A Tipping Point for Nurse Practitioner Scope of Practice?

In the months prior to the publication of this article on 5/14/2014, several states enacted legislation that will give Nurse Practitioners greater or full independence to practice primary care medicine. These legislative measures have been hotly debated and the issues at play are quite complex. It appears that given the nation’s healthcare trajectory we may be in an era of punctuated equilibrium regarding the scope of practice for Nurse Practitioners.

Defining a Nurse Practitioner’s scope of practice

Laws pertaining to the scope of practice for Nurse Practitioners (NP) are specific to each state. Considering the regulatory regimes of each state would require a book. To simplify matters, the American Association of Nurse Practitioners (AANP) classifies states into three categories, Full Practice, Reduced Practice, and Restricted Practice.

The AANP asserts that the following elements fall under an NP’s scope of practice:

1. Evaluate patients
2. Diagnose patients
3. Order and interpret diagnostic tests
4. Initiate and manage treatments
5. Prescribe medications

Therefore, states are considered Full Practice when state laws allow NPs to perform all the elements under the licensing authority of the state’s board of nursing. States are classified as Reduced Practice when they reduce the ability of NPs to practice in one of these areas and/or require the NP to have a collaborative agreement with another healthcare discipline to provide patient care. States are classified as Restricted Practice when they restrict the ability of NPs to practice in one of these areas and/or require the NP to be supervised, delegated to, or team-managed by another healthcare discipline to provide patient care.

It’s important to understand these definitions because what appear to be nuances between them are actually major differences. Full Practice is commonly referred to as independence. NPs are free to provide primary care as described above by virtue of being licensed in the state.

In Reduced Practice states, NPs must be licensed and have a collaborative agreement with someone licensed in another healthcare discipline, most commonly a physician. A collaborative agreement is a written agreement between the NP and the physician that includes guidelines describing and delineating the the NP’s functions and responsibilities. It may also include detailed written protocols. In some cases, the collaborative agreement must be submitted to the state for review, approval, and record keeping purposes.

In Restricted Practice states, NPs may be prohibited from practicing one of the 5 elements listed above. Moreover, NPs must be supervised by a physician. This means that the supervising physician retains ultimate responsibility for all patient care. So the NP is technically allowed to perform only medical acts that are authorized by the supervising physician.

Nurse Practitioners vs. Primary Care Physicians

Issues involving the scope of NP care typically pit nursing groups like the AANP against physician groups like the American Medical Association (AMA). Of course, state level groups representing nurses and physicians tend to be the most actively involved at the state level.

The debate is often framed as a turf battle. Primary care has long been the realm of primary care physicians. As such, primary care physicians don’t want to give up any ground. They want to continue on with a team based approach in which they are at the center, operating in a supervisory role. By contrast, NPs and other advanced practice healthcare professionals want to take the reins in areas that they are trained to perform in. While the struggle for turf is certainly a component, minimizing the issue to just this one point is a gross oversimplification.

BluePipes: Professional Networking and Career Management Tools for Healthcare Professionals

The patient care debate

The debate over expanding the role of NPs takes shape on several fronts. First, NPs and physicians disagree as to whether or not NPs can provide equitable patient care relative to physicians. The May 16, 2013 issue of the New England Journal of Medicine published a survey of physicians and NPs on issues related to quality of care. Nearly 66% of physicians said that doctors provide better care under like circumstances. 75% of NPs disagreed. Meanwhile, 82% of NPs felt they should be able to lead their own practices while only 17% of physicians felt the same.

Physicians argue that there is no substitute for the higher level of training they receive. They point out that physicians have 7 or more years of post graduate education while NPs typically have only 2 to 3 years of post graduate work. Physicians also point out that they accumulate more than 10,000 hours of clinical experience while NPs accumulate fewer hours of clinical experience than a physician receives in the first year of the physician’s 3 year residency.

NPs counter these arguments on two fronts. First, state laws that allow NPs to practice without physician agreements often require NPs to accumulate more than 3,600 hours of clinical experience under the supervision of a physician before the NP can work independently. So, while NPs may not have the same level of clinical experience at the outset, they certainly obtain it before becoming independent.

Second, NPs point to the growing body of research finding that NPs provide patient care on par with physicians. The AANP maintains a list of studies that currently includes 19 research studies. Among them is a 2 year study tracking 406 adults which found no difference in the quality of care between NPs and Physicians. Additionally, a 2006 meta-analysis of multiple studies found NP care to be on par with physician care. In the same study, NPs exhibited higher satisfaction scores.

Public opinion debate

There is also debate over public opinion on the issue. Of course, public opinion plays an important role in the democratic lawmaking process. So the two sides are heavily engaged in tracking and funding public opinion research on the issue.

The AANP conducted a survey in 2013 to measure public support for greater access to NP care. The survey found that two thirds of respondents support NPs being able to provide more services under Medicade while 62% support allowing NPs to provide services such as prescribing medications and ordering diagnostic tests without physician supervision. The AANP asserts, on the whole, the survey reveals that American healthcare consumers trust NPs to provide quality primary care.

Meanwhile, the American Association of Family Physicians (AAFP) cites a 2013 Ipsos poll that paints a starkly different picture of American attitudes on healthcare. The poll found that 72% of Americans prefer physicians to non-physicians. 90% would choose a physician lead team when given the choice. And American adults view physicians as more knowledgeable and experienced than non-physicians by a 2 to 1 margin.

Cost debate

Cost is another issue in the debate over expanding the scope of practice for NPs. The AANP asserts that NPs are a more cost-effective option for the American healthcare system. They point out that the average salary for physicians and NPs in 2010 was $208,000 and $97,000 respectively. They also point out that bringing a new NP to market costs 25% of what it costs to bring a new physician to market.

The AANP also cites numerous studies on the subject. For example, they cite a 1997 study published in Nursing Management which found NPs delivered care at 23% below the average cost of other primary care providers. They also cite a 2012 study which found that substituting NPs for primary care physicians in the state of Texas would have saved $16 billion in healthcare costs.

Physicians counter this argument on two fronts. First, physicians argue that the cost differences exhibited in the current market exist because of the current regime. NPs cost less because they are supervised by physicians who bear the burden of responsibility and liability for the patient care provided by the NP.

Additionally, Medicare, Medicaid, and Private Insurance payouts are all less for NPs than they are for physicians under the current regime. Physicians argue that expecting this to stay the same if the scope of practice were to be expanded for NPs throughout the nation is foolish. Eventually, they argue, NPs will push for equal payments for the same services and all cost savings will be lost.

Second, they assert that cost should not be a primary factor in issues pertaining to patient care are. Physicians assert that basing the decisions on cost will ultimately lead to a two tiered healthcare system in which some people can afford to have access to physicians while others will only be able to afford access to NPs. Of course, this argument hinges on the argument that physicians are better equipped to provide higher levels of care.

 Spike in NP scope of practice legislation

Regardless of which side of this debate you’re on, the fact is that legislation to expand the scope of NP practice is on the rise at the state and federal level. According to Kaiser Health News, there were 349 measures to expand NP practice considered between 2011 and 2012 at the state level. There were another 178 in 2013.

Since the passage of the Affordable Care Act (ACA), there has been a renewed vigor in states with more restrictive NP regulations to pass measures aimed at easing restrictions. The ACA is expected to add 30 to 45 million newly insured individuals to a healthcare system that is already exhibiting a shortage of primary care physicians. Moreover, the ACA is geared toward greater use of primary care physicians in general. To top it all off, the aging baby boomer population will continue to drive increased demand for years to come.

This has all states face-to-face with a potentially dramatic shortage of primary care providers. The Healthcare Association of New York reported that the state already had a shortage of 374 primary care physicians in 2012. Meanwhile, a study by the Robert Graham Center reported that California could be facing the most severe shortage of primary care physicians over the next 20 years. The report concluded that in order to meet demand the state would have to add 8,243 new primary care physicians, a 32% increase to its current levels, by 2030.

State laws past and present

State regulations pertaining to Nurse Practitioner scope of practice have been in flux since 1965 when Dr Loretta Ford and Dr. Henry Silver developed the first Nurse Practitioner program at the University of Colorado. According to Kaiser Health News, Alaska, New Hampshire, Oregon and Washington were the first states to expand the authority of NPs in the 1980s and a few others followed suit in the 1990s.

Some sources attribute the success of this original push to the states’ desire to increase access to primary care for their large rural populations. Other sources attribute it to the dramatic spike in healthcare costs exhibited during those two decades. It was probably a combination of both.

Now, many populous states are joining the ranks of their rural counterparts. In April 2014, Connecticut became the 18th state recognized by the AANP as allowing NPs Full Practice. Also in April, New York passed legislation that will remove the state’s Collaborative Agreement requirement effective January 1, 2015.  Minnesota passed similar legislation in May, 2014. And Kentucky passed legislation that allows NPs to precribe non-narcotic medications to patients without a collaborative agreement.

There have also been a fair number of defeats for similar legislation in other states. Perhaps the biggest defeat came in California where a bill originally supported by the AANP was amended to include provisions that caused the organization to ultimately oppose the bill. The bill, which was amended to allow NPs to work autonomously only in group settings like hospitals and clinics, died in committee. The American Association of Retired People (AARP) had also pulled support after the amendments were added due to concern that the California bill would serve as a model for legislation in other states.

Meanwhile, Michigan’s state senate passed a bill that would have provided NPs with autonomy but the bill never made it out of the house committee. Nebraska’s legislature passed a bill granting autonomy to NPs that was vetoed by the state’s governor. Other states, including Kansas, New Jersey, Massachusetts, and Pennsylvania all have legislation in process.

Punctuated equilibrium for NP scope of practice?

This spike in legislative activity is an indication that we maybe in era of punctuated equilibrium for NP scope of practice laws. Several factors seem to be converging and applying enough pressure to make this a time of great change. The current landscape of healthcare in America is in flux. Dramatic increases in the patient population seem inevitable. Training enough primary care physicians in time to meet demand seems nearly impossible. And even if we could, the cost of the current system could prove to be unsustainable for the country as a whole.

Meanwhile, the sphere of debate now seems to involve too many issues and interests to avoid change. Patient care, access, affordability, public opinion, budgetary issues and many other touch points are now intertwined with this issue. Major interests like the AARP, unions, teachers groups, and others are all weighing in.

All of these variables are converging to apply enough pressure to get NP scope of practice issues on the agenda with regularity. And getting your issues on the agenda is one of the faces of political power. The question is whether or not big defeats like the one in California can be overcome, or if they are a sign of the continued strength of the status quo. As always, time will tell.