SARAH: I'm Sarah Hexem, Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.
This is Part 1 of our special two-part series about scope of practice regulations for nurse practitioners. In the United States, 26 states now grant full practice authority, meaning that NPs – nurses who have advanced degrees can deliver health care without restrictions.
Whereas 13 states have what is often described as reduced practice and 11 states have restricted practice.
On this episode, we’re going to hear from Lynn Heard, a nurse practitioner in Pennsylvania where the current regulation is reduced scope of practice.
That means NP’s like Lynn are fully able, to provide a full spectrum of care. They can prescribe medicine, order tests, assess and diagnose patients, make referrals. But only if they have something called a collaborative agreement, typically with at least two physicians, though during the pandemic that requirement was reduced to one.
For more than two decades, Lynn has worked as a family nurse practitioner and had a collaborative agreement with the same physician. But in 2020, the doctor closed the practice and Lynn has since been unable to find a new collaborating physician.
LYNN: I got a message that he would no longer continue as my collaborating physician, and I was scrambling. I tried multiple avenues to try to find a new collaborative physician. And I just was not able to do that. So, at the very beginning of the pandemic, I had to send out letters to patients to say, you need to find a new physician or a new health care provider, because I don't have a collaborating physician at this time. So they, you know, were disappointed, needless to say. You know, I still get phone calls from them today, saying, When are you going to be able to, you know, take me on as a patient again? They call me and say, Well, my doctor prescribed this, what do you think about it, you know, so they're always looking for input. And unfortunately, I’m just not able to be their primary care provider.
SARAH: We’re also going to hear from two of Lynn’s longtime patients, including Bonnie McFarland. She’s no longer able to see Lynn and refuses to choose a new primary care provider.
BONNIE: Why can't we have a choice? That's how I feel about it. My choice is Lynn, I want Lynn. I don't want the doctors who don't take no time. I want Lynn who spends the time with me.
SARAH: Bonnie’s hope is that Pennsylvania will eventually adopt Full Practice Authority and that she can go back to seeing Lynn.
With Full Practice Authority now in effect in the majority of the United States, another of one of Lynn’s patients Susan Donces is wondering why Pennsylvania lawmakers are not in favor of independent practice for nurse practitioners?
SUSAN: I'd like to know who's pushing back? Like why? Maybe those people that are pushing back have never been, like me, just to a nurse practitioner.
SARAH: In 2020, we interviewed Lynn for At the Core of Care when PASNAP named her School Nurse of the Year in Pennsylvania. She’s worked a total of 26-years as a full-time school nurse in northeastern Pennsylvania and is now in the process of retiring from that position. But over the course of her career, Lynn also worked part-time as a family nurse practitioner in a doctor’s office.
And in 2018, she opened her own office just down the road from where she lives and continued to see patients from that practice regularly.
LYNN: It's a very small exam room. There's one exam table. I have my desk with my computer in one area, and the other, I have another little counter with my printer, and a little table with my otoscope and my audiometer and blood pressure cuffs, a vision chart on the wall. There's a sink in the room, and I have a small file, and everything else is through my electronic medical record. So very tiny, but it suffices and it works.
SARAH: Lynn says the working relationship she had with the same family physician for twenty-five years was both collaborative and independent.
LYNN: I was very autonomous, you know, I would go to him if I had a question, which wasn't very often, you know, same thing, he would come to me if he had questions, you know, regarding immunizations or a patient that I had seen, you know, or something that I documented, but, you know, I was pretty independent there.
So we worked as a team, you know, it wasn't that one was above the other, we just, you know, met the needs that we needed to and worked as that team.
I was more wellness focused, you know, I. When I met with a patient, if they were ill, why do you think you've got ill? What can we do to prevent this in the future, whether it was a minor sinus infection, or, you know, if it was even something more than that, you know, diabetic, what can you do to change your lifestyle? What modifications can you make? so I spent a lot of time educating patients and, and extra time going through things that they could do differently in their life.”
I would use medications as more of a last resort and see what changes we could make rather than adding a medicines only because of the side effects of medicines. And the main key for me was to establish rapport with not only the patient, but with the family. You know, there were times where the family would come into the office visit because they had just as many questions as the patient and I was open to that. Not all providers are open to that they like to talk to the individual themselves. You know, I feel it's important I feel that health is a is a family affair, and that we need to work together and you know, meet the needs of the individual patient.
SARAH: For two years now, Lynn has tried to find a new collaborating physician but has struggled to do so.
LYNN: In Pennsylvania, you have to have a collaborating physician, and then you have to have a co-signed, and I did contact the person who had co signed and he was not willing to do that. Also close to retirement age, he did not want to take on that, that role. So I, you know, I tried the American Medical Association, you know, I tried multiple physicians that I had known, but a lot of the physicians that I've worked with in the past work for an organization, so they cannot collaborate with someone outside of their organization.
It’s very hard to find an independent physician everyone is working for you know, conglomerate, they're working for a big health care system. You know, most of our independent practice providers in this area are working for an organization.
I've actually paused the search. I did have, you know, some that had offered, it was more than I could afford some more one off wanted a fee. I never had to pay a fee before. So in Pennsylvania, you need two, so for one physician it was $500 a month. So if you had to get a second one that's $1,000 a month, you know I was doing this part time, I was really just trying to meet the needs of patients, provide them with health care that they really, you know, were comfortable with. And I couldn't afford $1,000 a month or more.
SARAH: Without a collaborative agreement, Lynn cannot prescribe medications. But she is still able to conduct physicals, which she does mainly for patients who hold commercial drivers’ licenses or CDLs. She’s also providing patient physical exams at a residential mental health facility.
LYNN: So, right now, the only thing that I do is physical exam is for commercial drivers, I have a national certification as a commercial driver, medical examiner. So that's just what I'm doing here in the office. I do work part time for an inpatient mental health, I have a collaborating physician that was hired by that agency, and that, through that collaborating physician, I only prescribe for those patients. So nothing outside of that agency. And that was all arranged through my employment, I'm a contractor through that agency.
SARAH: Lynn isn’t sure about the future viability of her family practice, but sees a need for nurse practitioners in rural areas like where she lives...who can help provide broader access to primary care.
LYNN: You know, there certainly is a need in Pennsylvania. I think the need is, especially in smaller areas, rural areas, I think there's a lack of medical providers overall, there's not a lot of physicians that are going into primary care. So as a primary care provider, I, I know, when I'm over, I've overstepped my boundaries, I know when a patient needs to see a specialist, so I'm going to refer them to that specialist when I feel uncomfortable providing care, and I'm going to be honest with them and say, at this point, you need to see a specialist because, you know, my primary care or your care that's needed as well above my primary care role.
I mean, I have that background and experience. I've been doing it for a long time. And now all of a sudden, my hands are tied, I can't do you know. And I think that's what lawmakers need to understand is that we're not coming right out of school and saying, Okay, I can be an independent practitioner, you have to have that experience and that comfort with it in order to provide quality care.
SARAH: One of the patients Lynn is still able to see is Susan Donces. Susan lives nearby and recalls when Lynn told her that she no longer had a collaborative agreement.
SUSAN: She told me she would not be able to prescribe medication. And I'm fortunate enough that I don't need any. I'm lucky that I just take vitamins. So because she said you know that would be the only hindrance if I would need medication prescribed she wouldn't be able to do it.
I've been a patient with Lynn for probably 20 years. And I just get a physical every year, you know, she gets blood work. Within a day or you know, the next day, whenever the blood she gets it, she calls me and lets me know how everything was. So yeah, she keeps, she keeps me going. keeps me healthy. I don't go to anyone else. Yeah, she doesn't beat around the bush.
And to be able to come to see a nurse practitioner, someone that you're familiar with, happy with and want to continue to see and in my later years or you know who knows from day to day, if I will need medication? If something does happen, and then I wouldn't be able to see her.
LYNN: Susan is one of the very few that I continue to see, um, she's not on any medications. So I just ordered her bloodwork. And if she needs or due for her mammogram or colonoscopy, I could set that up. But for the most part, she's the only one. I do, you know, some of my CDL physicals, other are ones that I've seen, but for the most part, people are a lot of people are on medications. And I'm unable to do that. And so, you know, the testing I can do under my nurse practitioner license. And so that's keep it very simple.
SUSAN: It's just so comfortable. To find one person, you know, like you not to have to, you know, go to somebody else, you don't want to be switching.
And how about the aging community, like soon when I retire? I will be, I'll still be able to have Blue Cross and Blue Shield. But then Medicare kicks in. So are there nurse practitioners that will accept Medicare, and some doctors don't even accept Medicare? I'm worried that when I get 70 or older, like, where am I going to go? You know, I don't know if that will become an issue.
LYNN: Well, I know that there's programs out there, you know, a lot of the bigger organizations have created geriatric programs and facilities just for the elderly. So there is opportunities out there through Geissinger. You know, so I'm sure you'll find someone to care for you. But I know that, you know, you want to find somebody close to home and somebody that you feel comfortable with. So yes, I went through all of their credentialing and all of that with all of the insurance companies as you know, I have a Medicare/Medicaid number. But when I had to limit my practice, and I could not see people, the billing aspect was really not even worth it for me. So at this point, I see people for like, $30 Or like, if I'm doing a CDL physical, it's a little bit more, but most people have a copay of 30 or $45. So if I just charged $30 for a visit, you know, then that's very fair, and people are very, they're comfortable with that. I'm not out to make a ton of money. I just want to take care of people, and give them the best care that they can get. And I think I'm able to do that. It goes back to like, you know, when I was a kid, we had a family doctor, he would come to the house you like, you know, you relied on him for everything. And now, we don't even have that connection with a provider anymore. And I think that connection is so important.
SUSAN: You know that person is going to take care of you. You know, and that's what's so special about having them in the community are so close by instead of having to find someone else.
SARAH: Whereas it has been a different story for Bonnie McFarland. She lives nearby and had seen Lynn as her primary care provider for almost twenty years. Bonnie is upset about what happened to Lynn and has chosen to be without a primary care provider for two years now.
BONNIE: Oh, yeah, she sent me a letter. And I called her right up. I said, What's going on what I can do this. And she's like, she said, I can't do it anymore. She said, the doctor dropped me. And I said, Well, that's ridiculous, because she's got a lot under her belt , Lynn does. And I don't feel she should have to worry with her qualification, she shouldn't have to worry about having a doctor right there to coincide. She knows what she's doing. She's had enough training. So someone in her position, no, they should be okay, you know, where there should be a list of doctors that she could call if she needs a second opinion. That would give her the second opinion. Or talk it over with her. She shouldn't have to, you know, be in the boat she's in now, not to mention all her patients that she had.
She takes the time to listen to everything, for you to explain everything of what's going on. She's not pushing you out the door. If you're in with her an hour, you're in with her an hour.
I'm not a doctor person, I don't go to the doctors. She makes you feel comfortable. She listens, and then she acts upon it and does what she feels is right. And if it wasn't for her, I wouldn't be here. I had melanoma skin cancer, I had a mole that in a month's time went from normal to black. So I called up Lynn. I said Lynn, something's going on here. I want you to check it out. So she immediately got me an appointment in, came in. She looked at it, she turned around, she got on her computer, started making me all kinds of appointments. By the time I left her office, I had appointments for dermatology to get it checked and with the surgeon to have a double checked. So her quick reaction kept me from just letting it go. Because without her I wouldn't be here. I wouldn't have gone.
And, you know, I went and they called me up and said yeah, it was cancer. And I went to see the doctor and he told me he said this is going to kill you. He said we got to get in take this out. So they did, they cut my shoulder open. He took out a large mass, in that time Lynn had called a couple times to see how I was.
LYNN: I don't know that enough people know about the situation with nurse practitioners, you know, when they go in to see them, they don't know that behind the scenes, you have to have a collaborative physician, then they get very comfortable with them. And, you know, you lose your collaborating agreement, and they're without a provider that they've felt very comfortable with for years.
BONNIE: My choice is Lynn, I want Lynn. I don't want the doctors who don't take no time. I want Lynn who spent the time with me.
LYNN: I know. But there's some times when you have to see someone else's if you’re sick, you can’t just ignore health problems.
BONNIE: I'll go to the hospital then. And I'll see somebody but as to pick a permanent one. No, not I'm not ready for that yet, Lynn, you’re the one.
LYNN: As long as you’re seeing your dermatologist.
BONNIE: I got to make another appointment. Yeah, every six months, I have to go for it. So, and they're watching a couple, but like I said, they asked where to send it. And they say, Well, you know, no, you keep it here because until Lynn gets back in, I'm not picking a family doctor.
LYNN: You know, I just care about the patient's themselves. And hopefully, other people do that, too. But I don't want her to miss out on something important health wise in the meantime. Providers. Yeah, right. And I think the other thing that's hard is we've had, like when the office closed, we did lose that office, there was one office left in the area. And when I closed, I referred a lot of people to that office, and then that office closed. So people were like, like bouncing back and forth from provider to provider, and they just couldn't get established. So then that office closed. Now there's another one open, not accepting a lot of patients. We have another one that's opening, but still, you when you choose a provider, you want to be with that provider for a period of time and you want to get established. You don't want to have to bounce back and forth.
BONNIE: Well, I mean, I think a lot of people like I said nowadays, they're not just seeing the doctor. A lot of them are seeing the nurse practitioners and like she said, There everybody's bouncing to should we know bouncing, the nurse practitioners are capable we see them more often let them have more of a say in what goes on with people. And like I said, these lawmakers, if New York can do it, why can't they do it here? You know, we need somebody, Lynn is important up here, very important to a lot of people, as well as the other nurse practitioners. So they just need to get off their high horses and do something about it, instead of dragging their feet. They ought to talk to patients, if they're so worried about it. Well, call us, call me on the phone and ask me and I will tell you, like I told you here and the thing of how they're important. I’m not the only one out there who is not comfortable with a lot of doctors, because you they don't give you the time. It's come in, boom, boom, boom, all right out the door. She's the one. I had everything set up before I left here. You know, it wasn't the doctor she was collaborating with. And that’s what we need nowadays, everything is money, money, money, money. No, how about people's lives? That's more important than money.
LYNN: Yes, and I appreciate that Bonnie, your support. And I think that we have to get legislators to understand that perspective and understand how patients want to see someone that they feel comfortable with and I just can't we keep repeating that. But I think that's the important key right here is that we need to have that choice of who, what provider we want to see. And there are some wonderful for physicians out there, there are some wonderful nurse practitioners, you may have one that you don't feel comfortable with but then you have the choice to switch to someone else.
SARAH: Next time on At the Core of Care, we’ll continue with Part 2 of our special coverage and discuss broader scope of practice trends across the country. Joining us for that conversation are nurse practitioner and state policy expert Tay Kopanos from the American Association of Nurse Practitioners, along with Pennsylvania State Senator Camera Bartolotta to talk about removing barriers to care here in Pennsylvania.
TAY: It's estimated that over the next five years, one in three primary care providers will be a nurse practitioner. I think as we're looking at the workforce, what we're really looking at is, how are we going to effectively use people where they are located. And so one of the most important lessons that has come out of COVID is our healthcare system was broken before. And we know now where we need to fix it. We need to build in efficiencies so that we're utilizing everyone at the top of their license, that we're retiring outdated, bureaucratic barriers that stand in the way of patients getting care.
CREDITS
SARAH: Support for this episode comes from the Pennsylvania Action Coalition.
You can find our most current and past episodes of At the Core of Care wherever you get your podcasts or at paactioncoalition.org.
You can stay up to date with us on social media @PAAction and @NurseLedCare.
At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.
