A recent U.S. Supreme Court ruling about teeth-whitening services may have long-term implications for health care professionals and their practices across the country.
The dispute involves the right of dental hygienists to perform such services in North Carolina. The Federal Trade Commission brought a major anti-competition case on the matter. The high court did not settle the case, but rejected the state dental board’s claim that its actions were immune from FTC scrutiny.
“In this case, the North Carolina dental board’s members, primarily dentists, were drawn from the very occupation they regulate. They barred non-dentists [in this specific case, dental hygienists] from offering competing teeth-whitening services to consumers,” said FTC Chairwoman Edith Ramirez in a press release.
The American Nurses Association says the dental board case may have “far-reaching implications beyond dentistry.”
In Georgia, the experts are divided on how, or if, the case could affect professional practice laws.
What doctors and nurses say
Debbie Bartlett, CEO of the Georgia Nurses Association, says her organization “will utilize the Supreme Court’s ruling to help inform Georgia legislators about the need to support federal antitrust laws [as well as] avoid unduly suppressing pro-consumer competition.”
Georgia state practice and licensure law restrict the ability of nurse practitioners — nurses trained to perform many tasks often left up to doctors — to engage in at least one element of practice. Georgia nurse practitioners, also known as advanced practice registered nurses (APRNs), cannot write prescriptions for Schedule II medications. And their ability to order specific diagnostic tests is also limited.
The state requires supervision, delegation or team management by licensed physicians in Georgia in order for any nurse practitioner to provide patient care.
Donald J. Palmisano Jr., executive director of the Medical Association of Georgia, sees little reason for concern about the high court ruling, because the kind of situation cited in North Carolina does not exist here.
“The North Carolina case is drastically different than the way the licensing boards work in Georgia.” says Palmisano. Here, a board’s proposed actions are reviewed by the state attorney general’s office and released for public comment, he notes.
“The ruling in North Carolina never rose to the level where the Medical Association needed to contact the Georgia Nurses Association,” Palmisano says.
“The two organizations [in Georgia] have a fairly strong relationship. I don’t foresee [a big impact from the Supreme Court ruling] here,” he adds.
Atlanta nurse practitioner Mary Perloe agrees. “I actually think nurse practitioner collaborative agreements with physicians and using evidenced-based protocols make sense,” she says.
“I also believe that the nurse practitioners should bear responsibility for their practice. As NPs gain more authority, accountability needs to follow, and physicians need to be relieved of this liability,” says Perloe.
Rebecca Wheeler, the GNA past president, suggests the ruling may be a mixed blessing for those in the nursing profession.
“I think the decision is great for APRNs, but I am a little worried about what this means in order to protect our own RN scope of practice from medical technician or nursing assistant roles,” Wheeler says. “I feel like this is a bit of a double-edged sword for nursing.
“I’m not saying it’s necessarily a bad thing [referring to the Supreme Court decision]. We probably need to be prepared to ‘give a little’ if we want APRNs to be able to practice to the full extent of their training in Georgia.”
The issue of dentistry
The American Dental Association (ADA) said it was “extremely disappointed” at the U.S. Supreme Court decision.
The group said the decision “constitutes a dramatic departure from the Supreme Court’s established law, and throws into question the regulatory, licensing and disciplinary authority of thousands of professional boards across the county.”
“The ruling creates a quandary for professional boards . . . with no explanation as to what level of ‘active supervision’ is necessary to invoke immunity for each board,” ADA stated.
The association said it is planning to work with other organizations to provide some kind of guidance in view of the Supreme Court’s decision.
But among Georgia dentists, as among physicians in general, there seems to be less alarm about the ruling. Frank J. Capaldo, the Georgia Dental Association’s executive director, says there are a number of important distinctions between the dental licensing boards in Georgia and North Carolina.
“In Georgia, members are appointed to the Board of Dentistry by the governor, but in North Carolina they are elected to the board by other licensed dentists,” Capaldo says. “This difference in and of itself shows significant state oversight in Georgia.”
Some see more opportunities
Scope of practice limitations for nurses exist alongside a shortage of health care providers in Georgia, especially in rural areas.
The consumer group Georgia Watch recently reported that the number of licensed APRNs in Georgia has reached more than 9,500. With the physician shortage in the state, which is expected to get worse, APRNs could help fill this primary care gap, the group’s report says.
A total of 129 of Georgia’s 159 counties have a shortage of health care professionals. In fact, about 80 percent of Georgia’s counties contain substantial populations without a consistent source for primary care, according to the Georgia Watch report.
Georgia Watch and others continue to urge state policymakers to consider using more advanced practice nurses and physician assistants in health care shortage areas.
Many Georgia physicians, however, traditionally support the restrictions on the duties of nurse practitioners. They’re concerned about whether people who are not doctors — working on their own — have the training to safely diagnose and treat patients, refer them to specialists, admit them to hospitals and prescribe medications for them. These doctors think the NPs should continue to work under the oversight of physicians.
The right of Georgia nurse practitioners to prescribe medications didn’t come until 2006. Georgia was the 50th state to grant NPs prescribing ability.
Many health care experts say that with the influx of thousands of Georgians into the health care system under the Affordable Care Act, the time may be right for the state to review its scope of practice laws, especially in rural areas.
“There are, after all, cost realities here. We just need to be prepared,” says Wheeler, referring to NP restrictions.
“This [Supreme Court] ruling seems to open up the door for everyone, including medical technicians or nursing assistants, as much as it does for APRNs,” she says.
Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.