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Plan to give nurse practitioners greater role in patient care fuels debate

Nurse practitioner Anne Krekis spoke with longtime patient Henrietta Faison, 77, at Atrius Health in Boston this month.Pat Greenhouse/Globe Staff/Globe Staff

For two years, patients in the Greenfield area came to Julia McDougal Ronconi in their time of need. Working at a clinic with doctors and other providers, she treated their depression, anxiety, and substance use disorder.

Ronconi, a psychiatric nurse practitioner, longed to run her own practice. But Massachusetts makes it difficult for her to do so. So she opened an office across the state line, in Brattleboro, Vt., where nurse practitioners are allowed to treat patients on their own.

In Massachusetts, nurse practitioners can have regular patients, but they must work under the supervision of physicians. “It becomes a bureaucratic hurdle,” Ronconi said. “It’s a barrier.”


Her dilemma is at the heart of a political debate brewing on Beacon Hill. Governor Charlie Baker and dozens of lawmakers support legislation that would allow nurse practitioners in Massachusetts to treat patients and prescribe medications without supervision from a physician — as they can in every other New England state.

Many public officials and health policy experts say this simple change would expand access to much-needed primary care, particularly for low-income and underserved communities. And it would contain health care costs, they argue, because with more access to providers, patients would be less likely to delay needed care or to seek treatment in expensive hospital emergency rooms.

But the idea remains controversial. Physician groups are lobbying to keep it from becoming law, arguing that nurse practitioners are not qualified to independently care for patients. Previous efforts to lift the restrictions have died in the Legislature.

Resistance tends to be strong in states such as Massachusetts that have a concentration of renowned doctors and academic medical centers, according to experts who follow the issue. And often, nurses are still thought of as support staff, not as independent care providers.

Nurse practitioners have a master’s or doctoral degree, receive additional clinical training, and must be certified as “advanced practice” nurses. They are trained to evaluate patients, order tests, diagnose medical conditions, and prescribe medications, and they can work in primary care or specialties.


Advocates of expanding authority for nurse practitioners say they already are trained to take care of patients on their own, but the law in many states, including Massachusetts, is holding them back.

Twenty-two states and the US Department of Veterans Affairs allow them to practice independently. In Massachusetts, nurse practitioners must find a physician willing to sign a collaborative agreement and oversee their prescribing practices.

It’s a cumbersome requirement that adds expense and uncertainty, while keeping nurse practitioners from working to their full ability, said Stephanie Ahmed, state legislative policy director for the Massachusetts Coalition of Nurse Practitioners.

“It’s absolutely slowing down the delivery of care,” she said.

And it’s not helping patients, said Jennifer Derkazarian, chief nursing officer at Atrius Health, which includes Harvard Vanguard and other medical practices.

“The state of Massachusetts is asking a physician to review retrospective prescriptions for a cohort of patients they’re not responsible for,” she said. “There isn’t any value in that. It becomes an administrative issue.”

In addition to its large roster of doctors, Atrius uses hundreds of nurse practitioners to treat patients. And, in a break from other physician groups, Atrius supports legislation that would allow nurse practitioners to work independently.

Several physician groups strongly oppose loosening the restrictions, arguing that nurse practitioners lack proper training to safely care for patients because they don’t have to spend years in residency as doctors do.


The Massachusetts Medical Society told legislators earlier this year that “physician-led” teams should take care of patients. Dr. Maryanne C. Bombaugh, president of the 25,000-member medical society, said nurse practitioners should work alongside physicians, not independent of them.

“It’s moving in a direction of siloing, versus a direction of integration and teamwork,” Bombaugh said. “It flies in the face of what we are trying to achieve in our state” in health care.

A national group called Physicians for Patient Protection also opposes such policies, even encouraging patients online to report incidences of harm suffered at the hands of nurse practitioners. The group was formed last year, as a result of concerned doctors who connected on Facebook, said cofounder Dr. Carmen Kavali, a plastic surgeon in Atlanta.

“It’s not an elitism thing,” said Dr. Michelle Martin, a vascular surgeon in Boston and member of the group. “It’s a training thing.”

Martin said nurse practitioners sometimes refer patients to her who don’t need to see a vascular surgeon, resulting in unnecessary appointments. “They don’t understand enough to know who needs to be seen by a specialist and who doesn’t,” she said.

But those who favor giving nurse practitioners more authority are quick to point to decades of research on the topic. Studies have demonstrated that nurse practitioners provide high-quality care, that they are more likely than primary care physicians to care for poor and underserved patients, and that they provide care at lower cost than physicians, according to Peter Buerhaus, a professor at Montana State University who studies the nursing workforce.


“I don’t think there’s legitimate concerns,” Buerhaus said. “There has always been resistance, but there has also been a growing acceptance by many, many physicians.”

The Massachusetts Health Policy Commission, a state agency that studies health care costs, examined the issue this year and determined that removing restrictions on nurse practitioners would probably expand access to primary care. The commission’s report noted that the national supply of nurse practitioners is growing more quickly than that of physicians.

In 2009, a RAND Corp. analysis predicted that Massachusetts could save on health care costs if it expanded the role of nurse practitioners, among other changes.

The Baker administration, in a lengthy healthy care bill filed in October, proposed lifting restrictions on nurse practitioners.

“It’s fair, it’s right, and it will increase access — which is what the governor’s health care bill is all about,” said Marylou Sudders, Baker’s secretary of health and human services. “I’ve seen no data to suggest the quality of care offered by nurses is anything other than excellent in other states.”

A majority of Massachusetts lawmakers — 88 representatives and 29 senators — also support legislation that would remove restrictions on nurse practitioners.

Many states have already done so, and “no state has ever gone backward or ever placed more restrictions,” said Tay Kopanos, vice president of state government affairs for the American Association of Nurse Practitioners.


The constraints in states such as Massachusetts are “a quirk of history that’s still on the books,” she said.

Meanwhile, Ronconi, the nurse practitioner who set up her practice in Vermont, said she still gets calls from former patients who are struggling to find a new provider.

“I left a population of over 450 patients in Massachusetts,” Ronconi said. “By not allowing nurse practitioners to practice to the full extent of their training, there are patients that are not being cared for.”

Priyanka Dayal McCluskey can be reached at priyanka.mccluskey