New Jerseyans walking into an exam room with a bad case of the flu, back pain, stomachache or any number of other ailments have for years now increasingly been evaluated, diagnosed and treated by a nurse practitioner working with a physician.
Now that collaboration may be coming to an end, and nurse practitioners could soon see patients without any doctor oversight.
New Jersey is poised to become the latest state to grant full practice authority to nurses with advanced degrees, a move that supporters say will cut down on unnecessary delays, shorten wait times for care and give more residents access to more affordable care.
Doctors have launched an all-out war against the measure, with more than a dozen New Jersey medical societies banding together under the “Access to Care Coalition,” enlisting lobbying and public relations firms, and launching a robust website laying out their argument.
They say the move would water down the level of care to patients and allow hospitals and other employers to hire nurse practitioners instead of better-trained and better-paid physicians to cut costs. The bill would remove any doctor involvement in reviewing a prescription from a nurse practitioner before it is issued.
“Allowing for the removal of physicians from the care team places patients’ lives and health at risk,” said Dr. Mike Ruzek, president of the New Jersey Chapter of the American College of Emergency Physicians. “While we value [nurse practitioners], I believe the inclusion of a physician as part of a care team is a safeguard for patient care.”
Amita Avadhani, a critical care nurse practitioner at Princeton Medical Center, said nurses in New Jersey already do almost everything a doctor does, especially in primary care settings.
Current regulations are akin to “requiring you get a permission slip from someone in your neighborhood in order for you to legally drive your car,” she said. “You’ve already completed drivers’ education and passed the required exams. The Motor Vehicle Commission has issued you a license, and your neighbor won’t drive your car or ride along. But without their permission slip, it would be against the law for you to pick up your kids at school or drive to work.”
Doctor shortages
The movement to grant nurse practitioners “full practice” privileges began 30 years ago in less densely populated states such as Alaska and Oregon, where many residents didn’t have access to doctors. But more states have begun to allow the practice, including New York, Connecticut, Delaware, Maryland and 23 others.
The movement comes as the U.S. faces a shortage of between 37,800 and 124,000 physicians within 12 years, according to a report by the Association of American Medical Colleges. New Jersey is one of nine states projected by the federal government to have a shortage of primary care physicians and physician assistants as soon as 2025.
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The wait times to see a doctor are at an all-time high as New Jersey’s population grows — especially with a projected sharp rise in the number of senior citizensexpected in the years and decades to come. The average wait for a physician appointment for the 15 largest metro markets in the U.S. was 26 days in 2022, up from 24 days in 2017 and 21 days in 2004, according to a survey by the search firm Merritt Hawkins.
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Meanwhile, the number of nurse practitioners — called advanced practice nurses in New Jersey — has soared over the past two decades from 106,000 nationwide in 2004 to 355,000 last year.
Nurse practitioners must have four years of college, followed by a two- to three-year graduate program in advanced nursing. They must pass national certification board exams and maintain board certification throughout their careers, including taking continuing education courses to renew state licenses.
Doctors say that pales in comparison with their training: four years of college, four years of medical school and then three to seven years of intense, supervised residency, depending on the specialty.
What does the bill do?
Currently, advanced practice nurses in New Jersey can see and treat patients but must have a “joint protocol” with a physician to prescribe medicine or a medical device.
The bill — S1522 — essentially eliminates the need for a joint protocol, allowing nurses to write prescriptions independently after two years or 2,400 hours of working collaboratively with a doctor. The bill also makes a provision for nurse anesthetists to work “without any requirement for supervision by a licensed physician.”
New Jersey has already been allowing nurse practitioners to act independently of doctors for more than three years under an emergency executive order issued during the COVID-19 pandemic that Gov. Phil Murphy has yet to rescind, despite the urging of doctors.
Supporters say the three years has been enough time to show there is no widespread decrease in care. Opponents say few practices have actually allowed nurse practitioners to operate without a doctor’s oversight during this period.
Doctors vs. nurses
Nearly every medical society in New Jersey, representing a variety of physician specialties, is against the measure. Those who support it range from nursing associations to Planned Parenthood and AARP.
At a legislative hearing in December, both sides spoke strongly of how the measure would affect care.
Dr. Camille Green, an internist in Hunterdon County, told the panel that she likely saved the life of a patient after realizing her nurse practitioner colleague missed that the patient likely had diabetic ketoacidosis on a lab report. Dr. Walter Lapicki, an anesthesiologist, recounted how he saved the life of a 2-year-old in the emergency room, when the child was was choking on a peanut, because he had sufficient training in other disciplines. “Make no mistake, they are not and will never be the expert physicians,” Lapicki said of nurse practitioners.
Doctors said a cash-strapped hospital or other provider would hire more nurse practitioners over doctors. The median salary for a nurse practitioner in the U.S. is about $121,000, federal data shows. Primary care physicians make between $199,000 and $242,000 nationally, according to the data. Nurse anesthetists make $196,000 nationally, and anesthesiologists make $331,000.
Doctors cite a 2022 study by two Stanford University researchers that said patients treated by nurse practitioners at a Veterans Affairs emergency room had increased medical costs, longer hospital stays and “less favorable patient outcomes.”
The American Association of Nurse Practitioners counters with data showing that primary care nurses bill for fewer tests and image studies than primary care physicians do.
Marcel Kaganovskaya, a Bergen County-based family and mental health nurse practitioner, said he rarely sees the physician with whom he is supposed to collaborate. The physician is not involved in his patients’ care on a regular basis, he said. But lab tests and other paperwork are often sent to the physician, causing a delay for Kaganovskaya’s patients, many of whom are children and already have a three-month waiting list to see him.
Other New Jersey nurse practitioners told the panel they would likely seek more work in neighboring states like New York and Delaware that allow full practice. Pennsylvania does not allow it.
One of the biggest supporters of the measure is a physician, Dr. Vicente Gracias, a professor of surgery and vice president of health affairs at Rutgers. “In the end, more providers will provide more care just like the docs,” he told the panel.
Will the bill pass this time?
The legislation has had other iterations in past years but has never advanced far in either house. However, unlike past versions championed by Democrats, the current bill has bipartisan support. Its 20 co-sponsors are a mix of Democrats and Republicans, including some of the most liberal and conservative lawmakers in the Senate.
Observers believe it has a better chance of being approved with the two-year, lame-duck legislative session closing out in January, when bills are often hurried through the Senate and Assembly.
The biggest supporter of the bill, state Sen. Joseph Vitale, D-Middlesex, chairman of the Senate’s health committee, said it helps tackle a serious problem
“This is not a shot at doctors and the work they provide,” he said at the committee hearing. “It adds to the pool of individuals that can provide the care that we need at the right time, whether it’s primary care or mental health that we are in short supply.”