- Associated Press - Sunday, August 10, 2014

LINCOLN, Neb. (AP) - A vetoed bill that would have given nurse practitioners in Nebraska more independence will come up for debate again next year in the Legislature.

Sen. Sue Crawford of Bellevue said she plans to again introduce the measure, which Gov. Dave Heineman vetoed in the last session despite strong support from lawmakers.

The bill would have removed a requirement that nurse practitioners secure a written agreement to consult with a doctor before they can practice in Nebraska. The so-called integrated practice agreements are designed to ensure that a physician is available for collaboration or referral if a patient doesn’t respond to treatment.

Instead, the bill would have allowed nurse practitioners to work in Nebraska if they accumulated 2,000 hours of experience under the supervision of a more seasoned nurse practitioner.

Heineman vetoed the legislation in April, citing concerns for patient safety. Lawmakers had approved the bill on a 43-0 vote, but the session ended before they were able to attempt an override. The governor is leaving office in January due to term limits.

Crawford said she has reached out to all of the senators who are returning to the Legislature next year as well as candidates for the Legislature, seeking their support and asking them to contact her with questions.

The proposal won’t affect the requirement that nurses consult with doctors about especially complex matters.

Crawford said groups such as the National Governors Association, Veterans’ Affairs and the Institute of Medicine have called for the elimination of the agreements. A report by the Federal Trade Commission concluded that the agreements amount to a restriction on trade.

In addition, Crawford said, hundreds of studies have confirmed that nurse practitioners provide safe and efficient care.

“These are well-established entities that have looked at this question from a fairly objective perspective and come to the same conclusion,” Crawford said. “It’s rare to have an instance where the evidence is so overwhelming on one side.”

Supporters of the bill said the integrated practice agreements make it harder to recruit and retain nurse practitioners, who could help reduce health care shortages in rural Nebraska.

Heineman said in his veto letter that he spoke with Nebraska Chief Medical Officer Dr. Joseph Acierno, who expressed concerns about patient safety. Heineman said he would have signed the measure if lawmakers had required at least 4,000 hours of supervision for new nurse practitioners, instead of 2,000.

However, the agreement required between nurse practitioners and doctors in Nebraska isn’t demanded in the District of Columbia or 17 states, including neighboring Colorado, Iowa and Wyoming, according to the American Association of Nurse Practitioners.

Nurse practitioners in rural areas may not have easy access to doctors who can sign the required agreement, so they can’t establish a practice, said Tara Whitmire, legislative chairwoman of the Nebraska Nurse Practitioners.

In addition, some physicians aren’t allowed to sign agreements with practitioners outside their health organization. Some doctors charge fees for the agreement that cost hundreds or thousands of dollars a month, Whitmire said.

Whitmire said Nebraska is already losing nurse practitioners to Iowa, and other states are aggressively recruiting health care providers to help treat aging residents.

“This has become more and more of an issue as evidence accumulates that this is an appropriate and cost-effective thing to do,” Whitmire said.

The Nebraska Medical Association opposes the bill because of concerns about patient safety, said Dr. Richard Blatny Sr., the group’s president-elect.

Blatny said nurse practitioners play a crucial role in health care teams that usually include doctors and physician assistants. But he said they still need supervision for complicated medical cases. Nurse practitioners are well-equipped to treat people with ear infections and other common ailments, but they may not immediately recognize more complex problems, he said.

Physicians also have more clinical experience, he said. Doctors accumulate 12,000 to 16,000 hours once they’ve completed their residency, compared to about 500 for a nurse practitioner. Yet under the bill, he said, nurse practitioners could set up independent practices without having to sign an agreement with a doctor.

“What it really boils down to is patient safety, in our eyes. (Nurse practitioners) are a valuable part of the team, and we need them. But the team approach seems to be where everything is heading in health care,” said Blatny, who practices family medicine in Fairbury.

To ease the shortage of doctors, he called for expansion of existing student loan reimbursement programs for doctors who agree to serve in rural areas as well as satellite offices where doctors can work a couple days a week.

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