SACRAMENTO, Calif. — As the demand for health care workers surges with the coronavirus case count, many states are rushing to lift restrictions on nurse practitioners, who provide much of the same care as doctors do.

But California allows nurse practitioners to work only under the supervision of a doctor, and most limitations on their practice are likely to hold.

Although easing restrictions is a simple regulatory matter elsewhere, such proposals in California are dragged down by decades of contentious political fighting — and the state’s powerful doctors’ lobby argues that California already has enough providers.

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These “are often some of the definitive health care battles that happen in Sacramento,” said Mike Madrid, a Republican political consultant who has been analyzing California politics for more than 25 years. “They’re evergreen fights, they never go away.”

Nurse practitioners are highly trained nurses with at least a master’s degree. By comparison, registered nurses have at least an associate’s degree.

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There are more than 290,000 nurse practitioners in the country, and about 27,000 of them practice in California.

In 28 states plus the District of Columbia, nurse practitioners can practice much like a physician: They can provide primary care, write prescriptions, and see patients. Some of those states require physician supervision when nurse practitioners are just starting out, but most allow them to operate without oversight right away.

But 22 states always require physician oversight, including California. Nurse practitioners in the Golden State must have a formal “collaboration” or supervision agreement with a physician who reviews their charts a few times each year.

In March, Alex Azar, secretary of the U.S. Department of Health and Human Services, encouraged governors to lift supervision requirements on some medical professionals to provide more flexibility for the health care system to respond to Covid-19.

Five states have suspended these requirements and an additional 12 have modified them to give providers with extra training more independence, according to the American Association of Nurse Practitioners.

The Mississippi Board of Nursing rushed to give nurse practitioners more authority to prescribe drugs on March 16. Wisconsin Gov. Tony Evers suspended supervision requirements on March 27, as did Kentucky Gov. Andy Beshear on March 31. New Jersey Gov. Philip Murphy lifted all supervision requirements for physician assistants and advanced practice nurses April 1.

Yet California has been cautious.

In a March 30 executive order, Gov. Gavin Newsom directed the state Department of Consumer Affairs, which controls professional licensing, the power to change or temporarily waive regulations to let the health care workforce respond to the crisis.

That opened the door for nurse practitioners to ask the department to kill the supervision requirements without actually lifting them.

On Tuesday, the department acted. It temporarily lifted the cap on how many nurse practitioners each physician could supervise, though it left in place the oversight requirement. Instead of one physician supervising four nurse practitioners, physicians can supervise an unlimited number of nurse practitioners.

“It’s unclear how this is helping anybody,” said Garrett Chan, president and CEO of HealthImpact, a group that studies the nursing workforce in California. Newsom’s order, he added, “created a bit of a buffer between him and these decisions.”

The department’s deputy director of communications Veronica Harms said via email that the department didn’t eliminate the supervision requirements altogether because it wants to keep patients safe while responding to the needs of the health care system.

“The Department approved what was needed to meet the immediate demand for health care,” Harms wrote.

For nurse practitioner Sonia Luckey, who practices at Providence Express Care, a primary care clinic in Newport Beach, Calif., waiving supervision requirements would let her serve her patients more holistically, she said.

Luckey, 54, is certified in both family medicine and psychiatric medicine and has been practicing for 26 years. The physician who oversees her is an internist, not a psychiatrist, so that limits how she can use her psychiatry training.

Though Luckey knows how to treat patients with severe mental illness, she has to refer them to someone else.

“That whole mental health side of me is unable to respond to this crisis because of the way the laws are structured,” she said. “I could be seeing a whole other cohort of patients right now.”

Sonia Luckey
Nurse practitioner Sonia Luckey practices at a clinic in Newport Beach, Calif. Courtesy of Sonia Luckey

The stress of the pandemic is worsening some of her patients’ mental health issues, she said. Shortness of breath, one hallmark of Covid-19, is also the hallmark of a panic or anxiety attack. Luckey said her extra years of schooling trained her to distinguish between the two in ways other providers can’t.

“I was able to prevent a hospital visit and prevent that exposure,” she said. “Not everybody can do that.”

Nurse practitioners have tried for years to get the authority to practice independently in California, and have been repeatedly thwarted by the powerful California Medical Association, which represents more than 48,000 doctors.

Doctors have a financial incentive to keep overseeing nurse practitioners. In exchange for reviewing charts and prescriptions every few months, physicians bill nurse practitioners between $5,000 and $15,000 per year, according to a report by the California Health Care Foundation and the University of California, San Francisco.

The association has one of the strongest lobbies in Sacramento. It contributed almost $6 million to candidates, political action committees, and other campaigns since mid-January 2019. It has fought for years against lifting the supervision requirements on nurse practitioners, defeating at least three such “scope of practice” bills in the legislature.

Most recently, the association opposed AB-890, which died in committee last year and was reintroduced in January. The bill, introduced by Assembly member Jim Wood (D-Santa Rosa), created two ways for nurse practitioners to operate without physician supervision.

The California Medical Association wrote in an opposition letter that the measure would lead to “diminishing the quality of care for and lowering the standards for licensed individuals practicing medicine in the state.”

“It’s politics,” said Susanne Phillips, the associate dean of clinical affairs at the University of California, Irvine, School of Nursing. “We have a very, very strong medical lobby in the state of California. They do not want to see California go to full-practice authority.”

Now, the California Medical Association is arguing that the state already has enough providers to address the pandemic because many doctors have been laying off staff and closing their offices.

“In a world where you have primary care physicians and literally thousands of other physicians out of work, I’m not sure what eliminating supervision of nurse practitioners gets you,” said Anthony York, spokesperson for the association.

The group argues that California has slowed the virus’s spread enough to avoid the severe health care provider shortages seen in harder-hit places like New York, Spain, and Italy. Many California emergency rooms are operating under capacity, not inundated, York added.

But nurse practitioners counter that emergency room statistics alone offer an incomplete view of the crisis.

If nurse practitioners had the ability to practice independently, said Phillips of UC Irvine, they would have the flexibility to treat patients in different settings, which would relieve pressure on hospitals and prove healthier for patients. For instance, a nurse practitioner could treat a new mother and her baby at an outpatient facility instead of in the hospital, where both patients and providers could be exposed to the virus.

“California’s current statutory scheme does not allow NPs to provide care in settings and communities that are in desperate need,” wrote the California Association for Nurse Practitioners, along with more than a dozen other groups, in a letter to the Department of Consumer Affairs on April 1. “California NPs are more prepared than ever to help address this public health crisis and to provide critically-needed care across the state.”

Correction: This story has been updated to correct the amount and nature of campaign contributions made by the California Medical Association.

This story was produced by Kaiser Health News (KHN), which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

  • Physicians charge each Nurse Practitioner $15,000 a year to be their “pimp”. The physician lobby spends $11 million per year to keep Nurse Practitioners from fair trade. Multiple, multiple studies show the care is equal with less law suits involving Nurse Practitioners proportionally. Nobody is ever going to force a patient to see a Nurse Practitioner! What are Physicians afraid of? Think about it and stand up for equal opportunity!

  • Dear Author, I am not sure if have ever been to a physician and NP for treatment but there is big difference between the two, care provided by NP vs MD. The reason comes from the fact: MD has been through a medical school. NP: no medical school. I am sure there is big difference you(the author) writing an article vs me (or college grade) writing an article. You can decide.
    NPs are wonderful on doing what they learn to do, day in and day out, like working in a family practice or primary care option. Anything new, or out of the ordinary, forget it.
    The stat should not lift or change any regulation at this time. It will lead to poor or may be dangerous care. If the NPs are as good as MD, we should shut down the medical schools and send all medical students to become NPs.

    • Here is a list of other publications you can sift around in regards to positive NP safety. It appears NP’s actually listen and take more an extensive history which impacts the plan of care. NP’s are also becoming more specialized then their previous 20 years with newer specializations that meet educational needs such as Emergency NP’s ,Critical Care NP’s, and of course Family Practice NP’s which have been around forever. There are even NP’s starting to learn Cardiac Intervention procedures etc in which your standard medical “Doctor” hospitalist cannot do nor has been trained. Training has been the issue and that issue is being met steadily only constrained due to lobbying and money.

      https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice

  • It used to be that a RN with a MSN ( MastersNursing) could apply to be a NP or PA after 5 years experience. Now since there are so many fly-by night “nursin’ skools” California is overflowing with graduates who can’t find jobs . So what do they do to avoid paying loans back…they can now go to become a NP. So we now have numerous RN’s who have never worked on a hospital floor, or in an Acutecare setting, suddenly prescribing medications and making diagnosis. What happened to Registered Nurses who have Experience First ??? The Boards is correct Not Dropping Rules.

  • Thank you for presenting very well rounded article. The only thing missing is the definition of MD supervision which is never clearly articulated. A collaborative NP/MD agreement states that the MD will be available to the NP for the purpose of consultation. Period. This means nurse practitioners are already seeing patients independently. The NP decides if he or she is in need of requesting a second opinion in the moment. The decision to take the MDs advice is also optional. How does this arrangement translate into safer or better or more comprehensive patient care? And the MD is now permitted to oversee an unlimited number of NPs? What happened the concerns regarding patient safety? This clearly serves to provide unlimited income for the collaborating MD. And drive NPs out of the state.

  • Anyone can be a general medicine doctor, even a Walmart cashier can manage UTI and pneumonia etc because most of the so called doctors claiming to have gone to school and residency normally use up-to-date, Google, Wikipedia and such resources to treat us. Anyone can do that leave alone the NPs. The only doctors whose work can’t be done by any tom dick and hurry are the specialist such as surgeon.

  • Nurse practitioners are trained in a completely different model than physicians. NPs do not go to medical school and they do not have to go through a residency. To say that they can provide the same care as a physician is irresponsible as they do not have the same knowledge base and training.

    • The article states “can provide much of the same care” – not the same care…NPs don’t claim to provide the same care and there is good reason. NPs are taught to listen to patients well and consider much more than what is right in front of them, something that most doctors do not. They provide safe and effective care at a much lower cost, especially when it comes to primary care. It’s about money and power. If it wasn’t, more docs would choose primary care.

  • The good old boys club is alive and well .. the USA healthcare outcomes when compared with other industrialized nations falls well below them yet we are number one in COST !!! And many Americans still have limited access to healthcare !!
    Why is that “Doctor” ?

    • Anyone can be a general medicine doctor, even a Walmart cashier can manage UTI and pneumonia etc because most of the so called doctors claiming to have gone to school and residency normally use up-to-date, Google, Wikipedia and such resources to treat us. Anyone can do that leave alone the NPs. The only doctors whose work can’t be done by any tom dick and hurry are the specialist such as surgeon.

    • The COST is not because of a ‘DOCTOR’ but because of consumer demands. USA cost is high for a reason–US doctors treat the ‘Rarest’ diseases in the world. No other country spends money on rare diseases. As a consumer I want my baby with rare genetic mutation, premature, to live for ever, leading to associated medical cost. US consumers do not want to take any responsibility for their health (like not using tobacco, alcohol and food) but demands best care possible, leading to high cost. In some European countries, individual who smokes do not get by pass surgery, try refusing it in the US!

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