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Why nurses and doctors disagree on part of the Medicaid expansion bill

The N.C. Nurses Association has long advocated for looser physician oversight restrictions. The SAVE Act would do just that, and the NCNA uses the SAVEasauras costume to advocate for this policy.
N.C. Nurses Association
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The N.C. Nurses Association has long advocated for looser physician oversight restrictions. The SAVE Act would do just that, and the NCNA uses the SAVEasauras costume to advocate for this policy.

The Medicaid expansion bill includes, word for word, the SAVE Act, a policy that nurses advocate for, but physicians oppose. If approved, it would loosen regulations on nurses that supporters say would increase access and reduce costs. However those in opposition to change say loosened regulations would reduce quality of care.

The North Carolina Senate for the first time has passed legislation that would expand Medicaid. The landmark move comes after liberal groups had for years been asking the Republican-led body to make this move.

However, the bill still faces a long road before it gets to Gov. Roy Cooper's desk. It first has to pass the House, where Republican Speaker Tim Moore has received it rather coldly. But setting politics aside, the legislation faces other challenges as well.

The bill includes major changes to Certificate of Need laws, regulations that tightly control where and when major health providers may expand. It also changes oversight requirements on nurses that they say are too onerous. WUNC health care reporter Jason deBruyn looks at these issues here and in a companion piece.

The Medicaid expansion bill includes, word for word, the SAVE Act, a policy that nurses advocate for, but physicians oppose. If approved, it would loosen regulations on nurses that supporters say would increase access and reduce costs. However those in opposition to change say loosened regulations would reduce quality of care.

Physician oversight

Advanced Practice Registered Nurses go through more schooling and training than lower level nurse designations
N.C. Board of Nursing
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Advanced Practice Registered Nurses go through more schooling and training than lower level nurse designations

Under current regulations, Advanced Practice Nurse Practitioners (APRN) may see patients on their own, make diagnoses, and prescribe some medications, but only under the supervision of a medical doctor. APRN's complete more schooling and have more clinical experience than other levels of nursing.

That nurse and physician must meet at least twice per year. The physician rarely sees the patients under the nurse's care, and isn't required to ever see any patient, though does shoulder some of the medical liability with the nurse. In large health systems, nurses and doctors work together as part of the larger network. In independent practices, nurses often pay a fee to a physician of another practice to provide that supervision. In larger systems, physicians employed by the system who provide nurse oversight can earn extra pay.

Nurses want fewer restrictions

The SAVE Act, incorporated into the Medicaid expansion bill passed by the N.C. Senate, would remove that physician oversight requirement, giving nurses full practice authority. Nurses say they have adequate training to be solely responsible for their patients. The vast majority of primary care is managing patients with chronic illnesses like diabetes, high blood pressure, and the like. If a patient comes to a nurse practice with a more rare condition, the nurse could refer the patient to a doctor just like a physician refers a patient to a specialist.

Doctors worry about patient care

The N.C. Medical Society, the association that represents physicians, strongly opposes any changes to oversight requirements. It says patients receive the best care when teams of providers work together, and those teams should include nurses and doctors. Because physicians complete medical school, they are more likely to catch signs or symptoms of a potential health problem, according to the society.

Expanding access and lowering costs?

The N.C. Nurses Association says physician oversight regulations are a barrier to entry into the health care marketplace. A 2015 study by Duke University professor Chris Conover estimated that loosened regulations could result in the addition of thousands of jobs and reduced health care spending in the hundreds of millions of dollars. The N.C. Medical Society says these estimates are far overblown.

The theory behind the savings is that nurses graduate with significantly less student debt. The average nurse leaves school with about $50,000 in debt, which the average medical doctor carries more than $200,000 in debt on average. Because, again, most of primary care is for common chronic diseases, something nurses say they are well qualified to handle, nurses can in theory charge less to manage these patients.

The Medical Society disagrees with this line of thinking, saying it's other regulations, which would apply to both physicians and nurses, as well as profiteering by health insurance companies, that are the bigger drivers of costs.

Why is this in the Medicaid expansion bill?

If North Carolina expands Medicaid, it would add an estimated 600,000 people to the government program. There would be an immediate need for more providers, particularly in primary care, and legislators hope that by reducing regulations on nurses, more of them would enter the marketplace and help provide care to these newly insured patients.

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