South Carolina NPs: The Fight for Full Practice Authority

Barriers to practice must be removed now in order to increase access to care, control costs, and improve outcomes—all of which impact economic development and quality of life.
Dr. Stephanie Burgess, Clinical Professor and Associate Dean, University of South Carolina

For nurse practitioners in South Carolina and other “restricted practice” states, providing treatment to patients can prove a struggle. According to the South Carolina Nurse Practice Act, NPs must practice within 45 miles of supervising physician, making it impossible to provide healthcare services in rural regions without doctors. Even though the vast majority of NPs have graduate-level training in primary care, they cannot serve as providers without the physical proximity of a medical overseer. Additionally, SC’s advanced practice nurses (APRNs) have severe limitations in ordering services for the disabled, home health services, Schedule II medications, and hospice care, further curtailing their ability to provide adequate treatment to people in need. Not only are South Carolina’s NPs being denied the ability to practice to the full extent of their advanced education, but more alarmingly, vulnerable populations in remote regions don’t have adequate access to care.

The Pulitzer Prize-winning Post and Courier (2018) explained a common problem with outdated “restricted practice” laws: when supervising physicians move or retire, NP-run clinics and facilities are forced to close. However, one way to meet rising nationwide demand for primary care providers is to allow NPs “full practice authority,” following the models in states such as Alaska, Arizona, Colorado, Oregon, Vermont, and many others. Of course, the main opponents to extending FPA are some doctors who claim that allowing NPs greater autonomy would “undermine the model of team-based, physician-led care.” The question is: who will treat patients when there are no physicians living within 45 miles of a healthcare facility? As Dr. Stephanie Burgess points out in her interview below:

  • There are less than ten physicians in private practice serving rural areas in SC
  • Forty-two out of 46 counties are designated as rural or “medically underserved” by the federal government
  • Eight counties have zero OB-GYN physicians: McCormick, Saluda, Lee, Fairfield, Williamsburg, Bamberg, Allendale, and Hampton

These days, more South Carolinians have access to health insurance. As a result, the demand for medical providers has increased dramatically. In fact, the University of South Carolina reported that 800,000 state residents received access to preventative care and routine exams with the passing of the Affordable Care Act. By one estimate, SC ranks 36th in the country for its relative lack of primary care physicians—a looming shortage affecting the whole country—and NPs are trained to provide many of the same essential services, including ordering diagnostic tests and prescribing treatments. Seventy to 80 percent of all APRNs provide primary care, and there’s ample evidence that NPs offer cost-effective and safe healthcare services with excellent outcomes. It’s no surprise that a wealth of national organizations have endorsed FPA for NPs, including the AARP, the Bipartisan Policy Center, and the Department of Veterans Affairs, which recently adopted FPA across its healthcare centers nationally.

NursePractitionerSchools.com (NPS) has been privileged to interview 45 NP professors on the issue of practice authority. In two new interviews with prominent professors from South Carolina, NPS once again makes the case for expanding FPA nationwide.

Interviews With Two Exceptional South Carolina NP Professors

The following interviews have been lightly edited for length and clarity.

Stephanie Burgess, PhD Clinical Professor, Associate Dean for Practice and Health Policy University of South Carolina, College of Nursing

Dr. Burgess is an experienced family nurse practitioner, who serves as a professor, doctoral project chair, and associate dean in USC’s College of Nursing. She has been a vocal leader in several organizations such as the South Carolina Nurses Association, Sigma Theta Tau, and the Statewide Coalition for Access to Healthcare. She provides primary care and women’s health services at two SC-based practices, including one managed by nurses. Notably, she’s received numerous awards, including a 2016 International Alpha Xi Lucy Marion Award from Sigma Theta Tau; a 2016 SC Hospital Association Leadership Award; a 2015 President’s Award from the South Carolina Nurses Association, and a 2014 National Advocacy Award for NPs from the AANP.

What is your view on moving toward full practice authority for NPs?

Barriers to practice must be removed now in order to increase access to care, control costs, and improve outcomes—all of which impact economic development and quality of life. Access to care is vital to areas of our state that need it most.

In South Carolina, 42 out of 46 counties are designated as rural or medically underserved by the federal government. According to the U.S. Health Report Card, South Carolina ranks “F” in overall health status. In 2017, SC fell from 42 to 44 in the ranks. Eight counties have no OB-GYN physicians (McCormick, Saluda, Lee, Fairfield, Williamsburg, Bamberg, Allendale, and Hampton). SC ranks 36th in the nation in primary care physician supply, with less than ten physicians in private practice in all of the rural areas. For the past three years, the top 15 reasons our poorest folks went to the ER were for primary care complaints, costing the state approximately $140,000,000.

Key partners support the removal of barriers to increase access to care, control costs, and improve outcomes. Such partners include the SC Department of Mental Health, physicians, the South Carolina Nurses Association, the Coalition for Access to Healthcare, the SC Healthcare Association, Eau Claire Cooperative, Agape, Colleges of Nursing in SC, certified nurse midwives, and nurse practitioners.

Have you ever felt limited by the NP practice laws in South Carolina?

Absolutely. For example, my physician collaborator retired when I was serving the underinsured and uninsured in a key rural area. Unfortunately, I was unable to secure another physician within the mileage constraints and collaborative agreement requirements. Therefore, I was not legally allowed to return to the area to provide services. Those patients are now without any primary care provider and are being cared for in the local emergency room—a very expensive avenue to obtain primary care. A lack of primary care not only impacts the individual, but also the community.

What are some actionable steps NPs and others can take to advance thecause?

Actionable steps include joining the Coalition, developing fact sheets, providing testimony at hearings, meeting with key legislators and the Governor, obtaining support from businesses and key business partners, and attending NP/CNM Lobby Day.

References:

Kimbi G. Marenakos, DNP Instructor Medical University of South Carolina, College of Nursing

Dr. Marenakos serves as an instructor in MUSC’s accelerated BSN program. For her recent doctoral program, she developed a quality and process improvement project to better address the mental health needs of the homeless. To that end, she works at the medical clinic within Charleston’s One80 Place Shelter, and teaches integrative nursing care to undergrads within her university’s Mental Health Scholars clinical rotations. Her research covers behavioral health in primary care, compassion fatigue, inter-professional education, policy reform, and community health, among other topics. She’s a member of several professional organizations, including the American Association of Nurse Practitioners, the American Psychiatric Nurses Association, the National Board of Certified Counselors, the Gold Humanism Honors Society, and Sigma Theta Tau International.

What is your view on moving toward full practice authority for NPs?

I think the whole situation is quite disappointing. It seems nothing more than an ego-driven turf war, and sadly, it is the patients that have been (and continue to be) sacrificed. We have literally thousands of underserved communities in the U.S. We have APRNs with the knowledge, training, and clinical competencies to fill those gaps in service, but with somewhat arbitrary, state-imposed restrictions on their scope of practice. This is not a coup d’état. Nurses do not aim to overthrow or replace MDs, only to work alongside them to provide the care that is so desperately needed.

Have you ever felt limited by the NP practice laws in South Carolina?

Yes, every time that I enter the on-site medical clinic at our local homeless shelter. I am there two days per week to oversee the Mental Health Scholars clinical group in the delivery of integrative nursing care to this incredibly vulnerable population. As a non-profit organization, the shelter has very limited resources, especially human resources. The MUSC College of Nursing has a beautiful partnership with the shelter, and I often wonder how much more we could be doing if APRN scope of practice restrictions were lifted.

Another way that I have felt limited by practice laws is when we are called “mid-level” providers and lumped together with physician assistants (PAs). There is a dramatic difference between the preparation of APRNs and that of PAs. APRNs were first RNs and they logged countless, hands-on hours at patient’s bedsides. Arguably, no one knows you better than your nurse! Some were associate degree RNs for many years before returning to academia to complete a BSN so they could even consider graduate school. Then one must complete another two years of didactic and clinical coursework for an MSN or three years for the DNP. Most nurses will continue to work throughout and many have families to support.

What are some actionable steps NPs and others can take to advance thecause?

Healthcare Policy Reform: As a Presidential Scholar at MUSC representing the College of Nursing, I remember taking a road trip to Columbia for Legislative Day. We met with representatives from around the state who are also healthcare providers. Remarkably, there was not a single RN in the mix. Nursing is the largest workforce not just in the state, but also the nation, yet we have little representation in our governing bodies. We need to have our voices heard on the front end of lawmaking, not just through lobbying for reform.

Inter-professional Education: With all due respect, I think the physician groups need to better understand how nurses are trained. MUSC’s Office of Interprofessional Initiatives works hard to blend students from all healthcare disciplines during the first two years of their programs. I think each individual college (medicine, nursing, dentistry, pharmacy, etc.) should be responsible for carrying that torch for the remainder of their degree programs. We need to more fully appreciate the unique contribution of each discipline to the holistic well-being of our patients.

Patient Education: Nurses have been ranked as the most trusted profession for many years running. We are trusted by the consumers of healthcare, and we need for them to understand and promote our cause. If we can educate the public about how APRNs can help reduce healthcare disparities, we will have a powerful ally. Ultimately, practice authority is granted by the consumer.

Advancing Full Practice Authority in South Carolina

This is not a coup d’état. Nurses do not aim to overthrow or replace MDs, only to work alongside them to provide the care that is so desperately needed…We need to more fully appreciate the unique contribution of each discipline to the holistic well-being of our patients.
Dr. Kimbi G. Marenakos, Medical University of South Carolina

As South Carolina’s population continues to grow and age, the demand for primary care providers is skyrocketing. One way to meet the needs of patients everywhere is to expand the pool of healthcare providers by granting full practice authority (FPA) to nurse practitioners. There’s overwhelming evidence that NPs provide safe, effective healthcare, typically at a lesser cost than physicians.

FPA has been endorsed by the the National Governors Association (NGA), the Macy Foundation, the National Policy Forum, and the Institute of Medicine (IOM), among many others. Notably, the Federal Trade Commission (FTC) has called for state legislatures to revise their regulatory models so NPs aren’t subjected to unnecessary doctor supervision. It cited an IOM finding that 16 states and Washington DC—regions with FPA—exhibited “no differences in [healthcare] safety and quality” compared to restrictive states such as South Carolina. Also, in the states with FPA, approximately half of NPs choose to work in traditionally underserved rural areas.

Overall, removing the burdensome practice restrictions in South Carolina and across the country is expected to:

  • Increase access to healthcare services, especially among vulnerable and underserved populations
  • Improve the continuity of care
  • Prevent healthcare clinics from closing when doctors retire or move
  • Decrease healthcare costs and bureaucratic inefficiencies
  • Enhance consumer choice

For aspiring NPs or South Carolinians who want to get involved, please check out the following resources:

Jocelyn Blore

Jocelyn Blore

Editor

Jocelyn Blore is the Managing Editor of NursePractitionerSchools.com. After graduating from UC Berkeley, Jocelyn traveled the world for five years as freelance writer and English teacher. After stints in Japan, Brazil, Nepal, and Argentina, she took an 11-month road trip across the US, finally settling into lovely Eugene, OR. When Jocelyn isn’t writing about college programs or interviewing professors, she satirizes global politics and other absurdities at Blore’s Razor (Instagram: @bloresrazor). Thank you for being interested.

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