Nurse practitioner Ruby Houck opened her medical clinic in Bertrand in 2000 knowing she would have to — according to law — find a doctor to be her collaborating physician.

“I asked every physician to that lived in my county — eight different people — but no one would agree to sign on,” she told the Legislature’s Health and Human Services Committee on Thursday. “The doctors did not see a need for another health care facility in the county.”

Finally, another doctor agreed to collaborate with her, and her practice grew by the week, she said. But in 2004, the doctor sent a letter saying he no longer wanted to collaborate, and she was left again to search. She contacted nine clinics with multiple physicians and five other individual doctors who all declined because of no interest, being too busy or having employer restrictions against collaboration.

She then asked a division of the state Board of Nursing for a waiver from the requirement, which is allowed by law in rural areas. It was denied because she didn’t have a formal referral system — which no nurse practitioners have, she said — and because her patients had a broad array of needs, and the board was not comfortable with her owning her own clinic.

Just when she thought she would have to shut down her clinic and find someone else to see her patients, a pathologist sympathetic to her plight found a Gothenburg doctor who agreed to be her collaborating physician.

But she worries that he may someday change his mind.

Houck and several other nurse practitioners told the committee about the problems they have had in finding collaborating doctors, or having doctors charge them thousands of dollars to sign a collaboration agreement.

They asked the committee to move to the Legislature LB753, a bill that would allow nurse practitioners to practice without an agreement with a physician after five years, if the person’s record were free of disciplinary action.

To become a nurse practitioner, a nurse must be a registered nurse with a graduate degree in a clinical specialty, must have completed 30 hours of education in drug therapy and 2,000 hours of physician-supervised practice, and pass a certification exam.

Their training and education, said Omaha Sen. John Synowiecki, who introduced the bill, should allow nurse practitioners to work without a collaborative agreement.

Sandra Borden, who works in a Grand Island clinic, told the committee that collaborative agreements have been used by the medical establishment to severely restrict nurse practitioner clinics and inhibit access to their services. Agreements exist almost exclusively in urban settings where the nurse practitioners are employed by doctors.

In rural areas, she said, agreements are usually with family members, “or they result from shamelessly crass financial relationships charging exorbitant fees” to sign and file a document, often with no supervision or oversight taking place.

Borden said a local doctor told her clinic she would sign collaborative agreements if they were kept secret from her medical colleagues, if she would have no involvement with clinic operations, and if they would pay her a fee of $36,000 a year.

The Department of Health and Human Services sent a letter to the committee opposing the bill, saying it is in the best interest of the public to retain the requirement for collaborative agreements.

Nebraska’s physicians association also opposes the bill, said lobbyist David Buntain.

He said he has not been aware of any problems brought to the Nebraska Medical Association. It would be willing to work with the nurse practitioners, if that is the case, he said.

“Requiring integrated practice agreements still makes sense today,” he said.

Patients expect a nurse practitioner to have a relationship with a doctor, he said.

Sen. Phil Erdman of Bayard questioned Buntain about the fees charged by some doctors to sign an agreement.

“It sounds like from some of the testimony today that the agreements they have are an opportunity for extortion,” Erdman said.

Sen. Arnie Stuthman of Platte Center said people in rural parts of the state deserve to have medical care. But if doctors aren’t going to go to small towns, and nurse practitioners are, they ought to work hard to come up with something that isn’t a burden or doesn’t keep nurse practitioners away from rural areas.

Reach JoAnne Young at 473-7228 or jyoung@journalstar.com.