Stephanneth Adams plans to leave Kansas.
The nurse practitioner landed in the state's rural southwest — where she saw patients in Garden City, Dodge City and Liberal — through a federal program aimed at stubborn health care shortages in urban and rural America.
But why stay? Adams has her eyes on Nevada, a state that lets its most educated nurses roll up their sleeves and work without permanently needing, as they do in Kansas, permission from a physician.
"I want to practice in a state that recognizes our qualities and our academic experience," she said.
Kansas makes advanced practice nurses ink deals with doctors that physicians say protect patients by ensuring those nurses will collaborate with their more educated colleagues.
Nurses disagree. They insist the contracts do little more than limit patient options, allow doctors to fend off unwanted competition, and, in some cases, give them a cut of nurses' earnings for little to no work.
Nationally, one state after another has come around to that way of thinking — dropping contract requirements like those in Kansas. Physicians trying to stop the trend fight back with less and less success.
"This has kind of been painted like it's a turf war," said Rep. John Eplee, an Atchison family physician and state lawmaker opposed to lifting Kansas' restrictions on nurse practitioners. "What this boils down to is, we just want patients to have access to safe care."
If Kansas scraps the contracts, he argues, why would physicians stick around in a state where nurse practitioners can take a shortcut through less schooling?
"That's like the days back in the 1950s," he said, "when a physician would go to medical school and then do a rotating internship and then go out and practice. No one does that anymore because society requires more training and higher standards."
That's not how the National Academy of Medicine, the Federal Trade Commission and many public health and health workforce researchers see it. To them, physicians in holdout states don't have the goods to back their alarmism.
"No studies suggest that (advanced practice nurses) are less able than physicians to deliver care that is safe, effective and efficient," the National Academy of Medicine says, "or that care is better in states with more restrictive scope of practice regulations. ...
"In fact, evidence shows that nurses provide quality care to patients, including preventing medication errors, reducing or eliminating infections and easing the transition patients make from hospital to home."
Welcome to the NP 'revolution'
Walk into your local medical clinic and you're increasingly likely to be seen by a nurse practitioner instead of a physician. In the span of about a decade, the number graduating from nursing schools has more than tripled.
Ed Salsberg calls that "phenomenal."
The founder of the National Center for Health Workforce Analysis at the U.S. Department of Health and Human Services and of the Center for Workforce Studies at the Association of American Medical Colleges suspects nurse practitioner graduates will rocket past the nation's supply of new physicians within a few years.
"It really has been sort of a revolution," says Salsberg, now a faculty researcher at the George Washington University School of Nursing.
He originally raised red flags, worried the nation was charging toward a surplus of NPs unable to put all that graduate education to use.
But so far, he says, the U.S. has "soaked them up."
More than two-thirds work in primary care, something that nurses, physicians and policymakers alike see as a blessing. Studies show those NPs can offer much of the routine health care that doctors provide, then refer cases beyond their training to the physicians.
But many doctors want to retain oversight or other control of that burgeoning cadre, including by requiring NPs to enter contracts that Kansas calls "collaborative practice agreements."
About half of the states have dropped such contracts for all NPs or all those with more than a couple years of experience, a trend that began decades ago.
In states that haven't, the same legislative wrestling match between advanced practice nurses and physicians plays out one year after the next. Emboldened by research validating their safety and by health care shortages affecting millions of Americans, nurses refuse to back down.
The U.S. doesn't have enough doctors — or at least, parts of it don't. Its population is growing and, since the 2010 Affordable Care Act, more of those people are insured.
Exacerbating that: The giant Baby Boomer generation is reaching an age that requires more health care. The generation's doctors are retiring. One in three Kansas physicians is over 60 years old, at a time when 1 million Kansans already live in areas with primary care shortages.
Researchers say states that roll back restrictions on NPs have more of them, with notable benefits for underserved communities. Skeptics argue that government could plot a different course instead, with targeted dollars for medical residencies and other incentives to reinforce physician ranks in the right places.
"The reality is, it's probably a little of all of it," says Candice Chen, former director of the medical and dentistry division at the federal Bureau of Health Workforce and an expert on graduate medical education at GWU's School of Public Health.
The National Center for Health Workforce Analysis, she notes, predicts a shortage of more than 20,000 primary care doctors by 2025. NPs can help fill the gap.
Where doctors tend not to go
Sofia Navarro was a pediatric nurse at Children's Mercy Hospital when she headed back to school to become a nurse practitioner.
She envisioned going into private practice, in a shiny new office with all the nicest gadgets and equipment that a health care pro could want.
That changed when a professor suggested Navarro wrap up her gynecological studies working public health in one of the state's poorest places, Wyandotte County.
"I ended up falling in love with public health," she said.
More than a decade later, she's still there, screening women for cervical and breast cancer and explaining puberty to teens. About half her patients, she estimates, have no insurance or policies that don't pay for much.
Peter Buerhaus is chairman of the National Healthcare Workforce Commission, a body created by the Affordable Care Act to puzzle out health care access.
He and others have plowed ahead with research for the commission on their own, mining Medicare and other data. Their findings?
NPs are more likely than doctors to serve people on Medicaid or without insurance, and people of color. The same goes for another of Kansas' sore points — rural areas.
"There's a strong body of evidence now," said Buerhaus, a professor at Montana State's School of Nursing. "Nurse practitioners are more likely to work in rural areas than physicians."
Medicare data also suggests their care costs less, Buerhaus says, and not just because Medicare pays them less. NPs appear to order fewer tests and procedures and pick cheaper options when they do.
Goal No. 1: Protecting patients
LaDona Schmidt knows what it's like to be a nurse practitioner. And a physician. The Lawrence doctor has been both.
What she learned from that transition opened her eyes. She went from knowing the basics of prescription drugs, she says, to understanding their workings at the cellular level.
Medical school, she testified to Kansas lawmakers, helped her save the life of a 4-year-old whom an NP had diagnosed with stomach flu.
"She recommended Tylenol, fluid and 'time,' " wrote Schmidt, the Kansas Medical Society's president-elect. The mother sought care again the next day. Schmidt noticed the child's enlarged liver, ordered tests and put him in the hospital.
"He continued to progress to liver failure," she said, "and fortunately was able to receive a liver transplant two weeks later."
Schmidt declined an interview. She and other Kansas physicians opposed to ditching collaborative practice agreements point to training. Family doctors slog through four years of medical school and three years of residency. Many specialty residencies last even longer.
NPs typically attend a two-year master's program, though universities in Kansas and elsewhere are shifting to doctorates.
Stories like Schmidt's frustrate Monica Scheibmeir, dean of Washburn University's School of Nursing in Topeka.
"Whenever my well-respected physician colleagues make comments about errors, they should remember they live in a glass house," she said. "And that never gets brought up."
Other researchers with medical and nursing backgrounds agreed. Absent data, physicians' anecdotes remain just that — anecdotes.
"There are horror stories about physician providers like that too, right?" said Chen at GWU, a trained pediatrician. "We have to figure out how to prevent those horror stories."
That means training providers of all stripes to know their boundaries, she said, and when to involve doctors or nurses with expertise different from their own to address a patient's care.
The FTC is unconvinced that restricting NPs is needed to achieve that. Collaboration is "'the norm" even in states that don't make NPs secure physician contracts, it says. NPs still refer their patients to physicians and hospitals.
The FTC warns of a one-way street that positions doctors as market gatekeepers. That can stifle competition and stick consumers with higher bills.
Though some states, such as Kansas, call their contracts "collaborative agreements" and dodge words like "supervision," the power dynamic is clear:
Doctors don't need the deals, nurse practitioners do.
A V.A. treasure trove
In 2014, a research team at the Department of Veterans Affairs that included physicians dug into past studies in search of the impact of NPs on patient health, quality of life and hospitalizations.
They found no negative impacts, but noted that recent, rigorous research was thin — and weaker than advertised by some proponents of unfettered NPs. Still, they said the lack of fresh studies wasn't surprising.
"Well-publicized, well-conducted randomized trials conducted in the 1970s proved the concept" that independent advanced practice nurses "can deliver care comparable to that provided by a primary physician."
The team suggested the VA could dig further by mining its own extensive quality and error data.
In 2016, the VA dropped collaborative contract requirements for NPs — including those working in states such as Kansas. A spokeswoman said the VA expects to complete a fresh study next year on the effects of independent practice.
Kansas NPs point to the VA's 2016 decision to try to win over state lawmakers. They'll try again next year after this year's bill died in a legislative maneuver to expand Medicaid. Their new version offers to make new NPs work a few years before dropping their contracts with doctors.
Kansas physicians say they're open to compromise of a different sort. They remain skeptical of granting NPs independent practice and distrust the Board of Nursing's ability to oversee NPs if they get it.
So keep the contracts, they suggest. Just improve them. Make sure doctors don't abuse them for financial gain and slack off on giving NPs meaningful help.
"We work side by side with these folks every day," says Jeremy Presley, a private practice doctor in Dodge City and president of the Kansas Academy of Family Physicians. "We value the care they provide."
Presley teaches nurse practitioners, works with them daily and sits on the advisory board for one of Kansas' doctoral nurse practitioner programs.
Kansas lets doctors ink deals with as many NPs as they want, and charge as they see fit. Some may work in the same building as the NPs. Others, across town. Still others, 100 miles away.
NPs offer anecdotes of physicians overseeing and charging half a dozen NPs in scattered locations without consulting regularly or at all.
"I feel bad for those folks," Presley said. "Frustrated for them, that those agreements aren't in a better — you know, aren't set up in a better way."
But it's unclear how common such situations might be, because neither the nurses nor the doctors report contract details to the state.
Nor is it clear how much income Kansas physicians collect this way.
A new national study found advanced practice nurses face contract fees more often if they work in rural areas or at nurse-operated clinics. In those cases, contract prices charged to the nurses or their clinics often topped $6,000 and ranged up to $50,000 annually.
In a small and not necessarily representative survey conducted by the Kansas Advanced Practice Nurses Association, half of 180 respondents said their collaborating physician got monetary compensation.
The costs ranged from $1,200 to $16,000 per year.
Celia Llopis-Jepsen is a reporter for the Kansas News Service, a collaboration of KCUR, Kansas Public Radio, KMUW and High Plains Public Radio covering health, education and politics. You can reach her on Twitter @Celia_LJ. Kansas News Service stories and photos may be republished at no cost with proper attribution and a link to ksnewsservice.org.