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California Considers Expanded Roles for Nurses in Primary Care

Apr 24, 2013

Credit Andrew Nixon / Capital Public Radio

Most counties in California have a shortage of primary care doctors. And with millions more people in the state expected to get health coverage next year, lawmakers are proposing ways to make sure basic care is available in areas that need it. One bill would allow nurse practitioners to treat patients without consulting a physician. Health care reporter Pauline Bartolone reports on what it might mean for patients.

Some nurse practitioners in California already see patients without a doctor in the room. Patients like Anastacia Casperson.

Casperson has struggled with homelessness and drug addiction, Now, she's at Glide Health Services, a clinic in San Francisco's Tenderloin district.  

Clark uses the visit as an opportunity to ask about other health matters - like her efforts to quit smoking. After a half hour visit, Casperson left with a prescription. She says she's been coming to this clinic for a few years.

"They have compassion for a client. They have understanding for a client," Casperson says. "I like the nurses here. Because they're like one big family, they all work together.

This clinic is run by nurses with advanced training. Nurse practitioners - or NPs - in California have at least a masters' level education.

A physician visits 12 hours a week, to sign forms and consult on difficult cases. A bill in the California legislature would allow more nurse practitioners to provide primary care independently. Supporters say that would enable more people to get care in inner cities and rural areas.

"It's difficult to get primary care physicians to work in a place here because the pay is low oftentimes and there's more money in specialty practice," says clinic manager Karen Hill.

"Housing is incredibly expensive here if you want to raise a family. And the population is difficult."

But Hill says this clinic wasn't started because of a lack of physicians. It was established with help from a nursing school, seeking to serve a vulnerable population.

"In reality there's a lot of what we do around education, and teaching and following up and coaching, that's really what makes a difference in a room," says Hill.

But physicians oppose lifting restrictions on nurse practitioners. 

"Nurses and nurse practitioners are a very, very important part of the healthcare team, but they are part of a team," says Dr. Paul Phinney, President of the California Medical Association.

Phinney says nurses have less training, and are not as experienced in testing and technology. Plus, he says, expanding the roles of nurse practitioners won't help the doctor shortage. N.P.s are already busy with patients.  

"It's very important as we move forward to use teams creatively to create higher levels of safe, high-quality care," says Phinney. "We need to keep those teams together. We don't need to dis-integrate our healthcare teams."

Phinney says the bill before lawmakers doesn't require nurse practitioners to work in a team as Glide does. So nothing would stop an NP from 'hanging a shingle' for a medical practice in Beverly Hills.

"I would be very surprised should this bill pass that all of a sudden you'll see a massive egress of nurse practitioners out into medically-underserved areas. I just don't see that happening," he says.

But University of California San Francisco health care economist Joanne Spetz says nurse practitioners are more likely to serve the poor and in rural areas.

She says they can be trained much more quickly than a physician. States have varying degrees of restrictions governing nurse practitioners, she says, and California falls in the middle.

"Nurse practitioner care is very safe. It's very effective. Patients tend to be very satisfied with it. And there's absolutely no evidence that restrictive barriers to their full practice have protected patients or saved anybody's life. There's a fair amount of evidence that those kinds of restrictive barriers inhibit access to care and prevent access to care," says Spetz. 

The nurse practitioners at Glide say they'll keep their physician, even if California's law is changed to give them more independence.