Bill Gives Advance Practice Nurses More Freedom

Hospital waiting area. (Public Domain)

Legislation to allow nurses with advanced credentials to work independently from medical doctors is back before Wisconsin lawmakers, but the measure still faces conflict between the nurses who have sought it for years and the doctors who have opposed it for just as long.

Supporters of the proposal say the bill would help address severe shortages of health care providers, particularly in rural and northern parts of Wisconsin.

“Over one million Wisconsinites live in an area where health care professionals are in short supply,” said Sen. Patrick Testin (R-Stevens Point), at a hearing last week to change how advanced practice nurses are licensed in Wisconsin. “Yet the state of Wisconsin continues to tie the hands of some of our most qualified health care professionals.”

Under current Wisconsin law, registered nurses (RNs) who get additional training and are nationally certified can qualify as a nurse practitioner, a nurse-midwife, a certified registered nurse anesthetist or a clinical nurse specialist. Their training also may include a master’s degree or doctorate in nursing, and depending on their certification they may be allowed to prescribe medication or other treatments.

Many of these advanced practice nurses may see patients directly and provide primary care, including writing prescriptions. Currently, however, they must have a formal collaboration agreement with a physician to fill that role.

Under the new legislation — SB-145 / AB-154 — Wisconsin for the first time would create a separate license of an advanced practice registered nurse (APRN). Most licensed APRNs would, after a preliminary period of years, be able to practice without a physician collaborator under the measure.

Broad support

More than half the states and the District of Columbia have already enacted similar legislation, Testin, a Senate Health Committee member, told his colleagues at the hearing. “These states run the gamut politically from very conservative red states like Idaho to very liberal states like Connecticut,” he said. “There is no evidence that advanced practice nurses provide inferior care. Qualified professionals must be treated as such.”

Testin said collaboration agreements required under current law were an unnecessary restriction that the state successfully suspended during the COVID-19 health emergency in Wisconsin. That allowed advanced practice nurses to deliver health care to the fullest extent of their training and qualifications, he said.

When the restriction was reinstated, however, “those handcuffs [were] slapped back on,” he said. “These nurses stepped up only to be told by some to take a step back.”

The legislation has broad support, not only from the professional associations representing nurses and nurse practitioners, but from representatives of the insurance industry, the public health field and some business lobbying groups. The opposition has arisen exclusively from physicians.

A year ago, Gov. Tony Evers vetoed similar legislation, citing the failure of the authors to address issues medical groups had raised. But in his draft 2023-25 budget, he included language to create an APRN license similar to many of the previous bill’s provisions.

While the provision was removed by leaders of the Joint Finance Committee on the grounds that it contained policy not appropriate for the state budget, Testin said authors of this year’s bill found it helpful in trying to address the governor’s earlier opposition. He said supporters have made compromises to win support from Evers and doctors as well.

A medical lobbyist told lawmakers at last week’s 3-1/2-hour public hearing before the Senate Health Committee that “there’s a path to yes” on a bill that could meet objections doctors and Evers have raised — but that  it will need more changes before the doctors stand down.

A chief sticking point is the how many years of practice a nurse who qualifies as an APRN must have under a doctor’s supervision before being permitted to practice independently, said Mark Grapentine, the Wisconsin Medical Society’s chief policy and advocacy officer

The legislation as written currently specifies 3,840 clinical hours — approximately two years.

The medical society and a bevy of other groups representing medical specialties are asking for a total requirement of four years of supervision, Grapentine said — two years before the nurse qualifies for the advanced license and two years after qualifying.

“I don’t know why it is a bad thing, to try to make sure that any health care provider has experience in providing care, before they’re allowed to … practice completely independently,” Grapentine said. “Physicians can’t do that.”

Under the current legislation, the one group of APRNs that would continue to be required to have an ongoing collaboration agreement with a doctor are nurse anesthetists. The doctors want the provision to specify that the doctor must be one specializing in pain medicine.

Grapentine said they were seeking that distinction both because of the complexity of anesthesiology itself and to head off potential concerns about liability and malpractice litigation.

Dropping barriers to health care

A parade of other hearing witnesses testified that the bill was needed so that highly credentialed nurses could do more for their patients with fewer barriers.

Diane Schadewald, an advanced practice nurse practitioner licensed in both Wisconsin and Minnesota, testified about meeting with patients virtually in both states who used an online health care firm that she worked for.

When treating a patient living in Wisconsin, she worked under the umbrella of a collaborating physician whom she said she never needed to consult. For Minnesota patients, she worked under that state’s law as an independently practicing nurse practitioner.

Regardless of which state the patient lived in, “my knowledge and expertise as a nurse practitioner was the same in both instances,” Schadewald said. “I didn’t become more knowledgeable or gain expertise in the five seconds in which I moved from working within a collaborative agreement for a patient in Wisconsin to working as an independently practicing provider for a patient in Minnesota. I provided safe, quality care for both of these patients.”

Jake Brehm, director of operations at a medical clinic in Medford staffed by nurse practitioners, said that the facility has treated 8,000 patients a year. The clinic’s staff routinely collaborates with other health care professionals who are “content experts,” Brehm said.

But he described an unnamed regional health care system that opposes its staff physicians serving as collaborators with personnel outside the organization. Other independent physician groups in the region “oftentimes see our nurse practitioners as competitors” and refuse to provide the required collaboration agreement, he added.

“I’m here to say that my nurse practitioners with a doctorate level degree should be able to practice in the state of Wisconsin without the pressure of losing everything they’ve worked hard for, due to the need of a formal collaborative agreement,” Brehm said.

Witnesses spoke of the difficulty of arranging collaborative agreements at all, and of the high fees some physicians charged in return. “We have nurses who are paying hundreds and sometimes thousands of dollars to doctors who may not even be in the state of Wisconsin just to do their jobs,” Testin said.

Grapentine testified that collaboration agreements should not be that way.

“This whole system of how you have a collaboration agreement — that’s just a piece of paper, and it’s designed to make money — that is not what physicians should be,” he said. “We do not think that should happen.”

Sen. Mary Felzkowski (R-Irma) challenged him. “Let’s put a cap on what they’re going to be able to charge,” she said, and made the demand repeatedly through the course of his testimony.

After she had pushed the argument several times, Grapentine replied, “I think that is a very valid element in this whole discussion on this bill.”

Legislature revisits giving advanced practice nurses more freedom was originally published by the Wisconsin Examiner.