Pro: When APNs need a contract to treat patients, access collapses
By Marcel Kaganovskaya
Senate Bill S2996 offers a clear and responsible path to sustain New Jersey’s overburdened health care system. The state’s emergency departments are already stretched to the breaking point. Average emergency room visits now exceed three hours — among the longest wait times in the nation.
Each emergency department visit costs New Jersey patients an average of $3,750, nearly three times the national average, even though research consistently shows that up to 60% of emergency room visits are nonurgent and preventable with timely access to primary and mental health care.
As noted in Karin Price Mueller’s article, “Is There a Doctor in the House?,” Executive Order 415 threatens to make a strained system even more fragile. By forcing advanced practice nurses, or APNs, to relinquish their ability to practice autonomously unless they secure a contractual collaborating physician, the order does nothing to improve patient safety while dramatically increasing costs, reducing access and accelerating the exodus of experienced clinicians out of state.
To understand the impact, it is important to be clear about what autonomous APN practice looks like in New Jersey. For years — long before the pandemic — APNs have safely provided autonomous outpatient care in primary and mental health settings.
The so‑called collaborating physician requirement has never meant that a physician is physically present, supervising care or co-managing patients. These physicians are not in the exam room. They are not seeing the patient. They do not provide real‑time clinical oversight.
They are simply names on a contract.
Those names now cost APNs anywhere from $1,000 to $2,000 per month for the privilege of continuing to care for patients they already manage safely and autonomously. This arrangement does not enhance care, improve outcomes or expand access. It merely adds cost.
That is not collaboration. It is a pay‑to‑practice system.
Unsurprisingly, some physicians have recognized this requirement as a lucrative business model. I personally know of a psychiatrist who earns more than $100,000 annually simply by supervising more than 50 APNs across the state, despite never being present in their practices, never directly involved in patient care and sometimes being out of the country.
That revenue is not tied to outcomes, access or quality. It is tied to paperwork.
The downstream consequences of Executive Order 415 extend far beyond individual practices. If even a modest number of patients lose access to their autonomous APN providers, the spillover into emergency departments will be immediate and costly.
Based on conservative estimates from a recent survey of New Jersey APNs — many of whom have been providing autonomous, community‑based care for more than six years — patients who lose routine access to medication management and follow‑up care could generate millions of additional emergency department visits annually and billions in avoidable health care costs.
These costs do not disappear. They are absorbed by taxpayers, hospitals and families, many of whom are already struggling to navigate a fragmented health care system.
The burden falls hardest on Medicare and Medicaid patients. Research consistently shows that physician practices are less likely to accept these populations, while APNs are significantly more likely to serve them. In primary care and mental health especially, APNs are often the frontline — and sometimes the only — providers willing to care for these underserved communities.
As an APN, I take pride in caring for these patients. I refuse to accept a system where bureaucratic barriers, rather than clinical judgment, determine whether vulnerable individuals receive care. APNs take the same oath to do no harm as our physician colleagues. Limiting access to autonomous providers does cause harm — by delaying care and closing doors for patients who already face barriers.
When APN practices close or scale back because physician contracts become unaffordable, patients do not magically find another provider. They wait months. Their conditions worsen. They end up in emergency rooms, crisis centers or without care at all.
A recent survey of New Jersey APNs confirms this trajectory. Many respondents report that Executive Order 415 has already forced them to reduce patient panels, delay new patient appointments or seriously consider closing their practices.
Others are exploring relocation to neighboring states such as New York, where autonomous practice is respected and clinicians are not required to pay thousands of dollars to practice.
The question is no longer whether APNs are safe or capable. Decades of evidence have settled that debate. The real question is whether New Jersey will continue to support an outdated, costly system that prioritizes paperwork over patients — or whether it will choose access, affordability and common sense.
Marcel Kaganovskaya, a doctor of nursing practice (DNP) and a licensed advanced practice nurse (APN), is executive director of the Society of Psychiatric Advanced Practice Nurses (SPAPN) based in Montclair.
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Con: When autonomy shifts care to med spas, patients lose
By Naveen Ahuja
The investigative piece “Is There a Doctor in the House?” recently highlighted what we have all seen since the pandemic: a surge in wellness centers and med spas statewide.
It shows how independent practice authority is drawing advanced practice nurses, or APNs, away from essential care and into elective, cash‑based medical spas — and the risks involved when these procedures occur without physician oversight.
The med spas featured are prime examples; both were opened by APNs who left primary care and emergency medicine under a temporary COVID order. This experience was a “game changer,” showing policymakers which specialties APNs would choose and which they would abandon if independent practice were made permanent.
In his final days in office, Gov. Phil Murphy formally ended the COVID state of emergency, rescinding remaining pandemic‑era waivers — including Executive Order 112 — effective Feb. 16. The purpose of Executive Order 112 was narrow and temporary. It relieved physicians of certain statutory oversight of APNs during an unprecedented public health emergency so they could focus on emergency and critical patients in hospitals.
It was never intended to permanently alter health care delivery or scope‑of‑practice laws, nor was it anticipated to extend into community‑based practice.
While some say APNs have been practicing independently since 2020, in reality the EO waiver of physician collaboration or joint protocols was never broadly implemented in hospitals or practice settings. During the height of the pandemic, hospitals relied on more — not less — clinical collaboration. Across New Jersey, APNs and physicians continued working together in team‑based care models.
However, some APNs viewed the temporary waiver as a business opportunity and left hospital employment, primary care, anesthesia and other essential specialties to open cash‑based aesthetic practices — medical spas offering Botox, fillers, IV hydration, laser treatments and weight‑loss prescriptions, often taking RNs with them.
The order did not anticipate APNs and RNs leaving essential health care roles at a time when access was already strained, nor the downstream effects on hospital staffing and patient access.
Now, those same APNs are asking the Legislature to fast‑track S2996 to grant permanent independent practice authority and protect their businesses and clients from the consequences of decisions made under a temporary order. That framing alone should raise concerns.
This experience exposes a fundamental flaw in the “access to care” argument for APN independent practice authority. Real‑world evidence shows that when granted autonomy, APNs left high‑acuity hospital specialties and primary care for elective, cash‑based aesthetic services — a shift driven by market incentives, not patient‑access needs.
This is not limited to New Jersey. Despite Florida law restricting APN independent practice to primary care, a 2025 peer‑reviewed, NIH‑indexed study of 328 autonomously practicing nurse practitioners found that more than 60% were working in wellness, cosmetic, aesthetic, IV hydration and other cash‑based practices. New Jersey has not collected comparable data on how many APNs practiced without physician collaboration after 2020 or in what specialties.
Scope‑of‑practice laws exist to protect patients. Claims that “no one was harmed” during the past several years are unprovable given the lack of comprehensive data and reporting. Harm is not limited to malpractice; it includes overprescribing, unnecessary testing, excessive referrals, delayed diagnosis and poor outcomes when APN training does not match patient complexity.
Plastic surgeons increasingly must correct complications from nonphysician aesthetic settings — including misplaced Botox, poorly injected fillers, laser burns, thread‑lift issues and scarring or contour problems caused by inexperienced providers.