OKLAHOMA CITY — Cynthia Sanford would love to expand her McAlester medical clinic so that she can treat as many as 20,000 more children a year.
But Sanford, owner of the Kidz Choice pediatric health clinic, said she's hamstrung by a law that requires nurse practitioners such as herself to be overseen by a licensed doctor in order to write prescriptions.
Ideally, Sanford said she would hire as many as four more nurse practitioners, more than tripling her clinic’s reach. But she can’t find enough licensed doctors willing to oversee an expanded practice.
Demand is so great, she turns patients away.
“I need more staff, and I can’t do that," she said. "You can’t expand your business. You can’t grow."
Arguing that the law serves no purpose other than to line some physicians' pockets, dozens of nurse practitioners spent Tuesday pressing lawmakers to end the required collaboration and give them authority to write most prescriptions without oversight.
The change, they argue, will improve healthcare access in rural areas where residents now travel great distances for care or go without because they can’t afford it.
Nurse practitioners — typically nurses with advanced training such as master's or doctorate degrees — can now provide basic care including physicals, wellness exams and treatment of broken arms or heart conditions without a physician’s oversight. They can also issue referrals to specialists.
However, they cannot prescribe medication without the oversight of a licensed physician. Prescriptions can be as basic as recommending a fevered child take Tylenol, to complex cases such as prescribing opiates to suppress the pain of broken bones.
As many as 3,000 nurse practitioners are affected by the law, officials with the Association of Oklahoma Nurse Practitioners estimate, and many work at small clinics around the state.
Rep. Josh Cockcroft, R-Wanette, who is sponsoring a measure to end the required collaboration, said the regulation is holding back nurse practitioners and limiting rural health care access.
Cockcroft said some nurse practitioners report paying $8,000 per month to doctors for the right to prescribe medication. Physicians may oversee two practitioners each, unless they have special permission to see more.
Cockcroft said the payments make it unfeasible for nurse practitioners to work in underserved, rural areas.
Meanwhile nurse practitioners note their doctors, who may be located hundreds of miles away, have little to no contact with them.
“Our thought is if there’s not going to be a face-to-face meeting, which does not happen a lot between the doctor and the patient, then why do we need that supervision?" Cockcroft said.
Dr. Sherri Baker, a pediatric cardiologist and president of the state Medical Association, which represents some of Oklahoma's more than 7,000 licensed physicians, said the effort to change the system is “unfortunate.”
“Some of our biggest concerns are the people that these nurse practitioners are going to be treating are not going to have the back-up safety of the doctor supervision,” Baker said.
The association opposes Cockcroft’s measure, citing "significant concerns" about what it would mean.
“If you want to practice medicine, go to medical school,” Baker said. “Don’t try these other ways to act like a doctor, be a doctor, without going to medical school.”
Baker said nurse practitioners are overseen by the state’s nursing board, not the medical board that oversees doctors.
Nor are they required to carry the same level of liability or malpractice insurance as licensed physicians, she said, because in many cases they're covered by the supervisory doctor’s policy.
Baker, who oversees a nurse practitioner as part of her practice, said she’s concerned by reports that physicians don't review practitioners' charts or see their patients.
Fees charged by doctors cover the costs of a practice, she said, and don’t go directly into their pockets.
But Patricia Farmer, owner of Pediatric Practitioners of Oklahoma in Claremore, said she pays several hundred dollars a month to a licensed physician that oversees her and her other practitioner.
She doesn’t know what the doctor uses the money for, but she said none of it covers the cost of staffing her practice. Instead, the IRS classifies the doctor as a contracted employee.
“It’s easy money" for doctors who charge practitioners for prescribing rights, she said, calling her relationship with her supervisory doctor a "symbolic relationship."
“He’s excellent at what he does," she said, "but he doesn’t have any interaction with our patients.”
When her last supervising physician retired in October, Farmer said she “had to scramble” to find somebody else. Otherwise she would have been forced to close her practice, which treats about 8,000 children a year.
She found a new doctor who got special permission to carry four licenses.
“If something happens to him today, we’re closed, and it could take six weeks to get everything through (regulatory agencies),” she said.
When Sanford started as a practitioner more than a decade ago, she said she paid a supervisory physician from Broken Arrow more than $12,000 a year.
The doctor provided nothing in return — no staff, no chart reviews and no time with her patients, she said.
Her current doctor, based in the community, charges her nothing for oversight, and they consult about patient care about every month.
In any case, Sanford said she’ll no longer be classified as a practitioner in 10 months.
In addition to working full-time, she’s a fourth-year medical student and is set to graduate at the end of the year.
“For my colleagues, though, this is a very important bill that needs to go (through),” she said.
Janelle Stecklein covers the Oklahoma Statehouse for CNHI's newspapers and websites. Reach her at email@example.com