The Register-Herald, Beckley, West Virginia

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March 10, 2013

Bill would allow autonomy in prescribing medicines

Nurse practitioners, midwives and anesthetists currently must have a ‘collaborative agreement’ with a doctor

CHARLESTON — Toni DiChiacchio can diagnose a malady, order tests and interpret the results once the lab turns them in.

Yet, when it comes to prescribing medicine, West Virginia law slams the door, unless she and others in her profession are in a “collaborative agreement,” as the medical profession terms it, with a physician.

“I have my own clinic,” the Morgantown woman says.

“I collaborate with a physician who is not in my clinic. My patients don’t know him. He’s merely an auditor. He periodically looks at the charts. We want to get rid of that element.”

To achieve a seamless bond between nurse practitioner and patient, DiChiacchio is hoping the West Virginia Legislature looks favorably on SB379, now in the hands of a doctor, Senate Health and Human Resources Chairman Ron Stollings, D-Boone.

Not only would practitioners be allowed to practice the full scope of their professional training, but SB379 also embraces midwives and anesthetists.

Midwifery is an old term, harking back to the Old Testament defiance by midwives against the kill-all-male edict of an ancient pharaoh.

In modern times, says Angy Nixon of Scott Depot, midwives are advance practice nurses, putting them in the same category as the practitioners and anesthetists.

“Our focus primarily is on healthy women and going through from the beginning of the life span to the end of the life span,” Nixon said.

“At any point, when a woman needs health care, a midwife could be a primary care provider. Midwifery often is associated with pregnancy and we also do normal prenatal care, tend to births, postpartum, breast feed support and newborn exams.”

Running her own practice fully a decade, Nixon has delivered more than 600 children.

DiChiacchio says 16 states and the nation’s capital allow autonomous practice for nurse practitioners.

Nixon says there actually is no definition of a collaborative agreement with doctors.

“In many cases, there are so many opportunities for us to do collaboration, but we rarely ever need it,” she said.

Depending on the need of the patient, DiChiacchio says there are limits on what medications those in her line of work may prescribe, and those off limits are controlled substances.

“I don’t think we have a problem,” she said, in a meeting Friday at the Capitol with Sen. Bob Beach, D-Monongalia, chief architect of the Senate bill.

“Actually, we’re very conservative when it comes to prescribing controlled substances. That’s not a battle we’re necessarily fighting now. Definitely, the problem in this state with narcotic pills is not from nurse practitioners. We have been very limited. So you can’t blame that on us.”

Another practitioner, Kendra Barker, who works in Preston County, says the rule merely says the nurses must collaborate with a physician if a question arises about specific medications they may prescribe.

In such agreements, she notes, her assent is given for a doctor to review two of her charts annually.

“I can see 600 patients this year and he could review two of those charts and fulfill the collaborative agreement and have no other impact on my practice,” Barker said.

DiChiacchio questions the value of such arrangements.

“This kind of law limits competition without providing any kind of patient safety,” she said.

“How is that really going to provide safety if they look at two charts after the fact?”

The Federal Trade Commission is strongly behind this type of full-scope practice legislation, if doctors are not, she said.

“They’re the ones holding this up,” DiChiacchio said.

“Not all of them. But people that are holding it up are physicians. My personal belief is that they feel like we’re going to be a threat.”

Research over the past four decades has held that nurse practitioners are “very competent” in providing care, and, in fact, have proven themselves to be better in coping with hypertension, diabetes and other chronic disorders, she said.

“And,” she said, “there also been research in states where autonomous practice is allowed that doctors aren’t making any less money. So, it’s really not an economic threat.”

A nurse practitioner must possess at least a master’s degree in nursing and be nationally certified.

In West Virginia, passage of the pending bill would affect 1,400 such nurses, 400 anesthetists, and about 75 midwives.

“Toni has a very thriving practice in Morgantown,” Barker said.

“If her physician decides one day he wants to pull the collaborative agreement, she has to shut down. She can no longer serve any of her patients.”

The same reliance on a doctor’s agreement holds sway for others in the profession, making autonomous practice even more critical, Barker said.

“If you no longer have that collaborative physician who’s willing to sign that paper which just says you can call them if you have a question, our practice is gone,” she said.

“That significantly impacts all of our patients. We all have practices that affect a number of patients throughout the state.”

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