On behalf of Ohio’s advanced practice registered nurses, we submit this rebuttal to the Ohio State Medical Association’s coalition letter opposing House Bill 508. It should be noted that the organizations listed on the opposing letter as coalition members are physician interest groups with a direct financial and regulatory interest in maintaining the current arrangement. They do not have support from organizations that represent public opinion or need HB 508 addresses.
However, the coalition supporting HB 508 includes primary care providers, nursing organizations, rural health advocates, mental health providers, addiction treatment providers, community clinics, hospital systems, and patient access organizations. This debate is ultimately about whether access to care should depend on a paid administrative contract between two professions — and the evidence is clear that it should not.
HB 508 allows an APRN with 5,000 hours of collaborative clinical practice under an SCA to practice independently. This approach maintains accountability while reducing unnecessary costs and improving access.
Over half of the states in the United States—27 states and 3 U.S. territories, including many states that border Ohio, have already passed laws removing the Standard Care Arrangement (SCA). The states that have passed these laws have not witnessed harm to their patients or a fragmentation of healthcare. In fact, they have seen improved access to care, cost savings for the citizens, decreased travel and wait times, and better healthcare results. (Yang, et al., 2021; Buerhaus et al, 2018).
Physicians Are Charging APRNs to Collaborate
The opponents claim no evidence exists of APRNs being charged for collaboration — yet simultaneously acknowledge that 400 APRN-owned clinics must contract with physicians to operate. OAAPN and supportive organizations have provided evidence and direct testimony time and time again to the exuberant costs being charged for Standard Care Arrangements. Private practice physicians charge an average of $300–$500/month for an SCA, and online brokerage platforms charge an average of $400–$800/month, pairing APRNs with in-state and out-of-state physicians who never see a single patient, never conduct a chart review, never lay hands on a patient, and in many cases never speak to the APRN at all — collecting a monthly fee for a signature and nothing more.
OAAPN encourages you to reach out to APRN’s in your district and ask them if they are required to pay for an SCA agreement—we are happy to set up conversations with practicing APRN’s in your district. Additionally, we have attached testimonials speaking to this issue. Additionally, I encourage you to review the following online sites that pair APRN’s with physicians: · Zivianhealth.com: Starting at $500.00 per month · Collabortingdocs.com: One-time $500.00 fee and starting at $600.00 per month · NP Collaborator.com: Starting at $400.00 per month · Physiciancollaborators.com: Starting at $500.00 to $1,250.00 per month
APRNs throughout the state, including those who testified in support of HB 508 have collaborating physicians they have never once spoken to, let alone worked alongside clinically. The physician organizations’ own letter frames the SCA as ensuring “physician oversight of the care provided by APRNs” — but no oversight occurs when the collaborating physician has never met the APRN, never seen the patients, and exists in the arrangement solely as a paid administrative signature.
Ohio’s 42,000 Physicians Do Not Create Ample Collaboration Opportunities
Counting all physician licenses as potential collaborators ignores how healthcare works: physicians practice across specialties — a dermatologist, radiologist, or anesthesiologist– cannot serve as a collaborator for a primary care or psychiatric APRN, yet all are counted in the Medical Associations figure. Compounding this, many of Ohio’s active physicians are employed by hospital systems and are contractually prohibited from entering into an SCA with an APRN outside their system, eliminating the majority of Ohio’s active physician workforce from the available pool. The root issue — a statutory dependency on a physician’s signature that can be withdrawn at any time — remains regardless of whether money changes hands.
What remains after excluding specialty mismatches and system-employed physicians is a significantly narrowed pool of independent physicians — many of whom are themselves concentrated in urban areas, not rural and underserved communities. APRNs from rural areas testified before House Medicaid, describing spending months searching for a collaborator, ultimately signing agreements with physicians in other states or distant parts of Ohio whom they had never spoken to, never met, and who played no role in their patients’ care.
HB 508 Does Not Fragment Care or Create Patient Safety Risks
HB 508 does not change scope of practice, licensure standards, certification requirements, or prescriptive authority — APRNs will continue to diagnose, treat, and prescribe same as they do now. 27 other states and 3 U.S. territories have passed this legislation and have not seen any fragmentation of care or risk to patient safety.
During the COVID-19 pandemic, Ohio suspended the SCA requirements — APRNs stepped up statewide, and there were no adverse outcome surges, no malpractice spikes, and no patient safety failures. Additionally, NP malpractice premiums have not increased in states that have removed the Standard Care Arrangement — they are the same and or less than Ohio. If there truly was a safety issue, insurance malpractice rates would reflect this.
APRNs Are Unable to Practice in Rural Areas Without Restriction
The argument that a collaborator can be located anywhere in the state proves the problem: if an out-of-state or across state physician counts as “collaboration,” the SCA does not function as clinical oversight. The need for an SCA alone is a restriction on the care an APRN can provide.
Over 57 of Ohio’s 88 counties are federally designated Health Professional Shortage Areas (HPSAs). According to data from the Health Resources and Services Administration (HPSA), approximately 1.8 million Ohioans live in a primary care HPSA. The U.S. Department of Health and Human Services projected Ohio would be short 1,200 primary care physicians by 2025. Additionally, the NP workforce grew in 20 state-designated primary care medically underserved areas within 5 years of adopting the removal of the SCA (Alliance for Better Health Care Access, 2022).
Rural areas are losing Physicians, and they are statistically less likely to practice in rural areas— APRNs are filling those gaps. In fact, APRNs represent 1 in 4 primary care providers in rural areas.
The SCA Is Not a Meaningful Clinical Safety Safeguard
Ohio Revised Code §4723.431 and OAC Rule 4723-8-04 do not require the collaborating physician to see patients, be physically present, examine anyone, or provide day-to-day clinical consultation — the SCA is an administrative document, and in a growing number of cases it is maintained with a provider the APRN has never met or spoken to.
HB 508 does not remove physicians from Ohio healthcare; it removes the bureaucratic mandate for an administrative contract that has become, in practice, a signature-for-hire arrangement. APRNs will continue to consult with physicians and other healthcare professionals when clinically appropriate, refer patients to specialists, and work within care teams — because their graduate-level education, national board certification, and professional obligations require it.
Support House Bill 508
HB 508 is supported by primary care providers, nursing organizations, rural health advocates, community clinics, mental and behavioral health providers, addiction treatment providers, hospital systems, and patient access organizations. The real-world impact of removing the SCA is not theoretical—it is well-documented across the states that have already taken this step. In states that have removed the SCA requirement, access to care has measurably improved, particularly in rural and underserved communities that struggle most to attract and retain providers. New clinics have opened in areas that previously had none. Wait times for primary care, mental health, and chronic disease management have dropped. The data is clear: removing barriers to APRN practice increases access to care without compromising quality or safety. Rural communities in Ohio are watching neighboring states reap these benefits right now. This bill gives Ohio the opportunity to close that gap.
HB 508 does not expand scope of practice, does not change education requirements, and does not remove professional accountability — it removes an administrative contract. We urge you to follow the evidence, follow the lead of Ohio’s neighboring states, and support House Bill 508.
Respectfully,
Mandi Cafasso, DNP, APRN-CNP
Summer Davis, MSN, APRN-CNP
Co-Chairs, Government Relations Committee
Ohio Association of Advanced Practice Nurses
Supporters of HB 508:
The Council of Behavioral Health and Family Service Providers
Bon Secours Mercy Health
Pacific Legal Foundation
Americans for Prosperity – Ohio
The Buckeye Institute
Shawnee Family Health Center
ANA – Ohio
For more info on HB 508 and ways to contact your legislators.