subsidizes (~550 residency spots/~900 medical students), so VA badly needs more residency slots so that it stops exporting medical students it’s paying to train.

  5. LarrytheG Avatar

    are you opposed to the free market and competition?

    if someone can save money and get the care they need why would you prevent that?

    it’s not the job of regulation to protect those who have chosen to invest in something in which others can compete with lower costs.

    are you saying that underserved folks don’t understand when they are buying substandard services and need the protection of govt – that would essentially “protect” them while also denying them services through alternative means?

    that sounds VERY – UN-CONSERVATIVE !!!

  6. LarrytheG Avatar

    re: ” Do we really want NPs right out of school with only ~500 hours of making medical decisions (under the supervision of an MD/DO) to immediately go out to rural areas and start practicing without physician supervision? ”

    as opposed to what? NO one going out at all? Have you seen the Charity Vans in that section of the state? they’re manned by the folks you oppose… and it’s the rural folks only access to any care…

    what’s your solution ?

    1. Blackbird Fly Avatar
      Blackbird Fly

      Read my post, buddy. My solution is for the state to fund rural GME positions.

      1. LarrytheG Avatar

        actually I saw no call on your part to fund…. wrong?

        how about stating what you would fund and where and how would you pay for it?

        1. Blackbird Fly Avatar
          Blackbird Fly

          re: “are you opposed to the free market and competition?”
          The Darwinian free market your referring to would leave SW Va with even less access than it has now. Nearly every rural hospital in the state runs red and are subsidized with COPN protecting those system’s profitable markets.

          The NPs will not fill the void in underserved portions of Virginia or they would already be there.

          re: “that sounds VERY – UN-CONSERVATIVE !!!”
          Who said I was a conservative?

          re: “how about stating what you would fund and where and how would you pay for it?”
          Nice LTG, you’re right, your posts skip the rhetoric entirely and are pure substance. You’re a troll. Funding for 20+ rural GME spots is already in McAuliffe’s budget, but I’m certain the GA will strip their funding.

          re: “Have you seen the Charity Vans in that section of the state? they’re manned by the folks you oppose… and it’s the rural folks only access to any care…”

          Nice anecdote; where’s your source? And no one here opposes NPs.

  7. LarrytheG Avatar

    here’s an editorial very apropo to the subject:

    ” Our view: Is there no conservative solution for rural hospitals?”


    1. Blackbird Fly Avatar
      Blackbird Fly

      This was an insightful article. Thank you for sharing! I tend to agree with the the fact that medicaid expansion may be needed. Congress, although attempting to repeal ACA, hardly pays lip service to an alternative. Also, one example Va could follow, would be that of Arizona’s which rescinds medicaid expansion if the fed funds less than 80% of the bill at any time.

      Maybe we can get along after all, LTG. (Sorry about the troll comment).

  8. LarrytheG Avatar

    geeze BF – you turned on a dime!!

    yes – my question has been all along – what does Va want to do instead of the Expansion and instead of McAuliffe’s proposal?

    how does the Va GA want to approach the health care needs of 400,000 Virginian’s many of them in rural red districts?

    Oh and here is the Health Wagon recently shown on 60 minutes – again

    be sure to check how they get their funding…

  9. LarrytheG Avatar

    The Health Wagon is a nonprofit organization providing mobile health services to the medically underserved in Southwest Virginia since 1980.

    The Health Wagon visits eleven sites in Virginia’s Buchanan, Dickenson, Russell, Lee, Scott, and Wise counties (and the City of Norton) to serve a severely medically underserved population.

    The Health Wagon’s staff consists of two Doctors of Nursing Practice, a Family Nurse Practitioner, two Registered Nurses, three Licensed Practical Nurses, an Outreach Coordinator, a Director of Operations, an Administrative Assistant, a Director of Development, a Data Systems Coordinator, and a Receptionist.


    Now the thing is – there are a dozen or more guys in the Virginia General Assembly who represent these people and who have found it apparently okay to do nothing at all other than oppose the MedicAid Expansion and proposals from McAuliffe .

    I suppose we should be glad that they’ve not called the law on the nursing practitioners… for trying to do what Doctors are supposed to, eh?

    when you look at this – it’s hard to not have contempt for their “representatives” in the Virginia General Assembly.

    1. Blackbird Fly Avatar
      Blackbird Fly

      To be fair, there are plenty of examples of free clinics in rural areas, ran by physicians, where not a single NP volunteers their time. That in and of itself doesn’t mean that NPs don’t volunteer in rural areas, just like your example cannot indict the physicians of Virginia. I promise if you could find data on volunteered time MD/DO compared to NP they would be the same of the physicians would have more donated time. Don’t act like physicians aren’t doing their part.

  10. LarrytheG Avatar

    how about you provide a link or two to some free doctor-run clinics ?

    we have 400,000 who do not have insurance – and the heck of it is – quite a few of them are full time workers trying to support their families but their employers do not offer insurance.

    these folks rely on ERs and in turn drive those hospitals to the edge of having to close – and do…

    it’s not like we have chosen to deny them care – as bad as that might sound morally. The truth is we’ve decided to pay for their care with ER prices…

    the problem is the MedicAid Expansion took away the ER subsidies.. and expected the expansion to pay instead.

  11. Blackbird Fly Avatar
    Blackbird Fly

    Just a few I’m familiar with: http://tappahannockfreeclinic.org/Our_Volunteers.html

    I think there were 1 or 2 NPs involved in any of these operations. That’s nice that you have that one example of a mobile clinic mostly run by NPs, but it hardly evidence that physicians in VA aren’t chipping in. In VA, given the fact that we have the 3rd most restrictive medicaid system in the US, we have a fantastic network of free clinics. Much more comprehensive than you see in most states, but that is not long enough. These clinics are stretching their resources further than ever before and need more support from the GA.

    re: “we have 400,000 who do not have insurance – and the heck of it is – quite a few of them are full time workers trying to support their families but their employers do not offer insurance.”

    Preaching to the choir.

    1. The Truth Avatar

      I am not aware of Tappahannock or Guadalupe Free Clinic but speaking for clinics in the Richmond, VA area which I am most familiar with, Cross Over Health Care IS NOT A FREE CLINIC. They are out of compliance by not having their most current 990 Form and Audited Financial Statements published but if you go to page 6 of their annual report you will see that 12% of their total revenue is derived from “Patient Contributions”.


      They charge a “Fee for Service” to the patients.


      They also claim they receive NO State or Federal funding which is also incorrect. The 5% from “Virginia Association of Free and Charitable Clinics” is the money that comes directly from the VIRGINIA General Assembly which would qualify as STATE Funding and the 14% CONTRACT REVENUE is what is received from CITY, STATE and FEDERAL Grants.

      They have 3 Nurse Practitioners on their payroll earning more than $70K per year with full benefits. They also have 1 Nurse Practitioner who is an Administrator.

      They have a FT physician who earns more than $140K per year, 3 PT physicians and the Executive Director earns over $110K. This organization paid out close to 2 million dollars in salaries and benefits for 31 FTE’s then claim they have 850 volunteers STRONG that were responsible for the operation of 2 clinics? What did the FTE’s do? There are more safety net services in Richmond, VA and organizations that support them than there are uninsured individuals. Each of these organizations has enormous operating expenses and extravagant salaries and benefit packages for the HIGHLY COMPENSATED EMPLOYEES on their payroll.

      Medicaid/Medicare Provider/Recipient Fraud is a hot topic. The same factors which would drive an individual to commit such an act also exist within the non-profit network and it’s easier to get away with because there are less controls and monitoring.

      I am an advocate for any assistance to be afforded to the uninsured but I’d rather see funding be applied to Medicaid expansion or to help individuals enroll in affordable health care whether it be through their employer or the Exchange and assist with paying their premiums and/or copayments and deductibles instead of wasting it on fraudulent safety net providers and the organizations that support them.

  12. LarrytheG Avatar

    Thanks for the Links – I’m familiar with ones in Va because of Enroll Virginia:


    Oh – and I’m NOT saying there are not folks chipping in – at all. I KNOW they are but I also know they are coming no where close to meeting the needs of 400,000 who lack access to health care and whom each of which has a delegate and a Senator in the Virginia General Assembly who is likely to be opposing the MedicAid expansion as well as McAuliffe’s proposals AND not offering anything as an alternative …

    AND I strongly suspect that they are using NP and such in ways that are probably illegal in Va.

    but I’m GLAD I’m “preaching to the choir”. If enough of us continue to remind legislators of their basic responsibilities to their constituents – perhaps we get changes.

    I believe when we shine a light on these things – it’s a little harder for these guys to stay in the shadows.

    1. The Truth Avatar

      According to the statistics published by the Virginia Healthcare Foundation more than 50% of the uninsured in VA are living above the 200% Federal Poverty level. I cannot tell you how many cases I see from individuals who are young, healthy, pay the “Doc in the Box” clinic fee once a year thinking they are invincible to a catastrophic illness/accident until it happens to them and they are hit with a 6 figure inpatient hospital bill and then are requesting a write off because they don’t have insurance or ways and means to pay for it. We cannot blame all the over utilization and ER bills on the “poor”.

      I saw the episode about the Health Wagon both times when it aired on 60 Minutes however I also think there needs to be a more stringent screening process in place for the recipients. One of the patients interviewed was being treated for cancer and the Nurse Practioner told her if she did not quit smoking she would end up dying and she did. If she was able to afford cigarettes I have no understanding why she was not able to afford coverage through the ACA? I don’t believe she should be denied care anymore than I believe someone needing treatment for a substance abuse issue should be. I feel the same way when I review the “poverty” statistics from the US Census bureau and find out how many households have cell phones, cable TV, computers and internet access. My point again is being uninsured is not always related to being unable to “afford” the cost.

      Although Medicaid has not “expanded” we need to remember FAMIS still exists and their family income guidelines are higher. There are NO REASONS a child should not be insured in the State of VA if they meet that criteria AND their caregivers are then eligible for coverage also. Often times parents are not aware they are eligible, they don’t get the proper paperwork in on time, they “forget” to renew until it’s too late, they may have a language barrier or a learning disability and don’t know how to reach out for help. For whatever reasons, the State may benefit from funding a social worker and monitor to oversee the screening processes at the safety net level to ensure patients are assisted with being properly enrolled into all the programs they are eligible for instead of continue to funnel money through all these other organizations who take a huge cut in “Administrative Fees” then distribute money to the “Clinics” who keep on seeing patients just so they can stay in business and continue being “HIGHLY COMPENSATED” employees.

      In rural areas like the Appalachians where the Health Wagon operates and Federally Qualified Health Centers and teaching hospitals such as VCU/MCV don’t exist Safety Net Providers are a lifeline but here in Richmond, VA and other urban areas the need for these services has decreased and it is a disadvantage and unethical for any patient to sacrifice the benefits of full healthcare coverage if it is an option and available.

  13. Blackbird Fly Avatar
    Blackbird Fly

    re: “but I’m GLAD I’m “preaching to the choir”. If enough of us continue to remind legislators of their basic responsibilities to their constituents – perhaps we get changes.”

    Been to see house and senate health committee members about this. They have a lot of rhetoric, but very little substance behind their arguments. They resorted to anecdotes about people pretending to be blind to receive benefits. You really can’t reason with these people, they are dead set on politically posturing against normalizing the ACA.

  14. LarrytheG Avatar

    re: ” They resorted to anecdotes about people pretending to be blind to receive benefits”

    and that’s consistent with what I’ve read and seen quoted.. and it’s a whole new level of hypocrisy…in politics…

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