Two bills would remove limits on nurses' ability to practice

Nurse practitioners say existing Missouri laws are preventing them from providing the best possible care to their patients, and lawmakers seem to agree.

Comprehensive reform bills revising the regulations that govern advanced-practice nurses have been introduced in the Missouri Legislature this session.

The changes would apply to nurse practitioners, certified nurse midwives and clinical nurse specialists.

"We here in Missouri, we find ourselves having some of the most restrictive statutes and regulations regarding advanced-practice nurses. Yet, on the other hand, we find ourselves with a critical shortage of providers," said Rebecca McClanahan, president of the Missouri Nurses Association.

In Missouri, 109 of the state's 114 counties are designated as health care provider shortage areas by the U.S. Department of Health and Human Services. This includes Cape Girardeau and all Southeast Missouri counties.

Currently, advanced-practice nurses in Missouri must have a collaborative practice agreement with a nearby physician, but House Bill 1371 and Senate Bill 679 would eliminate that requirement.

Sixteen states and the District of Columbia don't require advanced-practice nurses to have a supervisory relationship with another health care provider, said McClanahan, who is also a registered nurse.

The proposed legislation would also allow advanced-practice nurses to prescribe controlled substances, give orders to respiratory therapists and allow them to be reimbursed for care by Missouri's Medicaid program.

Bernita Bell, a nurse practitioner at Midwest Family Care in Cape Girardeau, said she doesn't think collaborative practice agreements are necessary.

"Other states get along without them just fine," she said. "If I moved from Missouri and went to D.C. to work, I wouldn't even have a collaborator. I think every state should be the same."

Midwest Family Care is a nurse practitioner-only practice. It is one of a growing number of similar facilities that doesn't have a collaborating physician on site.

Under the collaborative practice agreements in Missouri, physicians must review a certain percentage of the nurse's patient charts every two weeks. Advanced-practice nurses also must pay physicians substantial fees in order for them to collaborate with them. Physicians are limited to collaborating with no more than three advanced-practice nurses at one time and must be within 50 miles of them.

"Limiting the miles one provider is from another is very archaic," said McClanahan. "With text messaging, emails and telemedicine, those kinds of geographic restrictions just interfere."

Following the Joplin, Mo., tornado, this 50-mile limit prevented advanced-practice nurses who volunteered there from caring for patients.

"These nurse practitioners were highly skilled, ready, willing and able to provide care, but weren't able to because they were more than 50 miles from their cooperating physician," McClanahan said. "They found themselves doing electrical wiring rather than providing care for patients."

Nurse practitioner Kimberly Keser, of AWL Family Healthcare, said her collaborating physician is in Cape Girardeau because of proximity.

"We can't branch out. Maybe we've heard of someone who would be awesome as a collaborator, but they have to be within that 50-mile radius," Keser said. "I don't know any other type of career where you can't practice it without someone else."

In some specialties, such as mental health, and in rural areas it's difficult to find a physician willing to collaborate, she said.

Like Midwest Family Care, Keser's practice also does not have a physician on site.

Keser doesn't have a problem with seeking advice from physicians, but said she doesn't think it needs to be mandated.

"I think it's a good thing, but I don't think it necessarily needs to be in writing. I would collaborate even if I didn't have a collaborative agreement. I would still call people to share their knowledge," Keser said.

Bell, who owned her own practice in Illinois for seven years, said nurse practitioners know when patients need to be referred for more specialized care.

"We're all smart enough to know our limitations," she said.

In Illinois, nurse practitioners are allowed to obtain their own Drug Enforcement Administration number and prescribe controlled substances to patients, but under current Missouri law, a nurse practitioner's collaborating physician must agree to allow them to give prescriptions on their authority and their name must be on the nurse practitioner's DEA number.

Keser's practice does not prescribe controlled substances, but sometimes when a patient comes in who is in severe pain, that's what they need, she said.

"We find ways to work around it, but it's not what's best for patients at all times," Keser said.

This proposed legislation would add advanced-practice nurses to the list of providers who can prescribe, administer and dispense controlled substances and eliminate the need for a physician's name on these nurses' DEA numbers.

McClanahan said studies have indicated that advanced-practice nurses do not provide inferior care.

Both House Bill 1371 and Senate Bill 679 have had their first reading in their respective legislative chambers, but have not yet been assigned to a committee or scheduled for a hearing. A call to the Missouri Primary Care Association was not returned Tuesday.

mmiller@semissourian.com

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