Doctor shortage spurs law request
State's Nurse Practitioners want Independence
Friday, Jan. 22, 2010
By ALAN BRODY - Staff writer
ANNAPOLIS — Short of performing major surgery, Lorraine Diana is authorized to do just about anything that a licensed physician can at Hollywood-based Shah Associates: write drug prescriptions, diagnose conditions, order medical tests and refer patients to specialists.
But as a nurse practitioner, Diana must enter into a collaborative agreement with a doctor to provide health services, a requirement that has become increasingly difficult to fulfill as the shortage of primary care providers in Maryland gets worse.
That's one reason why nurse practitioners are asking state lawmakers to eliminate the collaborative agreement mandate that they say blocks timely access to health care and is a poor use of resources.
"What it really does is get rid of an outdated practice," said Diana, a Waldorf resident who serves as legislative chairwoman of the Maryland Coalition of Nurse Practitioners.
Rural areas of Maryland are particularly affected by the lack of physicians. Southern Maryland has just 13 percent of the primary care providers it should have, according to a 2008 report of the Governor's Task Force on Health Care Access and Reimbursement.
"Our primary health care system is crumbling," said Susan Delean-Botkin, a nurse practitioner who owns a 5,000-patient practice on the Eastern Shore.
As a result, nurse practitioners are leaving the state because there are fewer physicians with whom to collaborate.
"The issue is not having enough physicians to sign [the collaborative agreement]," said Diana, who specializes in gynecology. "We need them in order to practice."
But the powerful state physicians' lobbying group, MedChi, is opposing the measure on the grounds that the two sides can improve the collaborative agreement without eliminating it legislatively.
"We don't think they should take a sledgehammer to the statute because of some specific concerns," said Gene M. Ransom III, executive director of the Maryland State Medical Society. "I hope that the two groups can sit down and try to collaboratively work something out that is best for our patients and best for medicine generally."
Just last year, a similar conflict over the collaborative agreement between nurse midwives and physicians was resolved without legislative action, he said. That could serve as a model for discussions with the nurse practitioners, Ransom said.
"It is disappointing to me that we are down in Annapolis fighting before we've had a chance to sit down and work collaboratively," he said.
Advocates say their proposal would remove administrative hurdles, decrease paperwork, accelerate collaborative agreement applications and give the state Board of Nursing total oversight of nurse practitioners, as is the case in 27 states.
Currently, collaborative agreement applications take at least two months, and up to six months, to be reviewed by both the Board of Nursing and the state Board of Physicians, they said. That costs money and restricts some patients from receiving care in a timely fashion, Diana said.
The change would have no impact on existing malpractice insurance rates for nurse practitioners, she said. It would also allow nurse practitioners to volunteer at health fairs, perform student-athlete physicals and work on so-called "sickmobiles."
Two Southern Maryland lawmakers are championing the legislation: Sen. Roy P. Dyson (D-St. Mary's, Calvert, Charles) and Del. Sue Kullen (D-Calvert).
The bill does not change nurse practitioners' scope of practice and does not give them any greater medical authority than they have now.
"This does not allow them to become doctors," said Julia Pitcher Worcester, a lobbyist for the nurse practitioners.
The collaborative agreement mandate has complicated matters for P. Michael Patterson, a nurse practitioner in La Plata who took over Dr. Charlene A. Letchford's 4,000-patient practice in September.
Patterson has been searching for a new collaborating physician to replace Letchford, who now works for a hospitalist group at Civista Medical Center and wants to sever ties with her old practice.
Letchford has agreed to continue collaborating with Patterson until he finalizes a new partner agreement, which he said has been difficult given the deficiency of doctors and the cost for nurse practitioners.
"It's an extreme drain … and there is no real need for it in my opinion," Patterson said of the lengthy collaborative agreement. He pointed to research that shows nurse practitioners provide care that is equivalent or better than primary care physicians.
Patterson said he usually consults with specialists, not the primary care providers with whom he officially collaborates, when he has questions about his patients.
For instance, a cardiologist is better trained to answer questions about a patient's heart condition than a primary care provider, he said.
"The key to survival as a nurse practitioner is to have a good connection with your specialists," Patterson said.