When Miranda Lewis goes to work, she can’t predict whether she’ll treat a patient with a sliced-open finger or one experiencing chest pain.
“People always need something when they come here,” said Lewis, an Advanced Practice Registered Nurse and family nurse practitioner at PrairieStar Health Center, Hutchinson.
They say they see patients from “womb to tomb” at the walk-in federally qualified health center, with a cross-section of patients ranging from the homeless to CEOs.
“You just never know what your day’s going to be like,” Lewis said. “I like the face-to-face interactions, getting to know their story."
Patients request physicals for work or school, or they seek relief from an infection or they are concerned about their baby's health. Putting casts on fractured bones is rare, but she’s done that. She writes drug prescriptions and educates people about dealing with hypertension or diabetes. The educational piece is one of her favorite aspects of the job, she said.
Lewis is a graduate of Hutchinson High School, and she and her husband, Will Lewis, decided to raise their children near family. She did her clinicals at PrairieStar and “really just kind of fell for the place.”
She doesn’t have the years of schooling and training of a medical doctor, but her advanced degree studies and training qualify her to deliver a range of care. Particularly in rural areas of Kansas where physicians are in short supply, such nurse practitioners as Lewis could help fill in some gaps. But they’re in short supply, too.
Some think Kansas statute is contributing to the problem.
Short by any measure
Most counties in Kansas fit under the Health Professional Shortage Area umbrella for primary care providers. More than half of the counties with an undesirable HPSA score of 15 or higher are located west of Reno County, according to federal Health Resources and Services Administration data in March 2018.
Under a scoring system where higher means worse, Reno County fell in a category of counties medically underserved but not as drastically underserved as some other counties.
In August 2018, the Kansas Governor Certified Counties list for counties designated as medically underserved areas for the purposes of developing rural health clinics, numbered more than half the counties in Kansas.
In September 2018, US. Department of Health and Human Services workforce statistics suggested the percentage of primary medical care needs that are being met in Kansas at about 45 percent. The number of additional primary care health professionals required to meet the needs would be 142. By comparison, Missouri, Colorado and Oklahoma had even greater needs for health professionals than Kansas, and Nebraska had a smaller demand.
The Kansas State Board of Nursing’s latest available annual report, for fiscal year 2017, revealed an increase during the year in the total numbers of all categories of APRNs, rising from 5,167 to 5,362. However, the report also showed that some rural counties had one or none active APRN licensees living there. That data does not account for nurse practitioners who live in one county in western Kansas and work in another county and that occurs, according to Merilyn Douglass, an APRN in Garden City.
Supply and demand
At the end of December, ads pitched nurse practitioner job openings in a number of places, including Wichita and Overland Park — and Dodge City.
Western Plains Medical Center in Dodge City was looking for a nurse practitioner to establish an outpatient clinic near two manufacturing plants.
“There is a very strong compensation package in an economically healthy community with a low cost of living. Sign on bonus, relocation, loan repayment, and marketing allowance, plus a full benefits package,” the ad said.
State Sen. Mary Jo Taylor, R-Stafford, who serves on the Senate Public Health and Welfare Committee and whose husband, Todd Taylor, is the administrator at Stafford County Hospital, said a lot of times communities are taking the initiative to attract those professionals. “Our hospital will pay a certain percentage of your education if you come here,” she said.
Salaries for APRNs have climbed and some can earn in the six figures, depending on experience and skills, specialty, and location.
“Fortunately, that has started to become a little more commensurate with the responsibilities,” said Sally Maliski, dean of the School of Nursing at the University of Kansas Medical Center.
Maliski oversees campuses in Kansas City and Salina. The University of Kansas School of Nursing partnered with Salina Regional Health Center to open the latter campus in 2017. The “great need in western Kansas” for nurses spurred the creation of the Salina campus, Maliski said in 2017.
The University of Kansas' School of Nursing also is part of a consortium with Kansas State University and Pittsburg State University and has partnerships with community colleges. It and other schools of nursing in Kansas offer online classes, making it easier for students to pursue advanced studies.
Another effort to help boost health care delivery in rural areas is a federally funded grant project through ANEW (Advanced Nursing Education Workforce).
The purpose of the project is to provide advanced practice nurses with clinical education experiences in rural and underserved communities in Kansas. “So far, we have supported 28 APRN students. These students are enrolled in our Family Nurse Practitioner, Adult/Gerontology Primary Care Nurse Practitioner, and Nurse Midwifery programs,” according to Kay Hawes, associate director of News and Media Relations at the University of Kansas Medical Center.
The hope, said Maliski, is that as participating students experience and become familiar with working in a rural setting, they’ll desire to choose that option.
“Rural areas have their appeal,” Maliski said, for nurses. “They are part of the community, they are taking care of their neighbors and friends.”
The current grant runs through June 2019, and the School of Nursing is applying for another grant that would be larger and would run for four years, according to Hawes.
Scope of authority
In January 2015, the Henry J. Kaiser Family Foundation published a report titled “Tapping Nurse Practitioners to Meet Rising Demand for Primary Care” by Amanda Van Vleet and Julia Paradise.
Nurse practitioners have completed master’s degrees or higher level nursing degrees and close to 90 percent of all nurse practitioners are prepared in primary care, the report said. They can manage 80 percent to 90 percent of care provided by primary care physicians, it stated.
It takes much less time to produce a nurse practitioner than a physician — an average of six years of education and training versus 11 or 12 years for a physician’s training and residency — so nurse practitioners could be key to answering the expanding need for primary care providers, the report said.
The authors also pointed to a hurdle: More than half the states — including Kansas — have statutes reducing or restricting the full practice authority of nurse practitioners. Removing barriers for a nurse practitioner’s “full deployment” is a step states can take, the study noted.
Less than 10 days after that report was published, the Kansas Senate Committee on Public Health and Welfare conducted a hearing on Senate Bill 69. It would have removed the requirement that APRNs have a collaborative agreement with a physician — one of the barriers cited in the “Tapping Nurse Practitioners” report.
Ultimately, the bill died in the committee.
Merilyn Douglass, of Garden City, president of the 3-year-old Kansas Advanced Practice Nurses Association, said in December 2018 that a new bill is being drafted to remove the barrier and it likely will be introduced in February in the state Legislature.
Kansas is not the only state mandating APRNs have a written collaborative agreement with a physician. Other states require an even bigger role for the physician, while slightly more than 20 states give APRNs full scope of practice authority.
KU's Maliski said the required collaborative agreement restricts the ability of APRNs to practice at the full scope of their education and training, fully using their “knowledge,” “skill” and “judgment.” She would like the Legislature to pass full scope of practice authority legislation “not only for our graduates but for the health of Kansas.”
Generally, nurses and nurse associations also favor that, but physicians and medical associations oppose it.
In 2015, Hays APRN Michelle Knowles wrote in her testimony for Senate Bill 69 that, “Advanced practice nurses are searching farther and father, many times from 30 to 200 miles away to get an agreement signed. It is unnecessary.”
Gregory Beck, Leavenworth, described in his testimony how the search for a collaborating physician affected his wife, Judith Beck. She had tried to launch two different health care businesses but was stymied by the challenge of securing a written physician agreement. One obstacle included how much compensation a physician expected for the amount of work performed.
The Kansas Medical Society’s testimony against the bill in 2015 stated, in part: “The fundamental premise of this bill is that APRNs and physicians are essentially interchangeable and that the two professions have a body of knowledge and clinical skills that are equivalent. That is not the case.”
An accompanying chart showed over 10,000 hours of supervised clinical education and training for a physician compared to 500 to 750 total patient care hours required through training for APRNs, based on an Institute of Medicine report.
“We do not allow MD students who graduate and do not match with a residency to practice independently, so why would we allow someone with less experience in making medical diagnoses to practice without collaboration?” Lynn Fisher, a physician from Rooks County and vice president of the Kansas Academy of Family Physicians, wrote in testimony against the bill.
Douglass said in late December that the bill being readied for 2019 likely would have four components:
• Remove the collaborative agreement requirement.
• Allow APRNs to prescribe drugs without the current protocol language.
• Require APRNs to carry malpractice insurance.
• Require APRNs to have a national certification.
Nearly all APRNs already work for an employer providing malpractice insurance or they carry their own policy, and those currently practicing without national certification would be grandfathered in, Douglass said.
“If our bill passes, collaboration doesn’t go away. There is no intention to practice independently or as a silo,” Douglass said. The teamwork concept will continue, she said.
Douglass has worked as a family nurse practitioner in Garden City for the past 21 years. For the past three years, she has worked in a privately owned clinic and has her physician agreement with a local doctor.
“I’ve called him probably three times in 2018,” she said, to ask a question.
Douglass said if she moved to Hutchinson to establish a clinic, she couldn’t open it until she had a signed agreement with a physician. If the agreement was not required and she came here to establish a clinic, still one of the first things she would do would be to introduce herself to physicians and other health care professionals here to establish relations, she said.
Nurse practitioners seeking a physician face the obstacle of large entities that prohibit their affiliated physicians from entering into an agreement with an APRN, she pointed out.
Lobbyists are assisting nurse practitioners on this new bill and will advise whether to start it through the House and its Health and Human Services Committee or through the Senate and its Public Health and Welfare Committee, according to Douglass.
“We’re trying to garner more business support and support from patients,” Douglass said.
State Sen, Barbara Bollier, D-Mission Hills, is a retired anesthesiologist, and her husband, Rene Bollier, is a family practice physician. She is the ranking Democrat on the Senate Public Health and Welfare Committee.
“We have huge discussions on this,” Bollier said of conversations with her husband. Both have personal experience as physicians with collaborative agreements.
“I will tell you it was the right thing to do and it was the best for the patent, “ Bollier said.
She would oppose abolishing the requirement, citing the different levels of education for physicians and APRNs as one factor. She further noted that nurse practitioners are schooled in a collaborative practice arena, and existing statute fosters continuation of that approach.
Bollier said she does not think the statute is the reason rural areas cannot attract nurse practitioners. They aren’t going there because they don’t want to live there, she said.
“We need to work on ways to get nurse practitioners to areas that are underserved,” Bollier said. She would support telehealth's role, but that only underscores the need to focus on improving broadband access in rural areas, she said.
Douglass said some nurse practitioners now rely on distant physicians, but she questioned the practicality of looking to telehealth as the solution. A nurse practitioner is “not going to jump on her computer screen for each patient,” she said. “I revere their educational path, they worked hard to become doctors, and none of us want to be a doctor. We just want to take care of the population we were trained to care for.”
PrairieStar's Lewis said she doesn't have a strong opinion on the issue. She likes her current agreement with supervisor and PrairieStar chief medical officer Rogena Johnson. "I've never seen it that I don't have independence," Lewis said, and she likes "having the comfort" of a physician to contact.
Scope of authority debates pit trade associations against each other and what sometimes gets dropped in the debate is what is good for the public, said David Jordan, president of the Hutchinson-based United Methodist Health Ministry Fund.
He said it would be good to be able to try test approaches for tackling the primary care provider shortage that don't require going through the Legislature.
The state of California established an innovation office within the California Health and Human Services Agency to encourage pilot programs, he said.
“It’s an exciting innovation that would be helpful for Kansas and any state with a rural population,” Jordan said.
Colby hasn't been able to fill a behavioral health position in five years, he said, adding, "We need to be able to innovate."