Nurse Practitioners May Win Right To Go Solo

Paul Bass PhotoNurse practitioners would be allowed to treat patients and prescribe medications independently under a proposal by Gov. Dannel P. Malloy’s administration, a potentially significant—and controversial—change in the medical landscape aimed at expanding access to primary care.

The ability of nurse practitioners to work independently of doctors has long been an issue of contention between the two professions, and states vary widely in how they allow nurse practitioners to practice.

But the federal health law commonly known as Obamacare puts the debate in a new context: The expansion of insurance coverage to thousands more people is expected to raise the demand for primary care, at a time when the state already faces a shortage of primary care doctors and an aging physician population.

Connecticut law requires nurse practitioners—also known as advanced practice registered nurses, or APRNs—to practice in collaboration with a licensed physician. The Malloy administration’s proposal would still require APRNs to work in collaboration with a physician for the first three years after becoming licensed. But after that, an APRN would be allowed to practice alone.

“We’d like to see increased access to health care at lower costs, and that’s what this will give us,” said Anne Foley, undersecretary for policy development and planning at the state Office of Policy and Management, Malloy’s budget office. “We really do feel that the studies are indicative that APRNs can provide comparable outcomes compared to physicians.”

APRNs in Connecticut are required to have a graduate degree in nursing or a related field and certification from a national organization that certifies nurses in advanced practice.

Physicians have opposed previous legislative efforts to allow nurse practitioners to practice independently, saying that lawmakers shouldn’t reduce the training and education needed to provide medical care. And some doctors have argued that if APRNs practice independently, patients wouldn’t necessarily have access to a doctor to help address complex issues.

The fact that this year’s bill comes from the governor gives it added weight in the legislative process. A measure last year that would have made similar changes, added as an amendment to another bill, had enough support to pass the House but was never taken up for a vote, Foley said.

Barrier or Benefit?


Until 1999, Connecticut required APRNs to be supervised by doctors. Then lawmakers changed the requirement, calling instead for nurse practitioners to work “in collaboration” with a physician.

But nurse practitioners have said that the requirement still presents barriers to those who want to open their own practices. In some cases, nurse practitioners have had trouble finding a collaborating doctor or faced unreasonable demands from the collaborating physician or fees as high as $30,000 per year, according to the Connecticut Advanced Practice Registered Nurse Society.

In a survey, the society found that 22 of 94 members had negative experiences with mandatory collaborating agreements.

“Respondents noted that physician retirement, death, re-location, or other severance of the mandatory agreement, automatically renders the APRN practice illegal,” the organization said in a 2012 report submitted to the state Department of Public Health.

“Many fear having to involuntarily abandon their patients,” the group wrote.

The APRN society has argued that nurse practitioners would still work with other health care providers in caring for patients, but that removing the requirement would improve patient access to APRNs and could allow for innovation in care delivery, such as the creation of nurse-managed health centers in underserved places like rural areas or housing projects.

A Review by DPH

After receiving a request from the APRN society, the state health department launched a review of the scope of practice requirements for nurse practitioners. The review committee included representatives from 23 groups.

Public Health Commissioner Dr. Jewel Mullen said the process “did not uncover any documentation to suggest that the elimination of the collaborative practice agreement impaired safety.”

Mullen, a primary care physician who said she has worked with nurse practitioners since medical school, said it’s important to note that the proposal would not turn APRNs into doctors.

“It’s not a proposal to suddenly say, ‘The playing field is equal,’” she said. “The governor’s proposal is around patients’ access to health care.”

Ken Ferrucci, senior vice president of government affairs at the Connecticut State Medical Society, said the physician organization understands concerns about access to health care but wants to make sure that APRNs aren’t simply being used to fill the role of doctors.

“We would like to think that if this is a policy decision that legislators and the administration want to make, there needs to be a discussion as far as patient safety issues, understanding of training and education, and ability to prescribe medication without any collaboration of a physician,” he said. “And if there are going to be increased independence then there just needs to be increased understanding of what the capabilities are.”

Mullen said it’s also critical to ensure that doctors choose and stay in primary care, including by increasing their compensation.

“We’re not going to totally fix the problem [of a shortage of primary care doctors] by just eliminating a collaborative practice agreement,” she said. “We need doctors, too.”

Mullen noted that the proposal doesn’t allow a nurse practitioner to come out of training and practice independently, since he or she would need to work in collaboration with a doctor for three years first.

A National Issue

States vary in how they allow nurse practitioners to practice.

Seventeen states and Washington, D.C., allow nurse practitioners to treat patients and prescribe medications independently, according to the American Association of Nurse Practitioners.

Connecticut is one of 21 states that requires nurse practitioners to have a collaborative agreement with someone from another health care field to provide patient care.

And in 12 states, nurse practitioners’ practice must be supervised, delegated or team managed by someone from another field, according to the association.

In a 2012 paper, the National Governors Association suggested that states consider changing the practice restrictions on nurse practitioners. “Expanded utilization of [nurse practitioners] has the potential to increase access to health care, particularly in historically underserved areas,” the paper said.

At the end of 2012, there were 3,841 APRNs and 17,130 physicians with active licenses in Connecticut, according to DPH. The Malloy administration said there are now 4,025 licensed APRNs.

This story originally appeared in the CT MIrror.

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posted by: DrJay on February 19, 2014  5:15pm

There are many unanswered questions about this issue.
The average APRN completes 500 hours of clinical training in school, prior to practice. The average MD has 3200 hours of clinical training in medical school and another 9000 hours in residency. APRN’s are very qualified to handle routine and preventative care, which they now do very effectively in collaboration with MDs. But if there are diagnostic or therapeutic challenges which are more complex, they should (and do) seek input from physicians. Under the current scheme, that is done without an extra fee for the patient. If they are independent, a consult with a physician specialist will mean another bill. Also, malpractice premiums for APRNs will likely rise if they are independent . Will that mean higher fees for an APRN visit?
The current system works well and provides the best care for our patients. Let’s not break what currently works.
Jay Sokolow MD
President, New Haven County Medical Association

posted by: THREEFIFTHS on February 19, 2014  7:07pm

So would physician assistant also fall under this law?

posted by: DrJay on February 19, 2014  10:59pm

To ThreeFifths- under the proposed law, physician assistants would not be affected.

posted by: Career High School Parent on February 20, 2014  12:08am

Interesting story…

My daughter, who at the time was 4 years old, kept having issues with high fevers, “cold like symptoms”, wheezing et al…it was a nightmare. We were at the pediatricians office every few months with only short term success. Finally, after 18 months of this, we happened to see the new APRN in the practice as she was the only one available for a sick visit…she looked at her chart and saw a pattern…same symptoms, same medicines…all the doctors in the practice had seen my daughter at this point.

Her plan? To see have my daughter see and be worked up by an allergist, she was tested for Cystic Fibrosis and a CT scan of her head… Lo and behold, she had a raging sinus infection, horrible allergies and asthma. With PROPER medication to treat the sinusitis(prescribed by the APRN) a daily allergy med & some environmental changes, she improved immensely. We saw an almost 100% improvement. The allergies & asthma sx’s were now sporadic & gone within a year or so….To this day, She has never had another issue with a 104 fever or any of the other symptoms…she is now 18.

Enough said. :)

posted by: yim-a on February 20, 2014  9:00am

Study after study over the past 20 years comparing nurse practitioner and physician care in terms of outcome and safety have shown that nurse practitioners provide care equal to or exceeding that of physicians (see citations below for just three of the over 2 dozen clinal trials and metanalyses on the subject).

My years as a nurse practitioner in primary care have taught me that quality of care rarely is a function of the letters behind the name.  It depends on the experience, wisdom and compassion of the person behind the name.

Andrew Yim, APRN

A Meta-Analysis of Nurse Practitioners and Nurse Midwives in Primary CareBROWN, SHARON A.; GRIMES, DEANNA E.  Nursing Care, 1995, 44 (6)

2002 BMJ 324, 819; Horrocks S, Anderson E, Salisbury C.. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.. Apr 6;. :. –23.

Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trialMO Mundinger, RL Kane, ER Lenz, AM Totten… - Jama, 2000 -

posted by: THREEFIFTHS on February 20, 2014  9:54pm

This is nothing New.Look at the battle between psychiatrists vs psychologists.I was reading were psychologists become APRN so they can They can prescribe drugs.Also look at the battle Ophthalmologist vs Optometrist. Optometrists are not trained or licensed to perform surgery in an operating room. Ophthalmologist are trained or licensed to perform surgery in an operating room.I agree with DrJay.The current system works well and provides the best care for our patients. Let’s not break what currently works.

posted by: jherbst on February 21, 2014  10:21am

Good morning,

I do not think it is accurate to state that there are “battles” among psychiatrists/psychologists and ophthalmologists/optometrists, as they too have unique roles that they are educated and specialize in.  I became an APRN, not with the intentions of taking a shortcut into medicine, but because I respect and appreciate the nursing process which is based on caring for and healing the whole person.  I am very proud to be an APRN. 
And let it please be noted, that this system that we have that seems to be working?...Is most definitely not:

“In a May 2012 report, The Centers for Disease Control and Prevention cited a National Health Interview Survey that found that almost 80 percent of adults who visited EDs over a 12-month period said they did so because of a lack of access to other healthcare providers. One possible reason for the insufficient availability of timely care could be shortages of primary-care physicians (PCPs) in some areas of the country, according to the U.S. Government Accountability Office (GAO).”

See more at:

Nice to “see” you Andrew.  Hope you’re well.  Thanks for your post. 

- Joy Herbst RN, MSN, APRN

posted by: THREEFIFTHS on February 21, 2014  11:15am

Physician Assistant battle with APRN.

NP, PA Scope of Practice Debates Intensify.

posted by: jherbst on February 21, 2014  12:20pm

@threefifths:  I tend to air on the conservative side of care regarding antibiotic use, because I am acutely aware of the many providers who needlessly prescribe and its resultant widespread resistance to antibiotics.  I am also acutely aware of the exorbitant health care costs in the this country, and like to rely on my education and training in physical assessment before prematurely ordering imaging. 

I think it would be helpful for society at large to develop an honest, pragmatic, and realistic view.  I found this to be a logical and honest commentary for your consideration.


posted by: okaragozian1 on February 23, 2014  11:49am

Would you rather have a dental assistant drill into your teeth or a dentist?  Would you rather be represented in Court by a paralegal or by a lawyer?

The idea of allowing the less educated to engage in activities usually practiced by the more educated puts peoples lives at risk.  This “slippery slope” thinking that “a monkey could do your job” at the executive branch is not the answer to fixing a problem that doesn’t even really exist to begin with anyway.

This legislation is akin to jumping off the roof of a tall building believing that the Martians are invading after hearing Orson Well’s broadcast.  The Governor is trying to “head-off” an imaginary problem.

Yes, doctors will retire, some will move out-of-state and other will die suddenly, but other doctors will be graduated from schools all over the nation and other doctors will move in from other states.  And, no, no one is going to come to work as a doctor here in Connecticut unless the pay is right.

The answer isn’t having nurses do eye surgery, the answer is making salaries competitive enough to attract people to go into a field of medicine or to come to work here in Connecticut.

posted by: jherbst on February 23, 2014  12:39pm

Again, I cannot stress how important it is to NOT compare apples to oranges.  APRN’s are not trying to be physicians.  We have distinct roles that involve many common capabilities.  To be certified as an APRN requires practicing under the scope of practice of an APRN, but there are many things that we are able to provide without “physician supervision”.  APRN’s have a moral, ethical and legal responsibility in practice whether the Collaborative Agreement is required or not.

posted by: okaragozian1 on February 23, 2014  5:04pm

EXCLUSIVE: National clown shortage may be approaching, trade organizations fear!

See link:

And what is the Governor’s solution to that?  Allowing politicians to fill in on Sundays?

posted by: okaragozian1 on February 23, 2014  5:26pm

“jherbst” speaks of morals - what does he/she know about morals?  Morals are individual, not collective!  Every apple is not a Granny Smith apple.  We have cops robbing banks, we have priests molesting children.  What is this morals stuff?  You are trying to say that “ALL” APRN are some type of deities of impeccable and sparkling character?  You’re living in la-la land thinking the saving grace of your profession (APRN) replacing real doctors is morals!

Further, “jherbst” says, and I quote, “To be certified as an APRN requires practicing under the scope of practice of an APRN”.  “Scope of practice” means, to me, a set of defined duties.  What kind of circular explanation is that?  So to be an APRN you’ve got to do what an APRN is allowed to do?

If “jherbst” is a APRN, we’ve got problems as he/she can’t even get their point across.  Can you imagine this person running around with a needle?