Instead of requiring supervision by a doctor, Virginia’s new law requires nurse practitioners to be part of a doctor-led “patient care team.” And instead of limiting doctors to overseeing just four nurse practitioners, the law allows them to work with up to six. Most important, it removes a requirement that doctors regularly work in the same location as the nurses they supervise. Instead, the statute allows doctors and nurses in separate locations to use telemedicine techniques to collaborate.
The American Medical Association and the American Academy of Family Physicians have called Virginia’s first-of-its-kind law a model for other states that still require on-site doctor supervision of nurse practitioners.
According to Dr. Cynthia Romero, who was president of the Virginia Medical Society when it negotiated with the Virginia Council of Nurse Practitioners to create the law, “the turning point was when both sides realized that the primary focus had to be what was best for patients.” She says the new law is a step forward for patients and builds a bridge between doctors and nurses. “The road ahead is limitless,” she says.
Mark Coles, the chief negotiator for the nurse practitioners' council, is less enthusiastic but says the law represents progress. “It gives us a seat at the table in the legislature for future improvements,” he says.
But in certain parts of the state, nurse practitioners say the new law may be a step in the wrong direction. They worry about new language that requires them to consult with supervising doctors on all “complex” cases. Although rules scheduled to be released next month may clarify which cases are considered complex, some nurse practitioners fear the definition may be subject to differing interpretations.
The American Academy of Nurse Practitioners and other nursing organizations recently issued a position paper opposing the whole idea of requiring nurse practitioners to join a doctor-led team if they want to practice to the full extent of their training.
“We broadly support team-based care when it reflects the needs of patients, says Tay Kopanos, head of government affairs for the academy. But when a nurse practitioner can’t bring her best efforts to a clinic without joining a doctor’s team, Kopanos says, “we do not support it.”
Difficult terrain
About 300 miles southwest of Buckingham County – in the Appalachian Mountains where Virginia shares borders with Tennessee and Kentucky—the shortage of health care providers is profound. Working out of a converted recreational vehicle known as the Health Wagon, two nurse practitioners, Teresa Gardner and Paula Meade, do their best to serve a four-county region where idle coal mines have left many jobless and without health insurance.
The non-profit Health Wagon, started in 1980 by a Catholic missionary, has expanded its reach over the years to meet the growing demand of a population that is sicker than most in the country. But the steep and winding roads, often coated with heavy snow and ice in winter, make it dangerous and sometimes impossible to reach everyone in need.
At the Central Virginia Community Health Center in Buckingham County, where doctors and nurses practice side-by-side, the new Virginia law may not present a problem. The kind of ongoing collaboration between doctors and nurse practitioners called for in the law happens naturally in the course of every day. The same thing goes for doctors and nurse practitioners working together in hospital settings.
But, Meade says, team collaboration could be dicey in the hollers of Appalachia. “I’d love to start every day with a multi-disciplinary team meeting,” she says. “Nothing would make me happier.” Driving a mobile unit along treacherous highways and seeing at least 45 patients every day in cramped quarters, however, doesn’t leave much time for meetings.
Sicker than most
What she and Gardner fear most is the requirement in the Virginia law that nurse practitioners consult their lead doctor on all “complex” cases. Gardner and Meade collaborate with each other throughout every day and they often seek advice from their volunteer supervisor, Dr. Joseph Smiddy, who at 70 years old, still has a day job practicing medicine across the border in Kingsport, Tennessee.
“Dr. Smiddy would murder me if I called him every time a complex case walked through the door,” Gardner says. “They’re all complex. Most of them are train wrecks. I’d love to treat someone with a common cold.”
For his part, Smiddy says any law that would increase the pressure on nurse practitioners willing to work in remote mountain areas has got to be the wrong approach. He plans to ask his lawyer to review the statute to see whether it increases his own medical liability as a volunteer team leader.
He agrees that nearly all of the Health Wagon’s cases are complex, no matter how the law defines that term. The area has a high incidence of COPD (chronic obstructive pulmonary disease), heart disease, diabetes, obesity, cancer, prescription drug abuse and mental illness. More than a few patients have 10 diagnoses, Smiddy says, and many are on 30 different medications.
“Teresa and Paula are brilliant doctors," Smiddy says. "They need to be a national example – a model for how to do it for the rest of the country… We’re not ever going to have enough doctors willing to ride around in a mobile unit the way they do. They’re the real deal. We need to do everything we can to support them.” he says.
*Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.
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