Nurse Practitioners: A Commonsense Solution to the Primary Care Shortage

Troy Brown, RN

Disclosures

November 12, 2018

The Nurse Practitioner Solution to the Primary Care Shortage

States should lift scope-of-practice (SOP) restrictions on nurse practitioners (NPs) and hospital boards, and credentialing bodies should permit NPs to assume expanded roles in primary care settings, according to a new report[1] from the American Enterprise Institute. These steps would significantly ease the worsening primary care shortage, at a time when millions of Americans have no access to primary care.

Physicians also need to understand that NPs provide quality healthcare to patients who need it. "NPs and physicians should work together to build relationships that allow for their respective roles and practices to evolve, respecting each other's strengths and ultimately leading to a workforce that is more responsive to communities' health needs," wrote Peter Buerhaus, PhD, FAAN, a healthcare economist and professor of nursing at Montana State University. Buerhaus presented his research and participated in a panel discussion at the American Enterprise Institute on October 15, 2018.

The report, "Nurse Practitioners: A Solution to America's Primary Care Crisis," maintains that NPs are uniquely positioned to meet the primary care needs of the country's most vulnerable citizens and relieve some of the burden on public health insurance programs. Medicare is likely to be especially hard-hit as baby boomers reach retirement.

"The evidence discussed in this report points to a commonsense solution to primary care workforce-supply problems. The NP workforce is growing, far outpacing the growth of the primary care physician labor force. NPs are more likely to work in rural areas, which already do and will increasingly need more primary care providers. They are more likely to serve poor and vulnerable Americans, and their services cost less. Most importantly, they provide primary care of equal or better quality compared to physicians," wrote Buerhaus.[1] "For the health of Medicare and millions of people, NPs must be allowed to provide primary care to more Americans," he added.

What Restrictions Are Now Placed on NPs?

The National Academy of Medicine and National Council of State Boards of Nursing recommend full SOP for NPs, which means they may evaluate and diagnose patients, order and interpret diagnostic tests, and start and manage treatments. They may prescribe medications under the sole licensure authority of the state board of nursing (in most states) and prescribe controlled substances when authorized by the Drug Enforcement Administration.

But currently, only 23 states, plus the District of Columbia, permit full practice for NPs by law. Sixteen states allow what is called "reduced practice," and in another 12 states, NPs are limited to "restricted practice." (See a NP state practice environment map here.)

In states with reduced practice, state practice and licensure laws limit NPs in at least one element of NP practice, such as being granted only "limited prescriptive authority." In most cases, these states specify that to provide patient care, NPs must have a career-long regulated collaborative agreement with another healthcare provider.[1]

In states with restricted practice, as a requirement of practice, NPs must have career-long supervision, delegation, or team management by another healthcare provider, usually a physician.[1]

States are increasingly removing SOP restrictions. SOP issues do not end at the state level, however. Even in states that allow full practice, NPs may find their practice restricted.

"A nurse practitioner can be practicing in a state that doesn't have any restrictions and still find that the local medical society or a hospital or health system imposes restrictions on NPs," explained Buerhaus. For example, hospitals can refuse to grant privileges to NPs.

One reason that states differ with respect to SOP for NPs is that the profession has evolved at different rates in each state as a result of varying needs and issues. But the lack of clarity makes it difficult to practice and puts patients at risk.

"Patient safety is paramount. And having a lot of variation in how you go about doing your business simply based on laws that were set 30 years ago is setting us up for patient safety risk," said Eileen Sullivan-Marx, dean of the New York University Rory Meyers College of Nursing and the Erline Perkins McGriff Professor of Nursing.

"The academic literature finds no evidence of harm to patients associated with less restrictive SOP laws. When no harm is present, the restrictions serve only to generate artificial barriers to care that ultimately provide physicians with protection from competition, prevent the attainment of system-wide efficiencies, and constrain overall provider capacity," wrote E. Kathleen Adams, PhD, Emory University, Atlanta, Georgia, and Sara Markowitz, PhD, Emory University, and National Bureau of Economic Research, Cambridge, Massachusetts, in a June 2018 policy proposal for the Brookings Institution.[2]

Buerhaus agrees that having state-level SOP restrictions on NPs does not improve healthcare, citing one study that failed to find evidence that such restrictions improved the quality of care for Medicare beneficiaries.[1] "Some physicians and certain professional medical associations have justified their support for state regulations to limit NP scope of practice on the grounds that they are necessary to protect the public from low-quality providers and to assert that physicians must be the leaders of the health care team. We found no evidence to support their claim," he wrote.[1]

Increasing Access at Lower Cost

Primary care NPs who care for Medicare beneficiaries are significantly more likely to practice in federally designated Health Professional Shortage Areas and in rural regions compared with primary care physicians.[1] Medicare beneficiaries who lived in states that reduced or restricted NP SOP had higher use of resources compared with those in states with full practice, suggesting that patients in states with more restricted practice had less access to the benefits NPs provide.

Nurse practitioners save money, too. They are reimbursed at a lower rate than physicians, and their care is cost-effective. "What we're seeing is that NPs order on average about one third fewer test procedures than do physicians, and of those test procedures, they're choosing among the less expensive tests," said Buerhaus. "Accountable care organizations need to keep people out of these costly emergency departments and hospitals, so they need NPs. Insurers need to keep their costs lower, so they're increasingly interested reducing the costs of providing care. All of these groups need to recognize not just their economic interests, but also patient care and population health interests."

Team-Based Approach Needed

Physicians, pharmacists, NPs, and physician assistants all are important in primary care and should have expanded roles in delivering care in all settings, not just with vulnerable populations or rural communities but in the larger primary care system, according to R. Shawn Martin, Senior Vice President, Advocacy, Practice Advancement and Policy, American Academy of Family Physicians. "They all have a role to play, but they're not interchangeable," he added.

"We should be building the team and the team leader around the needs of the patient and the situation of the patient. It could very well be, and should be, physicians running that team depending on the situation, depending on the patient. But it may not be; it could be a NP, it could be a social worker—someone in behavioral health—who is the best qualified to manage that patient's team. Put the patient as the focus of the team, and build the team and its leadership around that," Buerhaus remarked at the meeting.

Martin raised the issue of healthcare providers in primary care tending to cluster, and that this means "our ability to address these outlier Professional Health Shortage Areas may continue to be challenging." He believes that this may become easier as we move away from a legacy fee-for-service payment model. "As we move into more value-based, population-based payment models, we're going to see a stronger desire of all providers of primary care—including social workers and others—wanting to be co-located and aligned with each other," he explained.

Barriers to Full Practice for NPs

Buerhaus and colleagues[3] conducted a national survey of primary care clinicians in which one third of primary care physicians said they believed increasing the number of NPs would lower the safety and effectiveness of care. But as Buerhaus and Sullivan-Marx point out, physicians may not be familiar with the plentiful research showing that this isn't true.

The report suggests that such talk is an excuse for a barrier to entry, meant to protect some physicians' narrow interests at the expense of accessible primary care for many Americans who need it.[1]

Some primary care physicians are worried that NPs may threaten their livelihoods. Buerhaus and colleagues[3] found that 3 out of 4 primary care physicians surveyed said they were worried that NPs would replace them, and 6 out of 10 said they thought their incomes would decrease with the greater use of NPs.

Advice to NPs: 'Go to the Wallet'

Asked what needs to happen for NPs to achieve full scope of practice throughout the United States, Buerhaus replied, "A period of engagement needs to occur. That is not about the American Medical Association, the American Nurses Association, and the American Association of Nurse Practitioners being the only participants in these discussions. Of course, they need to be involved. But in all the states and areas that are facing these problems, there needs to be local leadership, and that should be the local nurses, physicians, and hospitals. It's starting to occur because hospitals need patients, and primary care is one way of ultimately funneling patients into their organization."

NPs need to also be savvy, Sullivan-Marx explained. "Go to the money. Go to the wallet. We need to have insurers be more vocal. We need nurses to be on insurance boards; we need to have nurses who are influential within hospital boards."

Sullivan-Marx believes that people like the care they receive from NPs and NPs should go to society consumer groups, such as AARP, and other influential groups.

"We're way overdue for a reconfiguration of the workforce. While you have a lot of individuals who are still in the mode of protection and nearing their retirement, I can understand that they're reluctant to change," said Buerhaus. "But I think we have to call the question, and basically say, 'We can't let your concerns, your fears, your lack of awareness be used to justify the continued lack of access to care. We're talking many millions of people who need care."

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