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.
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.
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.”
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.