One day a week for 10 years, Stephanie Burgess made a trip to a clinic that serves the uninsured in rural Kershaw County and treated patients who might not otherwise have had access to health care.
Burgess was never paid. A clinical professor in the College of Nursing at the University of South Carolina, she went to treat the poor and enrich her students' experience. Last year, she had to stop making the weekly trips.
State law requires Burgess to sign a contract with a supervising doctor within 45 miles of where she is practicing. But the physician who oversaw Burgess retired. While the clinic remains open, the 300 patients she saw there each year were left without access to their primary care provider.
"I don’t know where those people are going," she said. "I guess they’re going to the emergency room."
The director the medical clinic said many of Burgess's patients have been taken care of. But others like them in rural areas must resort to the emergency room for their primary care needs.
With South Carolina facing poor health scores — the United Health Foundation ranks the state 42nd for overall health — some nurse practitioners want to be freed from regulations that require them to work under a doctor's supervision. They argue that nurses with advanced degrees can fill the gap left by a lack of primary care providers, especially in rural areas.
Many doctors' advocates, the American Medical Association among them, worry such a change would undermine the model of team-based, physician-led care.
"I think most veterans and patients expect a physician to be in that loop," said Dr. Alexander Ramsay, president of the South Carolina Medical Association.
In recent years, legislation that would have expanded the scope of practice for advanced nurses in South Carolina failed to pass the General Assembly. Now, some nurses hope a new Veterans Affairs rule will demonstrate the benefit of allowing them greater autonomy.
The VA announced the new rule in mid-December. It grants certain nurses within the VA system full practice authority, which means they can treat VA patients independently of physician oversight. The rule only applies to nurses with a post-graduate education in nursing.
VA Under Secretary for Health Dr. David J. Shulkin said in a statement the rule aids the VA in providing primary care. It is also a more efficient use of VA nurses, he said, and helps "alleviate the current access challenges that are affecting VA."
Such access challenges aren't unique to the VA. Jackie Baer, a family nurse practitioner, has run her clinic on rural Johns Island for about 15 years. She serves the poor and uninsured as a form of community service.
"I just realized the poor just never got the quality of care they deserve," Baer said. "I could be that bridge."
If her supervising physician, who Baer said is 70, retires, she will have to close her clinic.
Baer said she values her physician's expertise. But she often worries about what would become of the 3,000 patient visits she takes per year if she had to close.
"These people put so much trust in me," she said. "I'm an advocate for a population that's often overlooked."
Studies have for many years supported the notion that nurse practitioners could provide the same quality of care at a lower cost.
Family doctors were paid an average salary of about $202,000 in South Carolina in 2015, according to the Bureau of Labor Statistics. They are also the most sought-after kind of physician, according to a report from Merritt Hawkins, which reflects a need in the U.S. for more primary care doctors.
Government numbers show nurse practitioners on average are paid less than half what family doctors are in South Carolina — about $91,000.
The research body of the Florida state legislature estimated in 2010 that having nurse practitioners and physician assistants handle the majority of primary care appointments would save that state's health care system $339 million per year.
But some physicians' advocacy groups believe cutting physicians out of the equation may be a disservice to patients.
"The question is how often is someone going to be sick and have it not be recognized," said Ramsay, the S.C. Medical Association president. "We’re missing something if we’re not putting a physician in there."
He said he recognizes the value of nurse practitioners but does not think they should operate independently.
But leaders at the Ralph H. Johnson VA Medical Center are certain they will not sacrifice quality of care under the new rule. Dr. Florence Hutchison, the hospital's chief of staff, said the change allows nurses to shoulder more of the primary care responsibilities, which lets her deploy the hospital's specialty physicians more effectively.
Reach Mary Katherine Wildeman at 843-937-5594. Follow her on Twitter @mkwildeman.