Doctor: “Good evening, Just checking in.”

By Grace Vitaglione

Advanced practice nurse: “Hi! All is well here. No changes or concerns.”

Advanced practice nurse: “Good morning! Just sending my April check in. All is good here, no clinical concerns.”

Doctor: “Great! Glad all is well!”

Those texts cost one advanced practice registered nurse in North Carolina $6,000 a year, according to texts that a nurse supplied to the North Carolina Nurses Association.

If they want to work in North Carolina, advanced practice registered nurses — in particular, nurse practitioners — are required to work with a supervising physician. Certified registered nurse anesthetists require an arrangement with an organization that employs an anesthesiologist. Nurses say these regulations create unnecessary red tape and costs to the APRNs and to patients.

Doctors argue the rule contributes to patient safety.

APRNs have long fought for the right to practice independently. They want to see the law change so they can run their own businesses and clinics without a physician signing off on it.

And those physician signatures are expensive. Many APRNs report that they pay their physician supervisors upwards of $1,000 per month for supervision that doesn’t go much further than texts like those above. And they’ve been pushing to change the law in North Carolina for years.

Even as the legislative battle over eliminating that requirement drags into another decade, a new service has emerged: matchmaking agencies that pair APRNs with supervising physicians.

It’s become increasingly difficult for nurse practitioners outside of major health systems — such as those who own their own practice — to find a supervising physician, said Tina Gordon, CEO of the North Carolina Nurses Association. In that sense, these “matchmaking” services are meeting a real need, she said.

But with the extra costs that come along with supervision, these companies are “preying on the desperation of some APRNs to fulfill their contractual requirements to practice,” she said.

The companies respond that they are empowering nurse practitioners to take control of their careers and provide needed health care. They advertise the supervision gigs to physicians as a “side hustle” with low time commitment.

Nurses say those advertisements demonstrate how little the supervision requirement really matters for patient safety and positive health outcomes.

Still, Gordon said language added to a bill in the state legislature recently is “a step in a positive direction,” as it would define the four APRN groups in statute.

Long-fought battle

There are about 21,000 APRNs in North Carolina, according to the NC Board of Nursing.

Nursing advocates have been seeking legislation that would grant all four APRN groups — nurse practitioners, nurse anesthetists, nurse midwives and clinical nurse specialists — the ability to practice independently for years, but in the past decade, they’ve stepped up their efforts.

Currently, only nurse midwives have full independence, something that came to them as part of the 2023 bill that tightened abortion regulations in the state. That bill also dropped the requirement for nurse midwives to work under physician supervision once they’ve completed at least 24 months and 4,000 hours of initial practice. They can also be supervised by a more experienced midwife.

The other advanced practice nurses have argued that they’d always collaborate with physician colleagues as needed. But they also argue there’s no need to be financially tied to them.

Doctors have repeatedly fought the legislation, arguing that APRNs are not trained to practice individually, but rather as part of a coordinated care system in which doctors have the education, training and experience to lead these teams.

But APRNs have more flexibility and independence for their work in multiple other states, with research bolstering the nurses’ contention that their practices are safe.

No legislative changes took place this year before lawmakers left Raleigh last month for an extended summer recess. While members of the Senate have been more supportive of giving independence to APRNs in the past, measures have often failed in the House of Representatives, where there are two physician members.

House Speaker Destin Hall (R-Granite Falls) said he didn’t sense “a critical mass” in the House to move the legislation forward.

“The meat of that bill, I don’t foresee us taking up this long session,” he told reporters in an informal news conference on June 19.

Challenges to practice

Each time an nurse practitioner starts working with a new supervising physician, they must meet every month for six months. After that, they’re required to meet at least every six months.

It’s become increasingly difficult for nurse practitioners to find doctors who will agree to act as their supervising physician, Gordon said. Many large health care systems prohibit physicians who work for them from working with anyone outside of the system, such as an APRN with their own practice.

“The more systemized physician groups have become, the smaller the potential pool of physicians available to nurse practitioners to be able to check off this requirement,” Gordon said.

In the last few years, NCNA has noted the emergence of these new services designed to meet that need. Agencies with names like Collaborating Docs advertise on Facebook and YouTube with pitches such as “Ready to turn your side hustle into a success story?” Another company pitches to physicians, telling them, “Zivian Health provides physicians with mentorship and leadership opportunities, allowing them to do clinically meaningful work and generate additional income without increasing their patient load.”

Sarah, a family nurse practitioner in North Carolina who requested the use a pseudonym over concerns of negative impacts to her license, said she struggled to find that supervisor after leaving her in-person job during the COVID-19 pandemic lockdown. When she started working for a national company to practice telehealth, she was obligated to find her own supervising physician.

She found one through Facebook who charged $250 a month. Sarah told the physician about how hard it was to find a consistent supervising physician, and how ARPNs can’t practice without one.

That inspired the physician to start Collaborating Docs, one of the services matching ARPNs to supervising physicians. Busy with the new company, the physician stopped supervising Sarah and switched her to a different one through Collaborating Docs, costing her $500 a month.

“Now I’m sort of kicking myself,” Sarah said. “She’s making a crap ton of money off of desperate nurse practitioners who want to be able to practice independently.”

Kyle Renkei, chief operating officer of Doctors For Providers, another service that matches nurse practitioners to supervising physicians, said many of their clients prefer the service because it offers more safety and resources than a direct relationship, which could terminate at any moment without a backup. The system gives APRNs a support system and avoids interruptions in patient care, he said.

The company also provides a streamlined process to manage legal requirements in different states, he said.

All this frustrates Gordon, who said while physicians who want to go into business can respond to needs in a free market, nurse practitioners don’t have the same opportunity, as they are beholden to those physicians for signing off on their papers.

That doesn’t add any value to the patient or improve outcomes, she said. Plus, these services can cost a lot more than just finding a supervising physician on their own.

Higher costs

Amanda, a psychiatric mental health and family nurse practitioner, who also requested that her last name not be used for fear of retaliation, had to “scramble” to find a new supervising physician in 2024.

That led her to Collaborating Docs.

Amanda was trying to build her own practice, but Collaborating Docs wanted $1,150 a month to provide her with a supervising physician. That cost was too high while she tried to start her own practice, so Amanda threw in the towel after four months.

That money was far too much for the 15-minute monthly chat where she and the physician reviewed the care provided to one of her patients, as required, Amanda said. She had no problem asking for help, but never needed it, she said, and keeping up with the cost was too much.

Amanda was eventually able to find a semi-retired physician who charged her substantially less, so she’s started to build her own practice again on the side. Many nurse practitioners end up taking on a second job to keep their practices open, she said.

“You may not have enough patients per month to pay for that collaborator, or if you do have enough, you’re not going to make much of a profit to kind of survive on,” Amanda said.

B is an nurse practitioner who owns a primary care practice; she requested that only an initial be used for fear of retaliation. B also used Collaborating Docs, which cost $750 a month for her and $780 for her employee, a part time nurse practitioner.

While it was helpful that the service matched them quickly and efficiently, B said it meant she was locked into a contract with a high monthly fee. She said that her supervising physician sends out a group text each month to around 10 nurse practitioners, including her.

Renkei said what Doctors For Providers charges depends on government regulations, physician liability costs, and supply and demand, among other factors. The fee may be higher than what an APRN would pay a physician directly, but he argued they have also seen providers pay less than their previous agreement.

Doctors For Providers does not charge an upfront fee for the matching itself, although Renkei said he has seen other companies do that. Instead, they pay for company operations with a margin on the monthly fee.

“Many of the APRNs we work with have exhausted their efforts in finding a direct relationship with a physician already,” he said over email. “They are reaching out to us not because we are a required step in the process, but because what they are looking for can be incredibly difficult to find.”

Patient safety

Doctors say the requirement for a supervising physician is necessary for patient safety. But Sarah said her supervising physician doesn’t know whether she’s being safe or not. Her supervisor doesn’t audit a certain number of her charts weekly, or require that she talk to them before prescribing anything for a patient over a certain level of complexity.

“At least in North Carolina, they say it’s in the name of patient safety, but these people have no idea what we’re doing at all clinically,” Sarah said.

Amanda said she can call on her colleagues for any questions. For example, if a patient with dementia comes in, she would likely consult her colleague who’s a gerontological nurse practitioner.

Making sure you can adequately treat someone is part of being a responsible health care provider, she said, and if she didn’t know what to do, she would refer the patient to someone else.

She also said she’s very cautious about prescribing medications to her patients, and most of her colleagues are the same.

“You’re going to have good and bad prescribers or providers, regardless of what letters follow their name,” she said.

Sarah said it would be appropriate for an APRN to have a close working relationship with a supervising physician when they’re right out of school.

Amanda agreed, with the caveat that the service still doesn’t need to cost more than $1,000 a month.

Gordon said the companies’ advertisements calling the job a “side hustle” for physicians just shows how minimal the requirements are.

“Physicians are basically just handed money for doing very little,” she said.

That’s why there’s so much pushback to eliminating the supervision requirement, as people don’t want to give up a significant income source that takes relatively little time and effort, Gordon said.

Doctors For Providers doesn’t set any rules for the collaborative practice agreement, Renkei said, as that’s between the physicians and providers. State and federal policies may also set some time requirements, but it’s typically not a full-time role, he added.

A step forward

There is some hope for change resting on House Bill 696, which includes language that would codify the four APRN roles. The bill was put in a committee for lawmakers to work out a compromise, but not much movement is expected while lawmakers are away from Raleigh until late July, or beyond.

If passed, Gordon said the language could give title protection to advanced practice nursing roles so that someone else could not be hired to undertake the responsibilities of an APRN without having the appropriate certification and license.

Meanwhile, the fight continues to eliminate the supervision requirement. Gordon said it’s a matter of patient access to health care.

“The need for this legislation is also greater than ever, and that’s what keeps us moving,” she said.

Amanda said eliminating the requirement would help expand patient access as more APRNs could operate independently, particularly in rural areas. She said there are many people in rural North Carolina who can’t find a provider, especially one such as her who treats substance use disorder.

“I think that nurse practitioners really step into that gap where there are not providers and are willing to help patients,” she said.

Renkei said the reality is that the requirement is still in place, and without Doctors For Providers, many ARPNs could not open their own practices. Their ability to do so expands patient access, he said.

Collaborating Docs did not respond to repeated requests for comment.

Rose Hoban contributed reporting to this story.