Reducing State Restrictions on NPs Boosts Primary Care Supply

Leigh Page

July 12, 2013

On January 1, 2014, millions more people are expected to gain coverage under the Affordable Care Act, and they will be seeking services from primary care physicians who, in many cases, already have full schedules.

One way to meet this supply problem is to relax regulations on nurse practitioners (NPs) and allow them to independently provide basic primary care, as already happens in many rural states that have had difficulties attracting physicians.

In a new study published in the July issue of Health Affairs, Yong-Fang Kuo, RN, PhD, a professor of preventive medicine and community health at the University of Texas Medical Branch in Galveston, and colleagues conclude that reducing state restrictions on NPs would increase primary care supply, even when accounting for factors such as availability of primary care physicians and urban versus rural makeup.

"Modifying state regulations of NPs' practice is one path to expanding access to primary care," the authors conclude.

The researchers also note that greater use of NPs can reduce overall health expenditures in a state. A 2009 report by RAND Corporation found that a highly restrictive state such as Massachusetts could save $4 billion to $8 billion over the course of 10 years if it allowed NPs and physician assistants to independently treat 6 common primary care conditions, including cough, throat symptoms, fever, earache, skin rash, and nasal congestion.

In the current study, states' NP regulations were initially classified into 3 levels: allowing independent practice and prescription authority, allowing independent practice but requiring supervision for prescriptions, and requiring physician supervision for practice and prescriptions.

Many states have relaxed NP regulations in the past decade. States such as Arizona, Iowa, Oregon, Maine, and Washington allow the highest levels of NP autonomy, whereas states such as California, Florida, Massachusetts, Michigan, and Texas have the most restrictions.

Many of these states correlate with the study's list of states with the most and the least numbers of Medicare patients seeing NPs. States with the most number of Medicare patients seeing NPs were Kentucky, Minnesota, Oregon, Tennessee, Washington, and Wisconsin. States with the least number were California, Florida, Michigan, New Jersey, Ohio, and Pennsylvania.

The researchers note that a different set of states, however, would be most in need of primary care providers under the Affordable Care Act expansion next year. States such as Oklahoma, Georgia, Texas, and Louisiana have higher numbers of uninsured people and greater shortages of primary care physicians.

In this study, researchers evaluated a sample of Medicare claims since 1998, when Medicare liberalized reimbursement to NPs, to 2010, and found an explosive increase in billings from NPs. The number of NPs reimbursed for evaluation and management billing codes rose from 3114 to 37,638.

Most of those NPs were in outpatient settings. Breaking down the 2010 figure, 59.0% were in an outpatient setting compared with 10.0% in nursing facilities, 8.6% in hospitals, 6.8% in emergency departments, and 15.5% in multiple settings.

Health Aff. 2013;32:1236-1243. Abstract

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