Senator Ralph Hise along with colleagues — including the legislature's four elected nurses — introduces the SAVE Act during the 2021 legislative session in an effort to give advanced practice nurse practitioners more autonomy. (Photo: Taylor Knopf)

Olehonna Lynch started Pembroke Center for Wellness in 2010 because she wanted people in her home community to receive the best mental health care possible.

This story also appeared in North Carolina Health News

Lynch, a psychiatric nurse practitioner, said that before she started her practice the residents of Robeson County waited up to three months for an outpatient psychiatric appointment. When people can’t get help for their mental health issues in the community, they often end up in an emergency room in crisis.

Once they are stabilized, those patients return back home to again wait weeks for an outpatient follow-up appointment.

In contrast, Lynch said she can get a new patient in to see her in less than a week.

“It came down to one of those things where if you want it done right, do it yourself,” she said. “So that’s what I ended up doing. I realized there weren’t many options besides working at the hospital.”

Lynch has a background as a family nurse practitioner and later got her post-master’s certification in psychiatry because she said there was such a “huge need.” Lynch is the owner of her practice where she sees 80 to 100 patients a week and employees an individual and family therapist.

But her practice is tied to a psychiatrist who acts as her “supervisor.”

A North Carolina law passed in the 1970s requires advanced nurse practitioners to have a “collaborative agreement” with an overseeing physician. Essentially, Lynch pays $500 per month for that psychiatrist’s signature twice a year. The supervising physician doesn’t need to approve any treatment decisions or medications for Lynch’s patients. The physician doesn’t even need to be in the same building, or the same city or even the same county.

“I try to utilize her expertise more so that it’s not just a signature,” Lynch said. “If I have a difficult case, I will set up an appointment for my patient to meet with her for a second opinion. So I try to get more out of the collaborative agreement than just a signature and exchange of money.”

Lynch’s supervising psychiatrist works for Veterans Affairs at the local hospital and is planning to retire soon. When she stops practicing, the only psychiatrist in Robeson County — a county with 130,000 people — will be gone.

Unfortunately, this is not uncommon in North Carolina. In 2017, the Sheps Center for Health Services Research at the University of North Carolina found that 10 counties have no psychiatrists and 28 counties have less than the equivalent of one full-time psychiatrist per 10,000 people.

The retirement of Lynch’s collaborating psychiatrist also puts Lynch’s practice in jeopardy. Unless the law changes this legislative session, Lynch must have a supervisor to continue running her practice.

The SAVE Act

A bipartisan group of lawmakers has been trying for several years to pass a bill called the SAVE Act to remove that collaborative agreement requirement and allow advanced nurse practitioners to practice in North Carolina with more autonomy.

If the SAVE Act passes, Lynch said she will continue to collaborate with mental health professionals as needed. She said as it is, she consults other medical specialists regularly. Lynch said other advanced nurse practitioners contact her interested in starting their own practices, wanting to learn more about how to do it.

But the collaborative agreement requirement does deter some from moving forward, she said.

“We’re just trying to do the job we are trained to do with the least restrictions possible,” Lynch said. “We’re not trying to be physicians. It’s just difficult to practice with one arm tied behind your back.”

SAVE Act sponsor Senator Ralph Hise (R-Spruce Pine) said he pushes for the bill every year because the number of health providers in rural western North Carolina continues to decline and his constituents need access to care.

“We tend to put so many barriers from a policy standpoint, to make sure that [advanced nurse practitioners] can’t practice,” Hise said last week during a press conference announcing the filing of the SAVE Act (Senate Bill 249). “The end result is simply that people do not get the health care they need, particularly in preventative services.”

During the 2019 Nurse advocacy day at the legislature, the NC Nursing Association brought a visual for their message that the state’s nursing law restrictions are as archaic as the T-rex. (Photo: Taylor Knopf)

Advanced nurse practitioners are more likely than physicians to practice in a rural area, and North Carolina data shows that nurses who train locally are more likely to practice in a rural area than physicians.

For years, some physicians and their professional societies have opposed this legislation. In the wake of the pandemic, state lawmakers said this year could be different.

“Covid put the spotlight on gaps in our modern health care system, including overcrowded emergency rooms and lack of access,” said Representative Donna White (R-Clayton), a registered nurse, during the press conference in support of the SAVE Act.

The Save Act will address access but also move toward health equality for marginalized communities, said Rep. Carla Cunningham (D-Charlotte), who is also trained as a nurse.

“You can’t offer coverage to more people if you don’t have the workforce in place to deliver that care,” she said during the press conference.

Hise is more hopeful the bill will pass this time because there have been even more conversations about the benefits of the SAVE Act with people from different parts of the health care system.

“I wish anesthesiologists were more involved in that process, they’ve chosen not to,” Hise said. “But particularly among the other areas that are out there, they have been to the table and been working on this process to get us to this place.”

The North Carolina Medical Society has yet to take a stance on the bill this time around.

“We are in the process of reviewing this latest proposal. The NCMS supports public policy that results in the highest quality of medical care and puts patient safety first,” the society’s spokesperson Elaine Ellis wrote in an email to NC Health News.

Healthier Patients, Cost Savings

If lawmakers would have passed the SAVE Act in 2019, North Carolina could have already saved at least $866 million in health care expenses, argued Senator Joyce Krawiec (R-Kernersville).

“We can cut costs without cutting corners, and that’s what this bill does in a very effective way. Most bills that are introduced in these chambers usually cost a lot of money,” Krawiec said. “This legislation costs the citizens of North Carolina nothing and the benefits will be staggering.”

The North Carolina Nursing Association cited a 2015 study from the Duke University Center for Health Policy and Inequalities Research which concluded that removing barriers such as the physician supervision requirement would save the state “between $433 million and $4.3 billion per year while creating more than 3,800 jobs.”

“This is an opportunity to lessen the impact of physician shortages without compromising the quality of health care,” said Senator Jim Burgin (R-Angier). “Modernizing regulations is an important part of an evolving health care system.”

Representative Gale Adcock (D-Wake), the only advanced practice registered nurse in the General Assembly, said the health outcomes of advanced nurse practitioners’ patients are “as good and sometimes better” than their physician colleagues.

Representative Gale Adcock, the legislature’s only advanced practice nurse, during a 2021 press conference introducing the SAVE Act. (Photo: Taylor Knopf)

“We intend to continue to work with our physician colleagues as true colleagues interdependently as all health care providers do,” said Adcock, who has been a practitioner for 34 years. She just retired from a job where she actually was the boss to the physicians who were her supervisors.

The state is in the middle of transitioning the Medicaid program from one where reimbursement comes for every visit, test and procedure to one where providers get paid a lump sum to deliver more value and healthier patients.

Patient outcomes will be one of the key benchmarks for measuring how well providers are doing.

“You’re paying for how healthy your patient is, and that is not just how healthy is your healthiest patient, but how healthy is your sick patient,” Adcock said. “Advanced practice registered nurses bring a lot of bang for the buck. Because we keep people out of the hospital, we keep them in their homes and out of nursing homes.”

They also tend to be less costly to employ than physicians.

Adcock said that 23 other states and the District of Columbia have allowed their advanced nurse practitioners more autonomy, “and their citizens have not suffered from it.” And no state has reversed that decision, she added.

Mental Health Provider Shortage

Dona Francis is a psychiatric nurse practitioner who runs a mental health practice in Sunset Beach where she sees around 100 patients a week. Right now, she has a big dilemma. The 69-year-old wants to retire but cannot find someone to take over her practice. She says the collaborative agreement requirement is a contributing factor.

Francis’ supervising psychiatrist lives in the Charlotte area, and there are no psychiatrists practicing in Brunswick County. Francis is the only mental health provider in her county of 142,000 residents. The closest psychiatrist is in Wilmington, and the wait for an appointment is at least a month, she said. Many of her clients in Sunset Beach are older and do not want to travel that far.

“A lot of people don’t want to have to go an hour away when they’re already dealing with anxiety and depression,” Francis said. “And Covid has added another layer to that. They feel isolated being unable to see their family, children and grandchildren. Anxiety and depression has increased tenfold from where it was a year ago.”

She’s received a lot of new patients during the pandemic and said she gets new referrals every week. Francis said primary care providers don’t feel comfortable treating a psychiatric diagnosis, and they often don’t feel qualified or have time to do talk therapy with a patient.

“They have people for 15 minutes in their office and they’re out,” Francis said. “They don’t have an hour to sit with someone, help them process what’s going on, deal with their grief or help them with coping skills.”

Francis has been actively talking to nursing schools in the state in a quest to find her replacement. But she said graduating psychiatric nurse practitioners struggle to find a collaborating psychiatrist.

As she continues to search, Francis said she feels like she has an “ethical responsibility to stay the course, until I can get someone here.”