On March 30, 2020, Governor Edwards passed an executive order that would allow nurse practitioners to practice independently in Louisiana. The executive order was spurred on by the COVID-19 pandemic, during which residents found themselves unable to access appropriate healthcare.
“We have been doing this for over a year now. When the state needed nurse practitioners, we stepped in and we stepped up to provide as much health care as possible to areas that do not have access, and we’re talking about the rural communities,” Dr. Sandra Brown, Dean of the College of Nursing and Allied Health at Southern University Baton Rouge commented. “We’re talking about communities where there may be one physician to serve 13,000 patients.”
The executive order was so successful in improving access to health care that Representative Barry Ivey sponsored House Bill 495 which will make the order permanent. Currently, nurse practitioners are required to have a collaborative agreement with physicians, so although they may own clinics, prescribe medication, and see patients on their own, they need to have a doctor available by telephone to actually operate, imposing limitations on their financials and where they can set up clinics.
Nurses view the collaborative agreement requirement as expensive and unnecessary since they practice relatively independently anyways. It can cost a nurse thousands of dollars a month to have a doctor “on-call” although the physician collaborator may never end up coming to the clinic, reviewing patient care, or even be contacted at all.
“There are some people who have never even met their collaborator,” commented Kathy Baldridge, the president of the Louisiana Association of Nurse Practitioners. “In the 12 years that I have been a nurse practitioner, I have never called my collaborator with a patient question.”
Not to mention, needing to have a doctor on call can be a burden to not only nurse practitioners but also patients. “Something happens to this physician, all five clinics shut down. That means that all the patients, which is almost the entire parish, don’t have access to care,” said Baldridge.
“The bottom line is, patients will have access even if for some reason we lose our collaborator or if our collaborator is not available by phone,” explained Baldridge. “This happened in the Shreveport area…Nurse practitioners opened a clinic to serve their community that they grew up in, the majority of which was a Medicaid population. Their physician was part of the military, moved to another state and they couldn’t collaborate with him in another state. They tried to find a collaborator, unfortunately, the cost was cost-prohibitive to keep the clinic open and the clinic closed. Those patients are completely out of care. Now they have to go to LSU Health Sciences Center in the emergency room to receive primary care.”
Access to primary care is a huge issue in Louisiana, especially in rural areas. 95% of Louisiana residents live in primary care health professional shortage areas. This in part is due to less than 12% of all Louisiana physicians being primary care providers. However, 69% of nurse practitioners deliver primary care, offering a solution to Louisiana’s shortage problem.
According to Eric Peterson, a director at the Pelican Institute for Public Policy, Louisiana has an average of 26 physicians for every 10,000 residents. In big cities like New Orleans, that number is closer to 35 per 10,000 residents while in 15 rural areas in Louisiana there are fewer than 5 physicians per 10,000 residents.
“States that have done this have tracked the movement of nurse practitioners, and they have found that there is an increase of access to primary care in those rural areas because nurse practitioners, with the removal of that barrier, do move to those rural areas,” said Baldridge.
The bill has received bipartisan support from lawmakers who are worried about the lack of physicians in the state. “The gap for access to care is only widening,” said Representative Ivey at an earlier committee hearing. “That is what this bill is about; it is about access to care. This bill will save people’s lives.”
The bill passed in the House at the beginning of the month and is currently on its third reading and final passage in the Senate. While nurses support HB 495, some doctors have come out against it saying patient safety will be at stake. Nurse practitioners have disputed this, pointing to the two dozen states that have enacted this type of legislation without patient safety problems. In fact, eight of the ten healthiest states in the US do not mandate collaborative practice agreements.
“We are trained differently, removal of this collaborative practice agreement does not change what we do, we will not be doing more, we will be doing the same, but with the removal of a restriction so that we can be mobile and move to those parishes that need us the most, where we can provide access to those patients that don’t have access to care,” explained Brown. “We stay in our lane, we assess the patient, we identify the diagnosis, we come up with a treatment plan, and we know when to refer…we’re still going to be referring collaborating, and engaging with physicians, we’re not going to be on an island of our own.”
An amendment was added to the bill in the House that would require nurse practitioners to work 6,000 to 10,000 hours with a licensed physician before they can operate independently. An amendment was also added that would create a new board to provide oversight to nurse practitioners operating without collaborative agreements. Both amendments are projected to make the bill more palatable for its opposition, handily addressing their concerns.
