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Nurse practitioners want to change law that requires them to make deals with physicians to prescribe strong painkillers

By Melissa Patrick

May 25, 2017

This story by CHMP Media Fellow Melissa Patrick first appeared on the Kentucky Health News website.

 

Nurse practitioners Julie Gaskins, left, and Beth Partin own Family First Health in Columbia. (Photo by Melissa Patrick)

Since 2006 Kentucky’s nurse practitioners have been able to prescribe Schedule 2 drugs, the highest level of legal painkillers, under the supervision of a physician. Now their lobbying group says it’s time to let them work without that restriction because it creates a barrier to care that is badly needed.

 

Nurse practitioners are advanced practice registered nurses with up to seven years of education, including post-graduate training. They may prescribe medications, diagnose conditions, order and interpret tests, and deliver general care.

 

Once a Kentucky nurse practitioner works under the supervision of a physician of the same specialty for four years, he or she may prescribe drugs on their own for medical conditions such as high blood pressure or diabetes. But to prescribe Schedule 2 drugs such as opioids, they must have an ongoing “collaborative agreement” with a physician to do so, regardless of their experience.

 

“A collaborative agreement is for prescribing only; there is no oversight written into the contract,” said Jessica Estes, a psychiatric mental health nurse practitioner in Lewisport. “The physician doesn’t have to review any of my charts. I don’t have to call the physician every time I write one. I only have to have that collaborative in the event I needed to have a conversation with him,” adding that in her 14 years of practice she has only consulted with her collaborator two or three times.

 

Estes said nurse practitioners are trained to work independently without any supervision over their prescribing. “In fact, I do tele-psychiatry in Minnesota, where I’m completely independent” under that state’s law, she said. “Our scope of practice is actually limited by having to have that collaborator in Kentucky to be able to write those prescriptions.”

 

The American Association of Nurse Practitioners says 22 states and the District of Columbia allow nurse practitioners to practice with no restrictions on prescribing; 16, including Kentucky, have reduced prescriptive authority; and 12 are considered restrictive. Kentucky has more than 5,400 nurse practitioners.

 

Being able to prescribe Schedule 2 drugs is not just about being able to prescribe pain pills, said Elizabeth “Beth” Partin, a 25-year family nurse practitioner.

 

“It’s not always about pain,” Partin said, adding that the lack of a collaborating doctor leaves a nurse practitioner unable to prescribe medications for anxiety, insomnia, shingles, nerve pain, certain cough medicines or attention-deficit hyperactivity disorder – conditions that are often seen in a primary-care office.

 

Nurse practitioners often struggle to find a physician willing to sign an agreement for non-scheduled drugs, but it’s even harder to find one that will sign an agreement for controlled substances, especially since some insurance companies are refusing to pay for a nurse practitioner’s services unless their collaborating physician is also a provider for them.

 

Jessica Estes, psychiatric nurse practitioner in Hancock County, testified at a 2014 Senate Licensing & Occupations Committee meeting about a law that allows prescriptive authority for non- scheduled drugs after four years of supervision. (photo provided)

Estes said the psychiatric nurse practitioners in her group experienced this with WellCare, a managed-care organization for Medicare and Medicaid plans. She said because her collaborating psychiatrist was a private physician who accepted no insurance, the group had to change collaborators and ended up signing with a family practice physician who sees enough psychiatric patients to meet the requirements — and was willing to accept WellCare.

 

“Last year between the four nurse practitioners, we saw about 2,000 visits that were WellCare clients,” Estes said. “If I had not been able to secure that collaborator that also took WellCare, that’s 2,000 patient visits that we would not be able to see in 2017. They would have had to find a new provider.”

 

She owns Estes Behavioral Health, LLC, which serves more than 6,000 patients, an equal mix of adults and children, from 11 counties. She said about 40 percent of their patients are on Medicaid.

 

In “most of the counties that we serve, there really aren’t any other providers,” Estes said. “We’ve not run a single ad in the five years we’ve been open; it’s all word of mouth.”

 

Partin and her daughter, Julie Gaskins, also a nurse practitioner, are co-owners of Family First Healthcare, a rural health clinic in Columbia. Their practice has over 6,000 patient visits a year, with 72 percent of their patients on Medicare or Medicaid.

Traveling from Partin’s clinic in Columbia to Estes’ behavioral- health clinic in Lewisport takes a while. (Google map adapted)

 

Partin said it takes about three to four months for new patients to get an appointment in Estes’ practice, about 124 miles from her clinic. Adair and Hancock counties are in two of the 87 Health Provider Shortage Areas in the state.

 

Psychiatric collaborative agreements are also hard to secure because Kentucky has such a shortage of mental health providers. The Association of American Medical Colleges reports that Kentucky has 362 active psychiatrists, or 1 for every 12,192 Kentuckians, and almost 40 percent of them are 60 or older. Estes said the state has fewer than 150 psychiatric APRNs.

 

“I just had a conversation this week with one of my former nurse-practitioner students who would like to do some private practice on her own, and she’s called seven psychiatrists and they’ve all turned her down, because they are either employees of large organizations or they want an amount of money that she couldn’t afford to pay,” Estes said.

 

While some collaborating physicians don’t charge anything, most charge between $500 and $5,000 a month, or take a percentage of the nurse practitioner’s annual earnings, Estes and Partin said.

 

Estes said psychiatric nurse practitioners in Kentucky who can’t find a collaborator either end up working for a large medical group or hospital, or work in tele-psychiatry in states that don’t require such an agreement.

 

Lobbying and legislating

Legislation to remove the collaborator requirement for prescribing Schedule 2 drugs was introduced during the 2017 legislative session as Senate Bill 158, but did not make it out of committee. The Kentucky Coalition of Nurse Practitioners & Nurse Midwives is in the “early stages” of the legislative process for the 2018 session, said Partin, who has held a leadership role in all nurse-practitioner legislation in Kentucky since 1992.

 

Her adversaries are the Kentucky Academy of Family Physicians and the Kentucky Medical Association, which have said they do not support any change to the law, contending that it would add to the prescription-drug abuse that continues to plague the state.

 

KAFP President William C. Thornbury said in a statement,”Family physicians believe SB 158 conflicts with our governor’s policy to combat opioid abuse.” The KMA said, “With the ongoing issue of prescription drug abuse and the discussions around the country about the issue, we would oppose any changes to the current law.”

 

Senate President Robert Stivers, R-Manchester, who voted against the 2006 bill that expanded nurse practitioner’s Schedule 2 prescription authority, told members of the Senate Judiciary Committee in March that he would be looking into why “half” of the pain pills written in his hometown of 20,000 were written by nurse practitioners — a town that has 12 pharmacies and around 150 opioids prescribed per person each year.

 

Nurse practitioners disputed the alleged connection between the prescribing authority of nurse practitioners and the over-prescribing of opioids, citing data from the Kentucky All Schedule Prescription Electronic Reporting system.

 

“The problem in Kentucky existed prior to our ability to write those controlled substances,” Estes said. “The KASPER data very clearly shows that we are not the providers that are writing the majority of those prescriptions.”

 

Heather Shlosser, director of the psychiatric-mental health nurse practitioner program at Frontier Nursing University in Hyden, said efforts to decrease the number of opioid prescriptions will depend on making sure providers are trained to prescribe them based on evidence-based guidelines — and changing the culture of patients so that they understand that a pill is not always the answer, rather than simply limiting the disciplines that can prescribe them.

 

“Restricting practice is not helping to expand access and it’s not helping to educate the NP any further than where you stop them with the restriction,” she said. “All the literature tells us that the outcomes are the same whether the care is provided by the physician or a nurse practitioner.”

Tammy Adamson, a patient of Partin’s: “I’ve never had an experience here as to where they didn’t give me the time that I needed, and explained things to me.”  
(Photo by Melissa Patrick)

 

Gaskins said nurse practitioners are trained to take a holistic approach to care that focuses on education and prevention along with the use of appropriate medications.

 

Kentucky law only allows psychiatric nurse practitioners to write 30-day prescriptions for ADHD medications with no refills, and primary-care nurse practitioners are limited to a 72-hour prescription.

 

“That’s a huge problem, especially in Kentucky,” said Shlosser, who is also a mental health nurse practitioner in New Hampshire. “Kentucky has the highest rate of children being diagnosed with ADHD, according to the Centers for Disease Control [and Prevention].”

 

The CDC reports that 19 percent of Kentucky children aged 4 to 17 have ever been diagnosed with ADHD, compared to 11 percent of children nationwide.

 

Shlosser added that likely means “a huge number of children” in Kentucky need care for ADHD, but don’t have access to it or have to wait months or drive great distances to get care.

 

“That is not helping the 10-year-old kid that is struggling,” she said. “We are as providers constantly telling patients, ‘Get treatment, get help, you need to get it together,’ but where are they supposed to go if there are no providers?”

 

 

This article was produced as part of the Health Care Workforce Media Fellowship of the Center for Health, Media & Policy, New York, N.Y. The fellowship is supported by a grant from the Johnson & Johnson Foundation. Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Melissa Patrick

Rural Hospitals

By Diana J. Mason

May 25, 2017

I just wrote a blog post for JAMANews Forum on the closure of rural hospitals. It describes why they close and discusses policy responses that could ensure that these hospitals are able to promote the health of their communities in myriad ways, not just by providing acute care services.

As it was being posted, Trump released his proposed budget. If passed, it will accelerate the loss of hospitals in rural communities. When hospitals close, it severely impacts the economic survival of rural communities. The proposed cuts will not “make America great again.”

According to USAToday:

White House Budget Director Mick Mulvaney said it is a taxpayer-focused budget that seeks to help those who really need government assistance while nudging others who need to “get off of those programs” and “get back in charge of their own lives again.” The budget would also make room for tax cuts estimated to cost $6.2 trillion over 10 years, with more than three-quarters going to the top 20% of taxpayers.

But various sources are weighing in to counter the rhetoric that the budget cuts are in the interests of taxpayers in rural America.The proposed budget will damage the health of rural communities in a number of ways. Here are three:

  1. It will slash Medicaid funding beyond the cuts already proposed in the House-passed American Health Care Act. Some rural areas will be the hardest hit. Rural areas have lower household income levels and higher rates of poverty than urban areas. The expansion of Medicaid under the Affordable Care Act (Obamacare) helped poor men gain health care coverage for  which they had previously been ineligible.
  2. It will eliminate telehealth funding. Telehealth is crucial to linking rural communities to specialty services. In my JAMA blog, I noted that the survival of rural hospitals in dependent, in part, on being part of a larger health system that has the specialty services, as well as intensive care. Telehealth enables rural hospitals to remotely access specialty services, including consultations on emergency care. Nurse Kristi Henderson, DNP, RN, FAAN, recognized this years ago when she built TelEmergency, an emergency telehealth service through the University of Mississippi to the remote and underserved rural communities of the state.
  3. It would reduce or eliminate other federal grant programs that help rural hospitals to survive. Rural hospitals have a very thin operating margin, so even small reductions in funding can cripple them and lead to closure. In addition, the budget would slash funding for the state offices of rural health, undercutting communities’ efforts to monitor and address the impact of cuts on health.

Lots of political commentators are pointing out that Trump’s budget would hurt most those who voted for him, including people in rural America. It’s up to Congress to pass a budget. What they pass will determine whether these communities will die or thrive in Trump’s America.

 

Diana J. Mason
Diana is a founder of the Center for Health, Media & Policy, and HealthCetera Radio. She is the President of the American Academy of Nursing, the Rudin Professor of Nursing at Hunter-Bellevue School of Nursing, and a health policy expert and leader. Diana tweets @djmasonrn.

Nurses and Patients and Plagiarism, Part 2

By Joy Jacobson

May 23, 2017

Matt Saunders, flickr

In the six years or so that I’ve blogged at HealthCetera, I’ve written about the use of reflective writing in clinical practice and education, and I’ve examined poems that elucidate aspects of health and health policy. And in that time the post of mine that has been viewed most often—by far—is one I wrote three years ago, “Nurses and Patients and Plagiarism: The Consequences Aren’t Merely Academic.”

 

Why is there such an enduring interest in plagiarism? My post looked at a couple of literature reviews that suggest academic dishonesty among nursing students may have implications for ethical nursing practice. A new search shows the problem is far from resolved.

 

Last November, for example, the UK weekly journal Nursing Standard reported the results of its investigation that found thousands of UK nursing students had committed academic fraud, 79% of the cases involving plagiarism (the article is free but requires a login).

 

And in March Australian researchers Lynch and colleagues published an integrative review on plagiarism in nursing education (login required) in Journal of Clinical Nursing. The study illuminates several fascinating aspects of the plagiarism problem in nursing:

 

  • Students’ cultural or language background does not affect their likelihood of plagiarizing.
  • Many nursing students simply do not understand the basics of referencing and paraphrasing.
  • Inadvertent or accidental plagiarism is common.
  • Students are more likely to plagiarize if they are at risk of failing a course.
  • As unethical behavior in academia becomes “neutralized” and then “normalized” to nursing students, they are more likely to continue to engage in unethical behavior, with serious implications for clinical practice.
  • Some faculty find it an “enormous burden” to deal with academic dishonesty.
  • The threat of punishment has not reduced plagiarism in nursing education.

 

That last point seems important to emphasize. Just today a writer in Inside Higher Ed, Jennifer A. Mott-Smith, suggests that unless a student submits a paper she paid someone to write or copied and pasted it entirely, academic plagiarism should not be punished—that it instead should be seen as a teaching opportunity to help students “continue to practice the difficult skill of using sources.”

 

That has been my approach as a writing instructor with nursing students. But this can’t mean pretending it’s not happening. Rather, it requires something extra from nursing faculty and institutions—namely, real time spent on teaching writing as a process in which the student learns to think. Otherwise, the copying culture will not abate.

 

I’d like to hear from others, both nursing students and faculty. Is plagiarism an issue for you? How have you handled it?

Joy Jacobson
Joy Jacobson is the CHMP’s poet-in-residence and cofounder of our Writing Reflective Narratives for Clinicians program.