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Alabama’s Health: Scope of Nurse Practitioners

Expand scope of practice for nurse practitioners

The lack of primary care physician service in rural Alabama is well documented.  Fifty-two of Alabama’s 54 rural counties are currently classified by the Health Resources and Services Administration as having a shortage of such physician service.

When a county or sub-county area is classified as a shortage area for the provision of primary care, this means that there are not enough primary care physicians providing service for the area’s population to meet the minimal needs, much less optimal needs.  It is estimated that Alabama needs an additional approximately 150 primary care physicians, placed where they are needed the most, to satisfy our minimal needs or approximately 450 to meet our optimal needs.

Misty Ralyea, CRNP, sees a patient in the Brookwood Baptist Health Primary Care Network Clinic in Lincoln in Talladega County.

Add to this current shortage the fact that we are experiencing the “Aging of Alabama.” The Alabama Rural Health Association conducted a study in 2009 through which it was conservatively estimated that there could be the demand for an additional 1,785,000 office visits to primary care physicians each year by 2025.  This increase is mainly due to the aging of our residents and the fact that the presence of chronic diseases increases with age.

One solution to reduce the shortage involves the use of nurse practitioners (and other advanced practice providers) so they can practice to the full extent of their education and training. I have visited every medical clinic in 51 of our 54 rural counties to learn more about local health care issues.  I have seen physicians and nurse practitioners working together, giving each other needed time off from a demanding schedule, expanding clinical hours for patients who need to be seen outside of the traditional workday, and expanding days of clinical operation to include weekends in many rural locations.

Alabama is still considered to be one of the more restrictive states for the practice of nurse practitioners.  Additionally, reimbursement for nurse practitioners remains at some of the lowest levels – as low as 70 percent of the reimbursement that a physician receives for the same service.

Alabama has many rural areas that lack the population to attract full-time physician services.  The need for local health care is great in these areas and could be provided by nurse practitioners (and other advanced practice providers), especially if some practice requirements were relaxed. One barrier to expanding this service is the current requirements for having collaborative practice agreements with physicians working with nurse practitioners.

All nurse practitioners are required to work with a collaborating physician. The physician must be in the practice location with the nurse practitioner, including patient records review, for a minimum of 10 percent of the nurse practitioner’s practice time. This requirement is relaxed to include quarterly contact after the nurse practitioner has been practicing for two years.

Most nurse practitioners and collaborating physicians report that they enjoy and their patients benefit from their affiliation. However, the 10 percent direct supervision time requirement prevents many rural physicians from collaborating with nurse practitioners because of this demand on their own practice time. Also, one physician can only work with four full-time nurse practitioners. This rule especially impacts on greater utilization of nurse practitioners in our rural areas because of the smaller number of physicians practicing in rural areas.

With the expansion of telemedicine in Alabama, perhaps other ways can be found to increase the provision of primary care services by nurse practitioners (and other advanced practice providers) in rural areas, including in rural hospital emergency departments. Alabama’s health care needs are greater than those in most other states. Alabama needs to become a leader in more fully utilizing our limited health care provider resources.

Dale Quinney is executive director of the Alabama Rural Health Association, 1414 Elba Highway, Troy, 36081.