Update: Bill passes BUT it only expanded the limit to 75 miles. Senator Terry Burton offered a committee substitute that passed.
It is often reported that Mississippi is dead last in health care due to it being a poor state. However, it is the position of this website that crony capitalism and good ole boy rules limit health care access for many Mississippians as well. JJ reported recently that certificate of need laws limit health care while making it more expensive for those who can least afford it. Steve Wilson delves into the antiquated Nurse Practitioner rule over at Mississippi Watchdog. Nurse Practitioners can only operate within a 15 mile radius of their supervising physician. Such rules make perfect sense in rural areas such as the Delta where the poor are many and doctors are few. Mr. Wilson reported:
Nurse practitioner Christopher Fletcher works at a clinic in Picayune, Mississippi, where he sees patients and helps diagnose their illnesses, in collaboration with a local physician.
The doctor lives nearby. But if the M.D. moves, or retires, or dies, Fletcher would have just 90 days to find someplace else to ply his trade.
Under a four-decade old restriction, Magnolia State NPs cannot practice more than 15 miles away from their supervising physician. The law, say Fletcher and other critics of the restriction, limits access to care for patients and professional opportunities for nurse practitioners.
“It puts a severe limit on clinics with just a nurse practitioner,” Fletcher said.
State Sen. Angela Hill, who counts Fletcher among her constituents, is pushing a measure that would eliminate the 15-mile restriction and allow more clinics to be built in remote areas. Nurse practitioners would still have to work in collaboration with a physician under the bill.
Hill says the 15-mile limit is a crippling restriction in a rural state where many counties have one hospital. Only three states have such a restriction.
She also said doing away with the restriction would have the added benefit of reducing emergency room visits for minor ailments, because those patients could see a nurse practitioner instead.
“You would expand health care as far as access and you’d have business development too if you could have a nurse practitioner in a clinic more than 15 miles from a doctor,” Hill said. “You don’t need a doctor for everything. I’ve got some folks who want to build clinics throughout the state, but it’s just not cost-effective because they don’t have this rule in surrounding states.
“We’ve got telemedicine now, but we’ve got to have a nurse practitioner 15 miles from a doctor. That doesn’t make a lot of sense.”
The bill is in the Senate Public Health and Welfare Committee and will need approval by Tuesday’s deadline for bills to be out of committee.
Ryan Kelly, executive director of the Mississippi Rural Health Association, told Mississippi Watchdog that the measure would provide much-needed health care options for Mississippians.
“I think everyone agrees 15 miles is more restrictive than needed,” Kelly said. “I think people are realizing it needs to be abandoned because people need more access to health care in Mississippi. It’s just ridiculous how far people have to go to get access to health care. The only possible way is if you get really, really sick and you go to an ER. It’s a terrible way to treat patients and run a healthcare system.”
Standing athwart increased access to care is the Mississippi State Medical Association.
Communications officer Kristen Lucas told Mississippi Watchdog the organization opposes the bill because “collaboration between nurse practitioners and physicians is key to patient safety and quality of care. The distance requirement is in place to ensure that collaborative relationship is maintained.”
Fletcher called that notion “antiquated,” pointing out that most of his consultations with his collaborating physician are done via text message or phone call.
“With today’s technology, there’s no reason for a physician to be 15 miles from you,” he said. “The reality, in my experience, if the physician is not in the office with you and they’re within that 15 miles, if you’ve got questions or what not, you’re going to call them. It happens very rarely that they have to come to the clinic.”
Kingfish note: A nurse practitioner must have a master's degree in nursing. She can prescribe medications but must obtain a DEA number to prescribe narcotics and meet the same DEA requirements as a physician.
The 15-mile rule is nothing but good ole boy corporate welfare for doctors. The rule limits competition as well as access to health care. There is a shortage of doctors in the rural areas of the state. The shortage is so severe that representatives of the Aaron Henry Community Health Centers were begging the Medical Licensure Board last month to approve a limited medical license for a foreign doctor who failed part of his clinical board exams. Earlier post. The board approved the limited license. A 2008 Mississippi Business Journal article spells what the doctors' lobby thinks of Nurse Practitioners:
MSMA's president-elect Randy Easterling, M.D., practices family medicine and addiction medicine in Vicksburg where he does not have a nurse practitioner on staff. He also believes the state's patient/ provider ratio is frightening.The scuttlebutt around the legislature is that even if the bill passes the Senate, it will likely die in committee when it reaches the House. The bill would be assigned to the Health and Human Services Committee. One can easily guess who gives the most money to the chairman's campaign.
Filling a niche?
"Nurse practitioners fill a niche; mostly in rural Mississippi," he said. "If used appropriately, they don't dumb down the practice of medicine, but they must do what they're trained to do."
Easterling, who serves on the State Board of Medical Licensure, says the nurse practitioner movement is more than a growing trend in a state that graduates only 110 physicians each year and graduates three times that many nurse practitioners.
"I would like to see the medical school turn out more family physicians; that's the answer to the provider need, not more nurse practitioners," he said.
Magnolia family physician Luke Lampton oversees two nurse practitioners and admits that physicians can feel very strongly about them. He feels most physicians respect and admire nurse practitioners, but are very much against them being substitutes for physicians.
"Most will acknowledge their role but feel healthcare should center on the physicians," he said, "and most think it would not be good for healthcare to expand the role of nurse practitioners."
60 comments:
The 15 mile rule is a ridiculous relic that should be tossed. No physician is going to drive 15 miles (or 1.5 miles) if a NP needs assistance. They're going to tell the NP to go to the nearest ER. Furthermore, with the availability of Skype and other similar forms of communication that is pushing telehealth into anyplace that can get a signal, the physical presence of a physician is nonsense.
A proposed committee substitute to SB2025 will increase that radius to 75 miles. It will be before the Public Health committee today at 3:00.
I agree the 15 mile rule is ridiculous. However, it will not reduce ER visits. you go to clinic they want money. you go to ER you dont have to pay. See it every day. The emergency rooms are full of non emergency patients that should be in the clinic.
Randy Easterling runs the medical community. He has for years. With him in control, nurses will never be able to practice.
Randy Easterling pays off elected officials to keep nurses from working. I used to work with him and he was on the phone with legislators more than he was practicing medicine.
If nurses want to an MD then go to medical school.
If you live in a state that has a law that no other or even a few other states have it would be better to take a look at the law.
Legislators do what they are told by people that give them money. Doctors do not want competition. Most day to day medical services do not need a physician.
@ 10:18......one of the biggest problems you see around a hospital right now is people using the ER as a primary care facility, therefor when people come in that are truly in need of ER capabilities, the ER is so bogged down with non-ER care, that serious cases can end up waiting, and at no fault of ER personnel. With an absolute shortage of physicians / surgeons, NP's have become vital to the physician clinic, rounds, care capabilities. Freeing up NP's to reach further out into the community would help greatly in the delivery of healthcare, and also improve healthcare for all.
in the kingfish note, you use she. nurses can be men.
11:05 AM hits the nail on the head - period! That's what it's all about.
Agree that the 15-mile rule is silly and outdated. In many states, the only requirement for an NP to practice medicine is for an MD to conduct periodic chart reviews. With many practices now using electronic medical records, the doctor can review charts from their home and never needs to be on-site at the NP's facility. Even if there is an on-site requirement, it is usually a few hours a week or month, which many docs would be willing to accommodate via travel because they are paid to do so.
Kingfish is right in that this, along with other anachronistic laws and regulations serve to protect doctors, even in an age when there is an acute shortage of primary care physicians. The MMA is affiliated with the AMA. Here is an old, but interesting and relevant article about the AMA, which asserts that it effectively operates as a cartel to protect docs:
http://wallstreetpit.com/5769-the-medical-cartel-why-are-md-salaries-so-high/
This was a funny comment someone submitted but the screen name contained some unprintable language.
I would hope the 15 mile rule was to keep everybody and her sister from becoming an NP and linking up with a doctor in Bumfart 200 miles away, just to satisfy the industry requirement and state law. It's not as if ANY doctor ANYwhere is going to drop everything and head out to assist an NP. You watch.....if this passes, you'll see some doctors linked up with five to seven NPs and they will rarely if ever even be in the same room and some will never have met each other.
There are still two other states with a similar rule. That means we will wait. There could still be a reverse groundswell.
Cue Nina Simone.
This is what is wrong with out healthcare system.
In an ideal world a Nurse Practitioner would be part of the escalating continuum of care. An NP would not try to replace a physician. Nurse Practitioners are not doctors. They are great health professionals certainly capable of treating many simple conditions under guidance and supervision.
In this world there would be plenty of primary care physicians available and access to them would easy. They could through technology and other means have access to specialist consultation and opinion.
A person could present with conditions to an NP, if not resolution escalate to a Primary Care physician, who could resolve many issues through a multidisciplinary team of specialists on demand through technology or in person. Finally, present to the specialist directly as needed.
To be clear, I am not advocating for the 15-mile rule, I am just attempting to get everyone to think even bigger picture. I am for increased radius if there are evidence based ways to continue the collaborative relationship that allows NP to practice and receive quality control and feedback on their treatment plans and diagnoses.
However, the increased role of the NP in providing care was historically a "band-aid" reaction to our system as whole and the several lack of physician availability in many areas.
Today, we are normalized to this solution and want to expand it without thinking of better and more innovative ways in which we can actually ultimately fix our system as a whole.
While we look at expanding radius for NPs, we need to look more towards increasing total residencies for Primary Physicians and incentivizing students to pursue that path, we need to find optimum ways to use technology in our practices to increase our reach and access and effectiveness of treatment. We need to do many more things.
This long-standing controversy is full of generalized assumptions about physicians and nurse practitioners reflected in the comments above. Bottom Line: Until the training and clinical experience of any health care professional can equal that of 4 years of medical school and a minimum of 3-4 years of residency training (which a Master's degree,by the way, is not equivalent to), nurse practitioners should function IN the physician's office under direct supervision.
If I were an NP, I would be scared to death to practice in isolation. It what you dont know that you don't know that will kill you and your patient. Residency trained primary care doctors aren't perfect but they are a helluva lot more experienced in ambulatory medicine than NPs, most of whom worked exclusively in the hospital setting before going to NP school. Not just any fool (and that includes physician specialists who think they can do primary care too) has the tolerance for ambiguity and perseverance to make the right diagnosis as family docs or internists or pediatricians or gynecologists. Why can't we just all get along in the office and use NPs for special services like home visits to the newborn and elderly????
How are physicians appointed to the Board of Medical Licenusre? Is it similar to how North Carolina appoints?
The doctors are going to lose on this.
If used appropriately, they don't dumb down the practice of medicine, but they must do what they're trained to do."
Easterling, who serves on the State Board of Medical Licensure.
DUMB DOWN THE PRACTICE OF MEDICINE??? This guy is a joke.
This was a funny comment someone submitted but the screen name contained some unprintable language.
I submitted that post and don't recall anything being 'unprintable language'.
2:57-
I don't disagree with your point that NPs are to be part of the overall continuum of care. Indeed, they are equipped to handle a variety of simple conditions - many of which are being treated in the ER today. However, the 15-mile rule can have a negative impact on the expansion of NP services even at this level.
Furthermore, you state that "In this world there would be plenty of primary care physicians available..." Well, that is not the case in this world. The truth is that with an average PCP making somewhere in the mid-$100Ks, the return on 7 years of post-grad education looks less and less appealing. Depending upon the type of practice, some NPs can make low-$100Ks with far fewer years of education and no income. Do the math...
I don't know the stats, but it would not surprise me at all to find that PCP residency programs aren't even full. MS offers a program in which it forgives tuition to med school graduates who are willing to work a specified length of time in an under-served area because of a) the overall shortage of PCPs and b) the terrible prospects for anyone who chooses to practice in these areas where Medicaid/Medicare reimbursement makes it difficult to make a living and pay off student loans.
With Medicare/Medicaid reimbursements in the ballpark of $30-$50/patient visit, doctors have to run a virtual patient mill in order to make ends meet. Arguably, augmenting the PCP network with lower-cost NPs could increase the quality of care as patients might actually get more attention from a healthcare provider vs. a 5-minute fly-by from the MD.
Most doctors run patient mills now. Prior to the early 60's people got into medicine because they cared for patients. Ever since the mid 60's they get into medicine for the money. 4:58 says it correctly when he talks about a PCP return on investment. I havent been to a doctor in a long time where I didnt have to wait an hour or so with half a dozen other people to see the doctor as some people leave and others come in. Its all about numbers these days even when you see a specialist. My PCP probably spends 10 minutes tops with me, writes a script or refers to a specialist. As I said above they are all patient mills now.
The doctors own the board of health ( and thus the CON process), literally. Medical association snookered legislature into giving them eternal control by law. Heck, we could save money by simply turning it over to the state medical association, because they control the board anyway. The ultimate conflict of interest. Yet, the herd doesn't seem to mind. We are too busy arguing about poor people showing up at the emergency room.
1. NPs can do most of their post-graduate degree online. They need collaboration (whether 15 or 75 miles).
2. Didn't the BOML draft an update to the collaboration regs (expanding 15 mile rule), but withdraw it after threat of litigation from the Nursing Board?
3. This is Dead, Dead, Dead in the House.
NPs are not doctors....period.
I refuse to be treated by one because they simply lack the training required.
I know that my comments will start a storm of controversy. I have no "dog in the hunt," as the only advanced practice nurses that I can/will/wish to/do supervise are CRNAs, who, in general, are excellently trained. However, I am of the opinion that even CRNAs, who are at the pinnacle of superb training, should NEVER practice "independently," off site. On the subject of nurse practitioners, my experience of over 30 years in Mississippi, is abominable with NPs. They are POORLY TRAINED in Mississippi. I see ignorance when they practice independently (off site) on a daily basis. If you look carefully at their training, most of it is obtained online, with little clinical experience, in less than two years. They do NOT understand physiology well enough to care for patients independently. I see patients day after day who think that their NP is a "doctor." Their care of diabetics, especially, if usually deplorable. They just don't "get it." Other NPs that work in high intensity care, such as with hospitalists and ER physicians, under the direct care of physicians, may perform well. But left to their own devices in a clinic without a physician--forget it. For example, do they know when run-of-the-mill hypertension is not "hypertension," but, perhaps, renal artery stenosis? Not a chance! Do they pick up hyperthyroid patients, or even know which thyroid tests to order to make a diagnosis of hyperthyroidism? Often not. They have MINIMAL clinical experience, and no longterm understanding of the disease process. I'm fine with them working under the direct supervision of a physician, but, left alone, by themselves, NO! I've been SOOO disappointed in the quality of their training. I've reviewed care of NPs in off-site PAIN MANAGEMENT CLINICS, and it's shocking! They know nothing about pain management, opioids, alternative treatments, etc. I've seen them simply continue to write scripts for high doses of opioids with no supervision from anyone. In general, I'm much happier with the training of physician assistants, as they, unlike NPs, are trained using a medical, rather than a nursing model. (But of course, the powers that be in the Nursing World of MS kept PAs out of the state as long as they could.) I am not even of the opinion that NPs are "better than nothing," because they often aren't. I submit that I can take better care of patients using telemedicine than most NPs onsite. After all, they usually don't examine the patient carefully, or really know how to do a proper physical exam anyway. I believe that the future of good medical care in MS lies in telemedicine, rather than flooding the market with more NPs with poor training. I can't tell you how many NPs I know who spent 1-2 years nursing out of nursing school, and then went DIRECTLY to get their NP license. It's a JOKE! Even in Jackson we have NP practicing "junk medicine," with "bio-equivalent hormones" and such nonsense. I've seen patients diagnosed with celiac disease by NPs in Jackson who never performed ONE DIAGNOSTIC test. You may put me in the "NOT A FAN OF INDEPENDENTLY-PRACTICING NPS."
My wife is a nurse who believes that NPs should be in the office with a physician. She also believes they should have to have 2 years of practical nursing after getting a BSN before they can go back for their FNP. According to her, NPs who go straight from Nursing undergrad to and NP program lack real work experience that is vital to be an effective NP.
My understanding is NP's have to have 700 clinical hours to get the Master's degree. However, you will get little argument from me about beefing up the clinical or work experience requirement.
Nurses lack the understanding and education to provide quality card to patients. I am a Mississippi trained physician and dang proud my Medical Association is fighting this for us, the good guys.
What's the purpose of this job on the hierarchy of medical jobs, to begin with?
1) To provide another slot on the ladder of jobs that will enable advancement and higher income.
2) To provide a position that will allow medical doctors to experience some relief from the exhaustive patient load.
3) To create positions that will be able to take the burden of computer data input off physicians.
4) To create positions that will be able to engage in the battle with insurance companies.
5) To give doctors more free time to keep current with their reading, seminar attendance and afternoons off.
6) To improve the overall positive experience of patients, improve quality of care and contribute to a healthier population.
Choose any two. Number six, not a chance.
The rule is good to ensure proximity so the supervising doc will have closer ties and his/her reputation remains at stake. Someone in Southaven monitoring an NP in Pascagoula has very little skin in the game - if the NP on the coast practices shoddy medicine, no one in the Memphis area cares. It really has little to do with managing emergencies.
Dr. Mathias is 100% correct. I am a surgical specialist and I get hundreds of referrals yearly from NPs who clearly have no idea what they are doing. The unnecessary referrals drive up health care costs, especially since the vast majority of their patients are government insured.
The answer to our doc shortage is not making more non-doctors with less training, it should be providing better incentives to practice in MS and training more docs in state.
"Depending upon the type of practice, some NPs can make low-$100Ks with far fewer years of education and no income. Do the math..."
Explain how someone can make in the "low-$100Ks" with "no income".
We'll wait.
Can you link to the 75 mile bill that passed? I can't find it. There is one that is for 3600 clinical hours.
Absolutely 0 data exists showing healthcare outcomes decrease when a patient is under the care of an NP versus a PCP. As a prior commenter stated, most PCP's will see 50-60 patients a day while several NP clinics see 20-30. What data has shown, is that consumers satisfaction by the increased time spent, the emphasis on wellness, and not being talked down to in a condescending manner, has increased under NP care! This is a no brainer issue. 27 other states already have Full Practice Authority for NP's, none have had any issues.
Randy Easterling missed his life calling as a proctologist. That way he could be around like kind all day every day.
To the good Doctor (who posted above) and others who might need to know, here's a very short tutorial.
On this blog, in order to make paragraphs, all you have to do it hit 'enter' twice, at the end of a sentence.
On Facebook, and some other places, in order to start a new paragraph, simply press the 'shift' key with a finger from your left hand and the 'enter' key, twice, with a finger from your right hand.
I applaud the legislature taking up this important issue. It's about time!!! We have the momentum on our side
8:55 AM
I actually did not know that about Facebook.
Thanks!
FYI, the Mississippi State Medical Association "divested" itself from the AMA about 5 years ago.
Nurse practitioner have no idea about what they don't know, which makes them dangerous. Whoever said ^^that states without supervision have not had bad outcomes has not done any research. I have supervised several and most were really inadequate.I personally would not go to a "noctor" if I was ill. They simply have inadequate training. I am certain that most nurse practitioners get their care from physicians when they have health problems.
Randy Easterling is not the sharpest pencil in the box, quite frankly. That said, NPs should not practice without supervision.
@2:29-Thanks Randy Easterling for showing up to the discussion.
@2:31- bet you couldn't get into medical school. That's why you don't like Dr. Easterling. He is a very nice, smart doctor. Well respected by most at the capitol.
@2:47: I'm board certified in my specialty, FYI. I not only got into to medical school, I had a full scholarship. Randy Easterling is the lowest common denominator.I bet you couldn't get into medical school, however.
@ 3:05, is that Dr. Alford?
Most doctors in the state aren't fans of Dr Easterling. He has done tremendous damage to our profession by "having to always be in the news as the doctor" and involved in every political move our Association makes. Stay in Vicksburg, Dr East.
Hell no, I'm not Dr. Alford.
Most doctors? You speak for most doctors? I think not.
He definitely speaks for some of us - Easterling is a dim light bulb.
8:51; I cannot find the data to which you refer. You know, the data that you say shows patients like NP care since they're not talked down to. Can you provide a link? mmmmkay. Thanks.
I had an annual follow-up with my cardiologist (after stents) and was seen by a NP. She looked at my lipids profile and said, "Everything lookin' good. How many pillows do you sleep on?" That was it. I could probably have used some 'talking down to'.
Dr. Easterling, who sits on the MS State Board of Medical Licensure, has let his board-certification lapse, and is no longer board-certified.
I agree that Dr. Easterling is NOT a good representative for Mississippi's docs. He's not very smart, but he certainly knows how to put his finger in the air and measure which way the wind blows. He is dangerous to docs as a man with so much power. He's 'way too "political," and thinks he's the center of the MS medical world. He's not, not by a long shot. He's spent his entire professional career sucking up to the "powers that be," rather than practicing medicine. For some reason that most docs can't fathom, he thinks he knows a great deal, but he really doesn't, because he spends all his time trying to promote himself, and does nothing to help most docs. Most docs would like him to retire and leave the political world of the MSBML and MSMA in his rear view mirror. He's not unlike Dr. Hopson in Vicksburg, who continues to be the man behind the curtain in Vicksburg medicine, despite the fact that he long-ago outlived his usefulness. Easterling is a menace to MS medicine. Most docs don't respect him in any fashion. They see him as a political hack. Most docs are tired of hearing him represent himself on radio talk shows (Paul Gallo, for example) as the "voice of MS medicine."
Agree with @8:03 and @6:48 - we need a new voice for medicine in Mississippi.
How will all of these independent NPs be regulated via the Board of Nursing. Did you know that for ALL of the current NPs, the BON has only ONE investigator to cover the entire state?
Many have their controlled DEA certificate and have no clue what they are doing which only adds to the diversion problem in MS. Supervision is hard now, wait until the distance is increased. Protection of the Public is the #1 priority and if things change, buyer beware.
Also, agree that the NPs will be passed by as the patients will still flock to the ER where they don't have to pay. That argument is moot.
Not all doctors are against this bill, Infact, most are not. It keeps the collaborative agreement in place and in the control of MD's, but makes the rule workable. We all want the best for our patients. We have a shortage of physicians- this rule change helps fill in a gap of primary care with proper oversight.
#FTMF
Has this thread become the Randy Easterling show. The average Joe on the street never heard of the man. Nor has the average Jane or the average Quintarious. Who gives a shit. This is about Nurse Practitioners whose very existence is questionable. They exist only to pump up the inflated arrogance of doctors who don't want to bother with patient visits.
Blah, Blah, Blah...we won't be talking about this in 10 years.
Medical Licensure Board caved!
The biggest reason physicians are against the bill is money. Each NP pays them between $1000-$2000 per month depending on location to review 20 charts and be available by phone call. That's all they do. Add 3-4 per physician that collaborates, and it adds up very quickly. The original bill that was in the committee was to allow full practice authority after 5 years of physician supervision and was later changed to add the 75 mile limit, which really does nothing.
http://www.attn.com/stories/6233/states-wth-best-worst-preventative-healthcare Looks like our current system of letting the "good ole boys" handle it and restricting NP's from full practice authority is making major strides in our state. What people don't understand is that most MDs are gravitating to become hospital employees which gives them a 15 minute time limit consult. Due to the shortage of MDs all these guys have time to do is put out fires, let's face it, we are the sickest state in the US. Who does prevention?? We will never improve health outcomes without improving our prevention measures. NP would help thin out the population, give MDs more time to diagnose and treat and spend more time with the patient doing patient education, prevention, and improve outcomes!! Look at the big picture!
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