Intense lobbying, broad support, no votes: NC nursing bill in limbo

Years ago a psychiatric group sought to recruit new doctors to North Carolina, pitching potential new hires on the easy money they could make thanks to a state law.

Come to North Carolina, Carolina Partners said in a long-running job posting, and get paid to oversee advanced practice nurses, who are required to practice under a supervising physician.

“Because North Carolina's supervision rules are modest, money earned from supervising good, experienced nurses or PAs is almost passive income for the doctor,” the group said in its spiel. “Psychiatrists earn from $10,000 to $15,000 per nurse, so a doctor supervising four full-time nurses would earn up to $60,000 per year in extra income.”

The posting disappeared years ago, but it lives on as part of an ongoing debate over those “modest” rules, which nurses have pushed for years to change. They argue that the supervision North Carolina law requires amounts to little more than paperwork that doctors can charge tens of thousands of dollars a year to sign, generating that “passive income.”

Reforms to give advanced practice registered nurses the freedom they seek sit in limbo at the General Assembly despite broad, bipartisan support in both chambers.

For APRN’s, the old job posting represents their argument crystalized, not just in psychiatry but across a range of medical practices.

For doctors, it’s a one-off. An internet pitch not reflective of the way nurses and doctors work together, and must work together, to keep patients safe.

“Most doctors and APRNs are working in really good situations together, all across the state, to get the best outcome for patients,” said Chip Baggett, chief executive of the NC Medical Society, which advocates for doctors. “They’re trying to write law towards the rarity.”

APRN’s say it’s common enough. Bette Ferree, a retired family nurse practitioner in High Point, said the doctor who supervised her lived out of state. She said she sometimes sent him pictures to consult.

“And I bet, in 10 years, I may have talked to him five times,” Ferree said.

At a press conference on the bill last month state Sen. Gale Adcock, a former president of the North Carolina Nurses Association, said the law makes nurses get “a permission slip to go to work.” It keeps APRN’s, all of whom must have a masters degree, and some of whom have a Ph.D., from setting up private practices without paying a doctor.

That limits the number of providers, an issue state lawmakers have become more concerned with as large hospital groups sign agreements with doctors’ practices, consolidating the industry. Care in rural areas is a particular concern, and some state lawmakers wanted the SAVE Act, as the measure is called, paired with the Medicaid expansion bill that passed last week so that nurses could treat more of the newly insured patients expansion would cover.

"The paperwork currently required, and let's be clear, that's all it is, is a barrier,” said Adcock, D-Wake.

Baggett said he doesn’t dispute there are “bad actors” who abuse the system. He said the North Carolina Medical Board might be interested in the anecdotes nursing groups have told state lawmakers in lobbying for the bill, since board regulations are more robust than the underlying law.

The law, he said, “is never fully encompassing of how people need to behave.” He said thousands of doctors and nurses work together in North Carolina without nurses paying any direct fees because everyone is an employee with the same hospital group.

Dozens of states have passed something like the SAVE Act, and none of them have repealed it. Doctors say patient safety is at stake and point to a pair of studies showing poorer outcomes when APRNs treat patients without supervision.

The fight over anesthesia — whether an anesthesiologist needs to administer it or a nurse anesthetist can handle things — is a particularly fraught subject, generating much of the campaign spending and intense legislative lobbying that has helped keep the SAVE Act from coming to a vote in the North Carolina House despite having enough bill sponsors in recent years to pass.

Both sides accuse the other of bad faith. Asked last week whether a deal might be struck by narrowing the SAVE Act, which Baggett said goes further than similar laws in other states, state Nurses Association Communications Director Chris Cowperthwaite scoffed.

“Organized medicine has routinely refused to negotiate in good faith,” he said, an assessment shared by state lawmakers who support the SAVE Act. “Why would we cede ground before we can even get to the negotiating table?”

As for the old Carolina Partners job ad, that psychiatric group was taken over by MindPath, which has therapists in seven states. MindPath’s media office didn’t respond to a request for comment.

Stan Monroe, who was Carolina Partners’ chief executive and president, told WRAL News that the group had “higher obligations for doctors regarding nurse supervision” than the law’s “pretty minimal requirements.”

“But these minimal admin obligations did not obviate the fact that Carolina Partners believed a doctor was legally and ethically responsible for a nurse's clinical decision making — a real responsibility — and that most nurses and their patients benefited greatly by these supervisory relationships,” Monroe said.

Broad support, no vote

Last year's version of the SAVE Act had 76 sponsors in the House, more than enough to pass. Yet it didn't come to the floor. It was never heard in committee.

When supporters pressed the issue, Speaker of the House Tim Moore, R-Cleveland, used a parliamentary maneuver to make sure the bill didn’t come to the floor.

Moore said at the time, and again last week, it wasn't because of industry pressure. Instead, he said, it was because not every Republican sponsoring the bill actually wanted it to pass.

“Members will sign on to bills … but when they realize, perhaps, some of the other intricacies of it, they will reassess how hard they want to push that bill,” Moore said.

Moore has declined to name members with second thoughts. Asked how much special interest pressure has impacted the bill, the speaker said “none.”

This year the House version of the bill had 59 cosponsors as of Friday. It takes 61 votes to pass legislation in the House when all 120 members are there, and most bills that pass have far fewer sponsors.

Campaign spending

The fight drives campaign donations. North Carolina Health News, a journalism nonprofit, broke down some of that spending this month and said nurse anesthetists who support the SAVE Act increased their giving in the runup to the 2022 elections, donating nearly $204,000 through a political action committee.

On the other side of the issue, anesthesiologists donated more than $627,500 through eight political action committees, N.C. Health News reported. Sen. Ralph Hise, a prominent SAVE Act supporter who last month summarized the bill’s lack of progress in one word — “anesthesiologists” — was the target for some of that spending.

One entity spent at least $39,500 on ads boosting Hise’s opponent in the waning days of a primary that Hise won by 362 votes.

“Nurses get involved a little bit,” Hise, R-Mitchell, said with a chuckle last week, “but aren’t the large PAC spenders.”

Much of this money flows through NC Citizens for Patient Safety, which is funded by anesthesiology groups and by North Carolinians for Affordable Health Care, whose treasurer works for the N.C. Medical Society.

The group spent about $146,000 on the 2022 general elections. Much of that supported state Rep. Tim Reeder, R-Pitt, a medical doctor who is now a first-term Republican in the House. Reeder beat Rep. Brian Farkas, a Democrat and a SAVE Act sponsor, by 354 votes.

Nursing groups keyed into the race, too. The NC Association of Nurse Anesthetists PAC and the NC Nurses PAC both gave Farkas $5,600, the maximum allowed by law at the time for this sort of giving. The political action committees spread other donations around, giving $1,000 each to a wide range of lawmakers, and in many cases $2,500 to legislators in leadership positions.

Notably, neither nursing group gave to Moore, whose opposition to the SAVE Act was well known. Over the last 5 years, anesthesiologist PACs have donated at least $127,800 to Moore's campaign.

Kara Weishaar, a local attorney listed as executive director for the N.C. Society of Anesthesiologists, declined to comment for this article, saying she was not authorized to speak for the group on the record.

Baggett, the state Medical Society’s director, declined to discuss lobbying on the bill or campaign donations. “I’m not going to get into tactics,” he said.

‘Worse patient outcomes’

Doctor groups point to a pair of studies on patient safety as reasons why the supervisory law is needed.

In 2020 a clinic in Hattiesburg, Miss., published an analysis of the 10 years since it expanded the authority of its advanced practice nurses.

The clinic said its results were clear: Physicians performed better on nine of 10 quality measures. Monthly health care spending was $43 more per patient for patients who saw nurses — and those patients were slightly more likely to visit the emergency room, even though they were younger and healthier.

The clinic also noted that if it hadn’t added to its team of nurse practitioners and physician assistants — something the looser regulations enabled — it couldn’t have cared for thousands of patients who might have otherwise gone without care. But, the clinic said: “We believe very strongly that nurse practitioners and physician assistants should not function independently.”

The second study, published in late 2022, analyzed data from the Veterans Health Administration, which in December 2016 started letting nurse practitioners treat patients without a physician’s supervision. The arrangement was more efficient, researchers concluded, but led to “worse patient outcomes.”

The analysis also suggested a net increase in medical costs with nurse practitioners — “even when accounting for NPs’ wages that are half as much as physicians,” the researchers said.

Michelle Skipper, a nurse practitioner for 26 years, said she doesn’t need a law telling her to consult a doctor as needed.

“We are not asking … to work without our physician colleagues,” she said. “But what I don’t need is, twice a year, for us to have to sign a piece of paper that says we’re working together.”

Skipper works in Scotland and Robeson counties, poorer areas that struggle to recruit enough doctors and nurses. Skipper said she has a good relationship with her supervising physician.

But what happens if he retires? Will she have to close her practice? Will she find another doctor to work with? Will he or she be months out of medical school but, on paper, her superior?

“The day that he decides to retire, I would have to start from scratch,” Skipper said.

Next steps

Whether the SAVE Act comes up for a vote this legislative session remains to be seen.

On Tuesday, hundreds of nurses and nursing students plan to visit the legislature for an annual lobby day, meeting with lawmakers and pitching them on the SAVE Act.

The House version is HB 218, but there’s an identical Senate bill, SB 175. The Senate version has 21 cosponsors out of 50 members, plus support from the chamber’s most powerful lawmaker, Senate Republican Leader Phil Berger.

Berger, R-Rockingham, said this month that he supports holding a vote, but a decision hadn’t been made. He also said Senate leaders haven’t decided whether to stick the SAVE Act in the Senate’s proposed budget, a negotiating tactic one chamber sometimes uses to pressure the other chamber into accepting new policy.

Asked whether he’s concerned about industry pressure keeping this bill from moving forward, despite the large number of sponsors, Berger said no.

“That may very well have been the case in years past,” he said. “I think it is unlikely that that sort of pressure will keep us from bringing it up. If we don’t bring it up there will be other reasons.”

As for the House, Moore said last week that he wasn’t sure whether the bill would get a vote. But he also said that with hospital regulation reforms included in the expansion bill that has already passed, lawmakers “really dealt with a lot of issues that have been pending for quite a while” in health care.

“So we’re very pleased with where we are,” Moore said.