Nurse practitioners' drug-prescribing power was expanded in Covid-19 emergency; they're still trying to make it permanent

Kentucky law requires advanced practice registered nurses to have a collaborative agreement with a medical doctor to prescribe controlled substances. It's a requirement that they have worked for years to eliminate. 

Donna Isfort, APRN and CEO and owner of Estill Medical
Clinic. (Photo by Scott Utterback, Courier Journal)

In her final story for the Louisville Courier Journal, Sarah Ladd tells the story of Donna Isfort, an APRN who owns Estill Medical Clinic in Irvine, where she sees up to 1,500 patients a month.

In order to provide care for her patients, Isfort pays a physician who lives 40 minutes away $2,000 a month in order for her to sign a piece of paper that ensures that her practice is compliant with state law, Ladd reports.

Isfort told Ladd that the requirement is a "barrier that prevents access to care for a lot of people," especially in rural places like her community. She said if that requirement were to go away, she would be able to use that money to expand her practice. 

The law also creates a vulnerability in a nurse practitioner's ability to stay open. 

"If my collaborator decided he wanted to quit and gave me a two or three-week notice, I would have a hard time finding someone to replace him," she told Ladd. "And if my clinic were to shut down in this community, it would have a huge impact on health care."

Since she bought the clinic in 2010, Isfort told Ladd that to be compliant with the law she has partnered with two medical doctors, and her current collaborator is in Berea but doesn't see any of her patients. 

Isfort also talked about the challenges in finding physicians to work in rural Kentucky, and said this void is often filled by nurse practitioners. 

Ladd notes, "Estill County is one of many in Kentucky that is a federally designated shortage area when it comes to primary care, which means . . . there aren't enough providers to go around for the more than 14,000 people."

Delanor Manson, executive director of the Kentucky Nurses Association, told Ladd that the removal of the collaborator requirement would result in a healthier state. She said that practicing independently is within APRNs' scope of practice, making them "uniquely positioned" to provide health care to Kentuckians who don't have access to primary care. 

Finding a physician willing to collaborate with a nurse practitioner can be difficult since there are far more nurse practitioners than primary-care doctors in the state, Ladd reports: "As of October 2022, the commonwealth had 12,595 advanced practice registered nurses, according to a Kentucky Board of Nursing spokesperson. That's 10,000 more nurse practitioners in the state than primary-care doctors: there were roughly 2,500 in 2019, according to data from the American Academy of Family Physicians."

According to the American Association of Nurse Practitioners, 25 states and Washington, D.C., allow nurse practitioners to practice at their full scope of practice, meaning they do not require them to have a contract with a collaborating physician in order to fully care for their patients. 

During the Covid-19 pandemic, Gov. Andy Beshear used his emergency powers to remove the collaborative-agreement requirement, allowing nurse practitioners to prescribe controlled substances without it. His executive order ended in January, when the legislature did not extend the APRN's expanded authority.

"We basically did a pilot for two years" of such freedoms, Manson told Ladd, and nothing untoward came of it: "In two years, nothing happened, except that patients got more access. They got more care."

Ladd also notes a Health eCareers study that looked at Covid-19's impact on nurse practitioners in Kentucky, which found in part that  "removing practice barriers, as occurred during the executive-order period, could provide long-term increased access to care in the commonwealth."

Ladd previously reported that 94% of the state's 120 counties have a shortage of primary-care providers. 

Manson and others would like to see lawmakers lift limits for nurse practitioners during the next legislative session. Manson told Ladd that what they would like to see is a law that says after four years of collaboration and oversight with and by physicians, "if there have not been any problems reported to the Board of Nursing, then restriction . . . should be lifted." 

A bill has been filed during each of the last seven legislative sessions to remove what is called the "collaborative agreement for prescriptive authority-controlled substances, " and for the first time, it passed out of a full chamber during the last legislative session. House Bill 354, which included the provisions described by Manson, passed the House 84-8 but did not receive a hearing in the Senate, where the doctors' lobby, the Kentucky Medical Association, has long held sway in such issues.