SHALLOTTE, N.C. – A family nurse practitioner said a single paperwork requirement hampers her ability to deliver the care her community deserves.


What You Need To Know

  • State law requires advanced practice registered nurses, including family nurse practitioners, to have a supervising physician

  • In practice, supervising physicians play almost no role Lawmakers are trying to repeal the requirement

  • The measure is meant to encourage nurses to open practices in underserved rural areas

Debbie Varnam has been an FNP for some two decades, opening her own practice in Shallotte in 2006. From the day she opened her practice, she has had a supervising physician. She meets with the doctor twice a year to discuss some cases and the doctor fills out a form certifying they met. 

“He doesn't see my patients, I don't see his patients,” she said. “Basically I'm paying to have a conversation twice a year with a supervising physician.”

Varnam isn't the only health care provider in this town of roughly 4,500 people, but many small towns and rural areas aren't so lucky. Six rural hospitals have closed in North Carolina since 2014, taking with them a host of medical services. Doctors with their own practices are in short supply in rural areas, so nurse practitioners often fill the gap. If an NP can't find someone to serve as a supervising physician, they can't open a practice.

NPs working for a hospital can find a supervising physician easily. Because Varnam has her own practice, she had to ask a doctor in Oak Island, 20 miles away, to serve in that role. She has to pay a $1,000 fee each month for the service.

That takes care of her general practice. But Varnam also treats patients with opioid addictions, a job that sometimes requires her to dispense the opioid-blocking drug buprenorphine. Her primary supervising physician doesn't work in that field, so she had to find a second supervising physician to cover her opioid work. That's another $500 out of her pocket each month.

“The concept is if I have a clinical problem that I can't handle myself, then I would have somebody to call,” Varnam said. “But what happens is, I call whoever I need.”

The price tag isn't a mere nuisance. During the Great Recession, Varnam at one point fell behind on her fee payments to her supervising physician because so many patients lost jobs and thus couldn't afford to keep seeing her. The doctor she works with simply let her catch up on payments later, but had he cut her off due to nonpayment, she would have had to close her practice that day.

Lawmakers are looking to change that. So far, 77 state representatives and 25 senators have signed on to the so-called SAVE Act. The measure would eliminate the supervising physician requirement for the four categories of advanced practice registered nurses, or APRNs: nurse practitioners, certified nurse-midwives, certified registered nurse anesthetists and clinical nurse specialists. It's intended to increase the availability of health care services in rural areas. Rep. Gale Adcock, a Wake County Democrat who is herself an FNP, said in 80 of North Carolina's 100 counties, CNAs are the only people in the entire county who are able to administer anesthetics. Without them, surgeries would be impossible.

“There is no oversight. Many of these nurse practioners' supervising physicians are many counties away, so the supervision that is required does not add to the value, the quality or improve the outcomes of care,” Adcock said.

Varnam said if the SAVE Act passes, she would be able to hire an additional case manager using the money she saves from no longer having to pay for a supervising physician. That would help her office care for patients when she isn't seeing them directly, such as answering diabetes management questions.