Power, justice, and little white pieces of paper
July 30, 2005 -- Today the Savannah Morning News posted a story about a local primary care physician now serving an eight month sentence in federal prison, apparently in part for signing blank Schedule II substance prescription refills for nurse practitioner (NP) colleagues to use. Such NP prescription is reportedly unlawful in Georgia but in no other U.S. state. Don Lowery's "A doctor's 'conviction' violates the law" reports that Jack Heneisen wrote the prescriptions so that he and the NPs with whom he practiced at a rural Effingham County clinic could handle their huge patient load. Most of the lengthy piece is a fair discussion of the debate between those who favor greater NP autonomy because of its public health benefits, and physicians who claim that the NPs must be under physician control because they lack sufficient training.
The piece notes that in addition to the jail term, Heneisen has received a $30,000 fine, 250 hours of community service, and two years of probation, and that he has lost his medical license for at least two years. Heneisen reportedly practiced for 20 years in the county and enjoyed widespread support from the local community because of his frugal lifestyle, community service, and commitment to affordable care. The piece reports that "state and federal drug agents raided" Heneisen's clinic in 2003. The article notes that Heneisen pled guilty to one count of "illegal prescription filling" and one count of "destroying pre-signed blank prescription forms," both federal violations. Federal court records actually indicate that he pled to one count of illegally refilling an Oxycontin (Schedule II controlled substance) prescription in 2002, and one count of destroying the prescription forms that he had pre-signed allegedly for the same illegal refilling purpose in May 2003, after the original "raid." Thus, it would seem that the case centered on Heneisen's refilling of Schedule II prescriptions for existing patients, including those who saw only an NP on a return visit, and also those he did not think should have to return (and pay) for another office visit at all. Heneisen seems to have felt that it would not have been practical for the clinic to handle its very heavy load of patients (many of them chronic pain sufferers) or fair to the patients themselves if he had to personally review each refill. Heneisen's conduct suggests that he trusted the NPs enough to make judgments about whether the refills were appropriate.
Most of Lowery's piece concerns the development of NP autonomy, and the debate over how far it should extend. There are several quotes from Georgia NPs who support expanded prescribing rights, and several from a physician and the executive director of the state medical association, who oppose such rights.
On the nurses' side, the piece includes a quote from the American Academy of Nurse Practitioners about a "year-long study" comparing a physician practice to an NP practice at the same organization finding that patients of the NP-managed practice had only 43% of the total ED visits and only 38% of the total inpatient days. The study also reportedly found that the NP-run practice's monthly "per member" costs were about 50% less. The piece notes that Georgia NP Donna Hodnicki has done research documenting the safety and accuracy of NP prescription. She calls the limited NP prescriptive authority "ludicrous." NP Tina Roberti admits physicians typically have more formal education, but notes that NPs generally have more "one-on-one experience with patients." She points to research showing that the quality of NP care is comparable, and to the benefits to patients that NP prescription would provide, including greater access to care for underserved communities. Roberti also says that NPs have as much pharmacological training as physicians, and that 20 years of NP prescription in other states have produced no adverse results. Indeed, the piece points to no adverse results of Heneisen's conduct, though court records suggest the prosecutors did have an expert identify purported flaws in a tiny percentage of the health records they confiscated. Hodnicki suggests that those opposed to greater NP rights are motivated by "stubbornness and economic reasons;" greater NP autonomy would presumably be a threat to some physicians' bottom lines.
On the other side, the piece quotes David Cook, executive director of the Medical Association of Georgia, and Don Thomas, a family practice physician and influential state senator reportedly blamed by many nurses for blocking NP prescription rights in the state. Cook notes that Georgia NP's can phone in prescriptions for most drugs, and suggests that NPs pushing for the change really want "not to utilize the skills they have but to set up independent practices...without any supervising physician," or practices "where they are over a doctor who is more highly qualified than they are." Cook is also quoted as saying that there must be a "progressive hierarchy" in health care based on different levels of training and expertise. He asks why physicians should spend more years in training if nurses can do the same thing they can. Thomas feels that NP prescriptive authority should only occur "under a physician's license," and does not think NP's should be able to set up independent practices. Neither of these men points to any example of unsafe care by independent NPs, or any research showing such care to be a problem.
These statements reflect plenty of bias and fear, but little understanding of NP qualifications or practice. Of course, the fact that one group has additional formal training says nothing about whether a different group is qualified to perform a given task, particularly since different professional models may result in different approaches to care, regardless of the length of time spent in school. The issue is whether NPs are qualified to prescribe. The research and the NP track record clearly show that they are. In fact, no research of which we are aware supports the idea that physicians are "more highly qualified" to provide primary care or prescriptions than NPs are. Rather than assuming that more formal training means better skills at every relevant task, as Cook does, it might be more logical to ask why the NPs' training and practice model seems to enable them to provide primary care that is at least as good with less formal training. And the regressive notion that health care requires a "hierarchy" among different professionals is an enduring factor in a wide range of evils, from high rates of medical errors to the nursing shortage that threatens lives worldwide.
The Center thanks Mr. Lowery and the Savannah Morning News for the extensive, fair discussion of these issues. We salute Dr. Heneisen for his confidence in the abilities of NPs, and hope he is released soon so he can resume caring for patients, despite the obstacles that have been placed in his way by those who seem to have other priorities.
See the article by Donald Lowery "A doctor's 'conviction' violates the law" in the July 30, 2005 edition of the Savannah Morning News.
You can contact Jack Heneisen's attorney Steven Beauvais at <firstname.lastname@example.org> with letters of support or call him at (912) 232-3770.