Independent Nurse Practitioners Bridge Big Gaps in Rural Care
What can California learn from Colorado?
SAN LUIS, Colorado — When Francisco and Ramoncita Medina heard about the planned retirement of their longtime doctor Joseph Quintana, MD — the only physician in this rural town — they worried they’d be forced to move. The Medinas, both in their 70s, knew Quintana as their lifeline to care for diabetes, blood clots, glaucoma, asthma, gout, and more. Given Francisco’s hand tremor, his declining vision, and the slick winter roads, driving an hour to the nearest town of Alamosa for their frequent medical needs wasn’t feasible.
For several years, Quintana had been planning to semiretire from Valley-Wide Health System’s San Luis Clinic as soon as a young physician moved to the area to became part of the 27-clinic operation, which serves a vast area of southern Colorado. But a small town without a pharmacy or a coffee shop isn’t very attractive to a young doctor. Like others before her, the young physician lasted only three years in San Luis. “A lot of people don’t like it here because we’re in the middle of nowhere,” said Quintana, who was born and raised in the town. The town of 630 residents is 225 miles south of Denver and surrounded by picturesque, jutting mountains. Much of the local economy is based on ranching, farming, and trade jobs.
But in 2017, access to health care in San Luis grew stronger. Christy Smith, a nurse practitioner (NP) trainee and San Luis Valley native, contacted Quintana. She wanted to fulfill requirements for clinical rotations by working alongside the doctor, and she was eager to stay in the community after graduation because her husband farms potato, barley, and alfalfa there. The limitations that drove away outsiders were the very things she loved about San Luis. Over the next year she observed Quintana and started treating his patients at the Valley-Wide clinic on a team with two full-time medical assistants, a part-time physician assistant, a behavioral therapist, and a case manager. The clinic also offers dental and physical therapy services.
“I had confidence from the beginning that she could do my job well, because I believe nurse practitioners can handle 90% of primary care cases without any input from a physician,” Quintana said. “Many of the people I see come in for respiratory illnesses, urinary tract infections, back pain, and routine monitoring for hypertension or diabetes.” He was impressed by Smith’s patience and willingness to teach disease prevention and management and to explain the benefits of a healthy diet, exercise, and weight loss. By the time Quintana retired, Smith had become a certified family nurse practitioner (FNP-C), and in July 2018 she officially began seeing his patients. Quintana agreed to advise her about more complex cases, such as unidentifiable rashes or uncontrollable hypertension. As she gained experience, her calls to him became less frequent.
Limitations in California
If Smith were in California or 21 other states (PDF), she would not have the legal right to practice independently. Despite research showing that restrictive policies inhibit patients’ access to care and increase hospitalizations and emergency room visits, nurse practitioners in those states aren’t permitted to practice and prescribe without physician oversight. Meanwhile, 28 other states permit NPs to prescribe a wide range of medications and practice without a formal physician oversight agreement, though some states restrict NPs from prescribing scheduled medications or have other policies that could limit their practice authority. States like Alaska, Arizona, Iowa, New Hampshire, Oregon, Rhode Island, and Washington allow NPs to practice autonomously. A 2018 report by Joanne Spetz, PhD, of the Healthforce Center at the University of California, San Francisco, outlines the policy contradictions.
Even though the California physician supply is projected to meet less than half the demand for primary care by 2030, proponents of restrictions on nurse practitioners in California argue for ongoing physician oversight to safeguard quality care. But Jeffrey Bauer, PhD, a medical economist and health futurist, who has analyzed nurse practitioner performance for a half century, said data have not borne out this concern. “I’ve never found a single published article that contradicts the fact that nurse practitioners perform at least as well as physicians, and they do it at half the cost,” said Bauer. He studied more than 300 peer-reviewed citations for his new book, Not What the Doctor Ordered: Liberating Caregivers and Empowering Consumers for Successful Health Reform. “There is no longer an excuse for restricting the full practice authority of nurse practitioners.”
In states like Colorado, physicians and patients are reaping benefits from independent nurse practitioners. Tillman Farley, MD, chief medical officer of Colorado’s Salud Family Health Centers, said doctors alone cannot meet the needs of uninsured patients and those with low incomes in his area.
“The 20 nurse practitioners in our system are very helpful with the demand and are more likely to choose a career serving low-income patients,” Farley said. “I’ve observed that nurse practitioners are also more likely to spend extra time with people because they are good at listening and tend to work collaboratively with patients rather than hierarchically.” NPs are ideal providers for well-woman and child exams and for routine care for colds and chronic conditions, and that frees physicians to focus on difficult cases, said Farley.
In 1989 a similar division of labor developed in Durango, a southwestern Colorado town a few miles from the New Mexico border, when nurse practitioner Karen Zink, WHNP-C, MS, established a women’s health practice with a colleague. “It was a win-win situation,” said gynecologist and supporter Lloyd Lifton, MD. “They regularly referred surgical cases that allowed me to use the full extent of my training, and I would send patients with menopausal symptoms to Karen because she has a special interest and expertise in that area.”
During Zink’s clinical training, Lifton mentored her and trusted her as a provider. When she graduated, Colorado law required NPs to form a collaborative agreement with a physician to practice. Lifton agreed, which meant Zink’s prescriptions were sent in Lifton’s name. She had to develop a copious list of protocols for the dozens of conditions she treated and submit them for review by him.
Zink eventually started lobbying Colorado lawmakers for fewer restrictions on nurse practitioners. After many years of trying, the state legislature changed the law in 2010 to allow NPs to practice independently after 3,600 hours of mentored prescribing. Zink had already fulfilled this requirement years earlier, so she was free to practice independently right away, but many new nurse practitioner graduates in Colorado were not as lucky. Many struggled to find physicians willing to invest the time to mentor NPs for two years, and new graduates were leaving the state. In 2015, the regulation was revised to 1,000 hours of mentored prescribing.
Keeping Women Healthy
As an independent practitioner, Zink controls the ambience in her patient rooms and the time allocated to each appointment. She spends an average of 30 minutes per visit. Patients sit in an upholstered, cushioned chair when she confers with them about lab results, anxiety, insomnia, menopause, depression, and sexual matters. She works with an NP partner and employs a registered nurse, a licensed vocational nurse, an office manager, and a receptionist.
Kim Dinallo, 58, of Farmington, New Mexico, started seeing Zink 10 years ago for depression after a hysterectomy. Dinallo’s gynecologist had not recommended any treatment, and Dinallo’s sister suggested Zink. “I could not get out of bed, I cried easily, and I dreaded going to my job as a fifth-grade teacher,” Dinallo said.
Dinallo noticed that Zink was different from physicians. “She is personable, regularly sends me information, and is holistic in her approach,” said Dinallo. After Zink suggested that Dinallo try taking the antidepressant Wellbutrin and hormone replacement therapy, the symptoms vanished. Since then, Zink has helped Dinallo navigate dietary changes to prevent the recurrence of diverticulitis and to reduce the risk of heart disease.
At a recent appointment, the two reviewed blood tests showing elevated triglyceride levels. “Simple carbohydrates can drive up these levels, and triglycerides in women are predictive of heart disease and diabetes,” said Zink. After they methodically reviewed several days of Dinallo’s meals and snacks, Zink encouraged her to snack on celery with peanut butter rather than sugary fruits and to use real cream with coffee instead of a processed, sweet creamer.
A discussion like this takes more time, but Zink sets her own priorities. She prefers scheduling longer visits even if that means earning less money. “I am a nurse and I love women, so I enjoy talking about their mood swings, lack of libido, obesity issues, hot flashes, hypertension, diabetes, and everything else involving primary care” said Zink. “But it has taken years and years to gain full practice authority in this state.”
As political debates persist about whether nurse practitioners should have the right to practice independently, millions of Americans coping with shortages of health care providers sense their health and well-being are hanging in the balance.
“The critical issue at stake is access to care for underserved populations living in remote and rural areas as well as urban centers,” she said. “There is a significant body of evidence showing that the expansion of nurse practitioners’ practice authority will serve these populations well, especially as health workforce shortages loom large.”