Giving Michigan nurses more authority to prescribe drugs and treat patients

More times than she can count, MaryLee Pakieser said she has wished that the rules that govern medical care in Michigan would allow her to do her job.

A registered nurse for 43 years and nurse practitioner in the northern Lower Peninsula for 20, Pakieser said unnecessary delays crop up when one of her rural patients has to fill a prescription. Even though she prescribed the medication and said she likely knows the patient best, the name printed on the prescription bottle is usually that of the doctor with whom she collaborates. Under Michigan law, Pakieser is allowed to write prescriptions only under collaborative agreement with a physician.

“The pharmacy won't call me, they will call the physician,” she said. “Instead of five or 10 minutes to resolve, you added an hour or two while the physician is trying to figure out what is going on. They don't know all my patients.”

Not long ago, one of her patients walked into the emergency room at Munson Medical Center in Traverse City with a cough and infection. Pakieser is his primary care provider through a clinic that treats Medicaid patients who also have mental health issues. But hospital officials asked him for his primary care physician – and he told them he didn't have one.

A few days later, not responding to his medication, he was back in the ER. Pakieser said she could have prevented that second ER trip had she been alerted to his condition. “That information never got back to me,” Pakieser said.

Such confusion and delays could be reduced if Michigan joins a growing list of states that allow advanced practice registered nurses – who are more highly trained than registered nurses – more authority to diagnose, treat and prescribe medications for patients independent of a physician, supporters of this movement argue.

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It is a measure advocates and some legislators say could drive down costs and improve health care, especially in rural regions of Michigan as well as underserved urban areas. Earlier this year, Nebraska and Maryland approved that authority for nurse practitioners, bringing the total to 21 states.

But the idea continues to meet resistance in Michigan, particularly from the Michigan State Medical Society, which represents 15,000 physicians in Michigan.

“Nurse practitioners are wonderful,” said Rose Ramirez, a physician, former nurse and current president of the medical society, “but I think they need some kind of supervision and oversight. The best health care teams are physician led. I worry about the safety of the patients in our state who deserve to have well trained physicians supervising their care.”

Ramirez noted that physicians have a minimum of 11 years of education and training, including four years of college, four years of medical school and at least three years of residency training.

In Michigan, an advanced practice registered nurse must complete a nationally accredited master's degree program in nursing, pass the national board tests for their practice specialty and hold a registered nurse license from the state. Their master's degree includes a minimum of 500 hours of clinical training and their education, including undergraduate and graduate school, typically totals six years.

“Advanced practice registered nurse” is a broad category that includes nurse practitioners, certified nurse midwives, certified nurse anesthetists and clinical nurse specialists. Nurse practitioners engage in practice specialties that include adult and older patients, family practice and pediatric patients.

“Physicians have a great deal more education than nurse practitioners do and they have a lot more hands-on clinical training than advanced practice registered nurses,” Ramirez added.

Nurses as the face of medical care

Nurses are indisputably central to health care in Michigan. According to a 2013 survey by the Michigan Center for Nursing, there were about 133,000 licensed nurses in active practice in Michigan, of which 103,000 were registered nurses. Of those, approximately 4,700 were nurse practitioners, who serve as primary care providers for thousands of patients. In 2014, there were about 34,000 licensed physicians in active practice, of which about 16,000 are primary care physicians.

Proponents of giving highly trained nurses greater authority to diagnose and treat patients say the evidence shows that safety concerns are unfounded, despite the gap in training between physicians and nurses.

“People that are arguing that nurse practitioners are not safe are not arguing with the data,” said Kim Sibilsky, CEO of the Michigan Primary Care Association, a federally-funded nonprofit that oversees 40 health care operations in 250 medically underserved areas of Michigan

“I am not an advocate for physicians or for nurse practitioners. I am an advocate for comprehensive quality of care for people in underserved areas.”

Sibilsky contends it's a common misconception that nurse practitioners, if granted authority to practice independently, would suddenly make medical decisions for which they aren’t qualified. She said nurses are bound – as are doctors – by professional ethics that guide those decisions. In her experience, nurse practitioners readily refer patients to physicians when they encounter medical conditions outside their base of knowledge.

Typically, a family practice nurse practitioner will treat common conditions including minor injuries, routine infections and manage chronic conditions like high blood pressure, asthma and diabetes. A nurse practitioner is trained to refer more complicated conditions and more serious injuries to a physician.

“It's my belief that the vast majority of nurse practitioners know how to work well with physicians and are not inclined to work outside their scope,” Sibilsky said. “That's how they were trained. That's what they do.”

Satisfaction with nursing care

She and others cite studies that appear to confirm the pluses of expanding scope of practice for nurses with advanced training:

A review of medical literature covering 18 years, from 1990 to 2008, found no difference in either length of stay or mortality for a variety of patients cared for by physicians and by nurse practitioners. Patients treated by nurse practitioners also had similar rates of patient satisfaction, emergency department visits and hospitalizations.

In a 2012 review of medical literature, the National Governors Association concluded that “most studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures. Moreover, the studies suggest that NPs may provide improved access to care.”

A review in Health Affairs of studies involving insurance claim data found “demonstrated lower costs associated with (nurse practitioners’) care.” The report also noted that state restrictions on nurse practitioners seemed to be driven by “professional jockeying” by the medical establishment rather than treatment concerns. “Fearing increased competition, professional medical groups, health care systems, and managed care organizations have typically resisted expanding the practice scope of nurse practitioners,” the authors wrote. “Without an opposing outcry from consumers, patients, family members, and other stakeholders, insufficient stimulus exists among policy makers to respond to organized medicine.”

A study of health care costs in Massachusetts by the Rand Corporation, a nonprofit research organiation, concluded that expanding the scope of practice for nurse practitioners and physician assistants could cut medical spending in that state by $4 billion to $8 billion over the course of 10 years. Massachusetts spends about $60 billion a year on health care.

Sibilsky said that rural areas – where it is often hard to attract and retain physicians – would most benefit from giving more autonomy to nurse practitioners. Recent studies, including a June report from the Lansing-based Citizens Research Council, point to an ongoing shortage of physicians in rural Michigan, particularly northern Michigan, that is projected to worsen in coming years.

From 1979 to 1985, Sibilsky said, she oversaw health care clinics within the Alcona Health Center in rural northern Michigan. She said nurse practitioners and physician assistants were pivotal to their success, in part because nurse practitioners were more inclined to remain in practice in remote areas than physicians.

“The nurse practitioners and physician assistants, they were the foundation for health care in those areas. Those were the folks we recruited and they stayed.”

Physicians oppose expanded practice

In 2013, legislation to grant advanced practice registered nurses full practice authority passed the Michigan Senate 20-18, but died in the House last year amid opposition from the Michigan State Medical Society and other medical groups.

State Rep. Ken Yonker, R-Allegan County, a member of the Health Policy Committee, said he intends to introduce legislation this fall that would go part way to granting that authority. Yonker said the measure would rewrite the state health public health code to define the role of advanced practice registered nurses. It would also grant those nurses authority to prescribe medication without physician approval, with the exception of certain narcotics. But their ability to diagnose and treat patients independently would still be limited.

Yonker sees it as a possible first step toward granting full practice authority.

“Everybody wants to protect their industry and their value,” he said. “The lobbying against it is very powerful. It's hard to get the votes, especially when you have two doctors on the committee.”

The House Health Policy Committee includes state Rep. John Bizon, R-Battle Creek, a physician who remains skeptical about expanding scope of practice for advanced practice registered nurses. Committee chair Mike Callton, R-Barry County, is a chiropractor.

“I would be a little concerned about it, because their knowledge base and training base are a little different,” Bizon said of the nurses. “If you are going to have a captain of a team, I would prefer that that captain be a physician because I think their training is a little more extensive.

They could probably handle about 60 percent or 70 percent of what I do. For many of our patients, the nurse practitioner is their primary care provider. – Tom Marshall, chief medical officer, Alcona Health Center

“If you say they are the same as physicians, they aren't.”

Tom Marshall, a physician, is chief medical officer for the Alcona Health Center, where he said restrictions on nurse practitioners for prescribing some medications is at times a bureaucratic headache. The federally-funded center encompasses nine clinics that serve rural patients in Alcona, Alpena, Iosco, and Emmet counties, many living below the poverty level.

The clinics depend on a combination of physicians, physician assistants and nurse practitioners to deliver care. But while physician assistants can write prescriptions for narcotic pain medications on their own, nurse practitioners have to seek the signature of a physician. (Training for physician assistants is based on the physician model - PAs typically complete a two-year master’s program beyond a four-year undergraduate program, as well as clinical training at some schools of up to 2,000 hours.)

“It's a pain in the butt for us, frankly,” Marshall said.

Marshall said the eight nurse practitioners scattered among the clinic sites are a vital piece of the health care they provide.

“They do a great job,” he said. “They could probably handle about 60 percent or 70 percent of what I do. For many of our patients, the nurse practitioner is their primary care provider.”

Marshall said he did have some concern about what might happen should nurse practitioners receive expanded practice authority and decide to set up an independent practice with no connection to a physician.

“To know what you don't know is probably the most important thing,” Marshall said. “If they can hold true to what they've been trained to do and when they get out of their comfort zone, to refer the patient to somebody that can handle it, great.”

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Thu, 10/08/2015 - 10:11am
I would prefer to have a Nurse Practitioner as my primary care provider. I've found them to be thoughtful in assessing medical needs, cognizant of the scope of their own practice and ready to refer when that's what's appropriate. In the current medical environment, there are not enough physicians to care for the needs of an aging and often chronically ill population, as well as the rural patients and those who must rely on Medicaid.. I fail to understand how physicians can deny the role of the NP. In fact, most physicians I know welcome their skills. NPs are not in competition with physicians... they are there to expand the ability of patients to be seen and treated or screened for referral in a timely manner. This is not about turf. Interestingly, I've found that younger physicians are more likely to welcome the role of the NP. .
Thu, 10/08/2015 - 10:50am
Besides NP, I would encourage Certified/Licensed Natural Pathic Doctors, ND, to be included in this discussion. I see where people claim to be a ND. But when I look them up in the national registry for ND's I do not see their name listed. In order to be an ND, one has to take 4 years of medical school and pass the national tests. Some claiming to be a ND have taken some classes but have not taken extensive course work or taken the national test. However, having ND's approved I believe would certainly help with medical care in Michigan. For those that might think I am a ND,I am not an ND. Bob
Fri, 10/09/2015 - 4:10pm
We all are concerned about errors and mis diagnosis.. Even doctors are not perfect. However convenience is importantas wel aws time saved.My suggestion: grant them prescription writing priviliges BUT the law permitting it wikk exopire in two (2) years.The MSMS and the MNA will evaluate how it works out..All pharmicists must keep a separate record of nurse written Prescriptions . If all goes well, the law can be renewed.
Sat, 10/10/2015 - 6:39am
I support expanded roles of both a Physician Assistant and a Nurse Practioner - a Nurse with a BS and MS in Nursing. Programs must be developed and smartly integrated in a particular practice - specialty with a certification. If we want to lower health care costs, we need to seriously consider Cash-only payments by the recipient for certain procedures. Basic office visits, xrays, basic Blood Panels, stitches, etc. Decades of having company health insurance pay for everything like in the Auto Industry has raised the cost of healthcare so that one needs some sort of insurance for basic medical services. Insurance as a employee benefit for Dental Services has had the same effect on Dental Care Costs. There is no reason that a Dental Crown should cost approximately $1000 for somebody without Dental Insurance. If people had to pay for basic services, that Dental Crown Cost would drop by 30-40%! Until we tackle this business medical cost model, everything else is insignificant in lowering healthcare costs.
Sat, 10/10/2015 - 2:44pm
In a health care system that is collapsing and doesn't really know where the money will come from, we need to move forward and follow the evidence. There is no evidence to suggest that outcomes are any better with a physician providing your primary care. The biggest obstacle to overcome is the perception that "a physician must be better than a nurse". Of course, physicians are going to say that their training is better, but I have noticed in print, they always seem to exaggerate their training hours and downplay the experience that nurses receive during theirs. Just because nurses don't give the experience that they receive the first few years out of school a name (like a residency) doesn't make that experience less valuable. Michigan needs to follow the lead of other states that have already figured out that advanced practice nurses can alleviate some of the cost burden as well as serving many of the rural areas that have difficulty attracting physician providers. Patients are not dropping dead in these states. They're receiving cost effective, high quality health care. APRNs need to be practicing to the fullest extent of their education/training and licensure.
Fri, 10/16/2015 - 10:03pm
I really like your response, it aligns right with my thoughts on the entire issue. I have argued with people for years over this. Just because we don't call our post school experience a residency doesn't mean that we don't have any real experience and training that translates into the real world. I used to work in the open heart ICU and I know all of that experience working in that unit was an asset to me when I had to diagnose cardiovascular disorders, read ekg's and order and interpret laboratory tests that were pertinent to my patient's care. I just wish that more people would wake up and see what's going on here!
Sun, 10/11/2015 - 9:35am
They, ( Mastered prepared Nurses, do a great job at improving the medical care of impoverished areas, like up state Michigan, and in hospitals, also. Nurse practitioners saved my life a few times. It is not a question of either or, but Mastered prepared Nurses are a great addition to improved medical care.
Tue, 10/13/2015 - 8:31pm
The regulatory environment in Michigan contradicts all evidence and national recommendations. It causes harm to patients because it limits patient access to the cost-effective, high quality care which nurse practitioners have been proven to provide. It's time our legislators listened to the people (and the evidence, and the outcomes, and the national recommendations) and created an environment which is not hostile to NPs and patients. Nurse practitioners are educated, experienced, and board certified in their areas of speciality. They should be able to provide the high quality care they were trained to provide without impediment.
Fri, 10/16/2015 - 8:31am
Michigan legislators need to listen to the data and make decisions based on over 30 years of high quality outcomes from Nurse Practitioner care. Limits placed on NP's and the failure to pass independent practice legislation is based on the arrogant need for power and control from the MSMS. This is hurting the people of Michigan. We need the consumer to communicate with their legislators and share the quality of their experience with NP's, so their voice is louder than that of MSMS. The practice environment in Michigan is becoming more and more arduous for NP's. There will be a brain drain of quality NP's to other states with more favorable practice laws. I've been in practice for 25 years and starting to think about moving to Colorado for the favorable practice environment. It's time Michigan joins the 22 other states and pass laws for independent NP practice. Have a 3 year collaborative agreement with a physician for new grads, but then let the shackles be off! Let the patients decide who they want to see, and let the NPs provide their high quality care within the scope of their practice.
Tue, 06/07/2016 - 9:46pm
Julie, Things may have changed, but the last I heard, Colorado requires 2 years of physician oversight before an NP can obtain prescribing rights. EB
Sun, 10/25/2015 - 10:23pm
NP's are great for basic care. However, I was denied acceptance by a NP because I was taking Tylenol 4 for chronic pain. The NP states that she will not deal with any sort of pain issues. Who wants a provider that can't even handle your pain. They should still not deny you care, they can always refer you out. Patients that are in pain should be treated as people too. If you go into medicine not wanting to deal with patients in pain, you picked the wrong field.
Thu, 11/05/2015 - 3:37pm
Julie, if they cannot deal with what 100 million US Citizens have (Chronic Pain) then they should NOT be seeing any patients -- no cherry picking the "best patients" and leave those with chronic conditions to others --- Chronic Pain is a serious, SERIOUS issue and We need to speak up more *(esp. with the CDC trying to limit amounts due to politics of the Heroin ODs). \ NP demonstrate you take all, and take good care of ALL (no matter the condition). It might have been C2 meds as I do not think they can prescrrbe them, but that us an excuse as they can track the Doc down, explain, and have him Sign. Ever since Kevorkian died, chronic pain gets very little attention -- but it is an overwhelming issue (most do not want to deal with)....its sad and please note the above....
Tue, 06/07/2016 - 9:45pm
Julie, I know many physicians who avoid primary care because they do not like to prescribe narcotics. By avoiding a pain patient, they avoid having to decide if a patient is being honest or drug-seeking. This is not specifically a NP issue. It is an issue faced by all prescribing providers. EB
Jeff M.
Wed, 10/28/2015 - 6:35pm
Funny enough we in Ohio are fighting this same battle. Saying that care from Advanced Practice Registered Nurses is "unsafe" or "dangerous" is unfounded and is essentially beating a dead horse. Several studies measured outcomes and found NO DIFFERENCE in outcomes between physicians and APRN's. For the physicians, its all about the INCOMES and not about the OUTCOMES. They believe APRN's are a valuable asset to the medical community, as long as they are under THEIR control and they are collecting fees and billing from them. Michigan and Ohio need to recognize the full scope of Advanced Practice Registered Nurses. Quit playing politics and make a move in the right direction.
Tue, 06/07/2016 - 9:41pm
Physician education is often exaggerated. An individual topic can be as short as 2 weeks. Undergraduate training may or may not be a science degree with 3rd year biochemistry. There are US schools that accept an arts degree. In many countries, an undergraduate is not required for entry into medical school. The other assumption is that 100% of medical school training is exclusively hard medicine. The primary difference is one follows the medical model, the other the nursing model. In terms of "core education", between a BSN and MSN, the actual time spent in core curriculum appears to be similar - in the neighborhood of three years. NP's; however, do miss some things: surgical rotation, as an example. That said, that is not in the scope of practice for a NP. A surgical rotation is not necessary to diagnose the common cold. There is a way to settle most of the argument. Make residencies part of NP training. I feel that the benefit would be two-fold. Completing a residency in the medical model would curtail the training argument. A NP residency could potentially increase nurse practitioner acceptance by physicians. A "meeting of the minds", if you will. Finally, NP training does not currently focus on case studies, and working up patients. The clinicals for NP's are short. That is where I truly see a difference in the training. Before anybody decides to flame me, I was pre-med. Now, I'm soon to be an NP, by choice. I prefer the nursing model and patient-centric view of care. I will be applying for residencies... the few that are available.