SAVE the primary care providers!

Advance practice nurses satisfied a need during the pandemic. Don't stop them now

Responding to COVID-19’s death, suffering, and loss, by necessity governments swept aside some rules letting patients get more care from medical professionals who weren’t doctors. As we approach widespread immunity, either by vaccinating people or COVID patients recovering,  questions about whether these regulations that blocked patients from health providers were needed. Period.

And, as emergency orders ease, if erecting these barriers again makes any sense.

Gov. Roy Cooper relaxed a host of licensing regulations last April through an executive order. But there’s no guarantee the enhanced consumer and professional freedom will survive much longer. When the emergency orders end, lobbying groups that were willing to look the other way for a few months will want their power restored.

One battleground is over advance practice registered nurses — nurses who have a master’s degree or a PhD. Unlike RNs*, NPs in states allowing “full practice,” according to, “can evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments — including prescribe medications — under the exclusive licensure authority of the state Board of Nursing.” 

In other words, they can function much like (and often as effectively as) family practice physicians. The big differences: State-mandated training requirements and rules blocking advance practice nurses from setting up independent practices. While some APNs can complete their academic and clinical training in as few as three years, becoming an MD or DO takes anywhere from seven to 15 years (depending on the specialty).

Moreover, North Carolina and 12 other states force NPs and nurse anesthetists (see correction at end of story) to have an MD or DO supervise them. “Supervision” often means nothing more than signing paperwork. But those signatures let MDs bill private or government insurance providers for a “service,” driving up costs and causing delays in delivering care.

Plus, they block health care professionals who don’t have medical degrees from setting up independent practices where primary care is lacking.

Is the extra 20,000 hours of schooling (as a group defending doctors’ turf claims) worth it? During COVID, North Carolina and a lot of other states said no. For now.

Medical societies are using their muscle to get those rules back on the books. Even though shortages that predated COVID will remain, and worsen. There weren’t enough docs to serve everyone pre-COVID. Family doctors won’t open practices in inner-city and rural areas once the pandemic subsides.

“The gap between the country’s increasing health care demands and the supply of doctors to adequately respond has become more evident as we continue to combat the COVID-19 pandemic. The challenge of having enough doctors to serve our communities will get even worse as the nation’s population continues to grow and age,” said Dr. David Skorton, president and CEO of the Association of American Medical Colleges.

How bad?

Not surprisingly, the medical schools want the feds to pump more money into medical schools and crank out more doctors. Public Choice 101.

Lawmakers in North Carolina and elsewhere have other, better ideas. 

“With the recent COVID-19 pandemic, more states are looking at changing their occupational licensing requirements in emergency situations to better prepare for the high demand of certain professions. Current state legislation on the issue also aims at broadening universal licensure beyond temporary situations that focus on individual professions,” reports the National Conference of State Legislatures.

The NCSL is tracking legislation in 20 states that essentially would allow persons who’ve gotten a professional license in any state to get a license in their new state if they pay licensing fees, pass background checks, and show they have the requisite experience. 

Two years ago, Arizona was the first state to allow such reciprocity. Since then, 10 other states have passed similar bills; in two other states, they’re pending.

NCSL’s tracker didn’t include North Carolina, where late last week lawmakers revived the SAVE Act, a bill that would let NPs set up independent practices. The General Assembly has tried before, only to be stymied by the N.C. Medical Society and lobbying groups representing specialists.

Another way to address the shortage: Let immigrants who were licensed physicians in other countries become MDs in the U.S. Missouri is considering such a bill.

This isn’t a niche solution. More than 260,000 immigrants who are working in U.S. health care are “overqualified,” says a report from the Migration Policy Institute. They earned advanced degrees or licenses in their native countries. But when they moved here, industry-led licensing boards have refused to let them use the full scope of their knowledge and experience. They’re also earning a lot less than they could if freed to provide the care they’re qualified to offer.

The SAVE Act must go through legislative committees and floor votes. Entrenched medical lobbies will schmooze, cajole, and even threaten lawmakers who resist them.

But nearly half of the state’s House members and senators have co-sponsored the bill. Along with the state’s nurses association, NC AARP, Americans for Prosperity, and the N.C. Rural Center support it. 

We’ll see if a combination of demonstrated need can overcome self-interested muscle.

(Medical licensing is one part of N.C.’s medical cartel that demands action. Certificate of Need laws are also despicable. You’ll hear about them soon.)

You’re looking live …

I started something new this morning — a Facebook Live post re-introducing this whole Substack thing and relaying that, yes, this is what I’m doing now. I’ve learned that the Mighty Facebook Algorithm makes you more visible to your followers if you post a live video and people look at it. (Don’t worry. It stays on the site after I post.) 

I’ll continue to use FB Live to preview what I’m writing about. I may change the times just to see who’s paying attention. If you’re on FB when I’m live, please give me a “like” or ask a question. I’d love to hear from you.

Four strings of nylon, always put a smile on …

We Raleigh Uke Jammers played Saturday. It was wonderful. Even the chain saw in the adjacent neighborhood couldn’t stop us. (Dude’s saw was out of tune, too.) We’ll be back soon. 

Yes, we played “Wagon Wheel!” “Paradise,” too. (Congrats to John Prine’s family for the Grammys.) Ketch and his Kanilea with Old Crow do it better, of course. 

*Disclosure: My wife is an RN, so she wouldn’t be affected by any change in the law affecting APNs.

Correction: Reader Joel Briner, who runs an office that provides anesthesia services mainly to cosmetic surgeons, points out that N.C. nurse anesthetists CAN provide services without a supervising physician. He said most hospitals and ambulatory surgery centers have an in-house anesthesia department supervised by physicians, but independent practices can operate. I appreciate the clarification and apologize for the error.