Delaware Docs Doubt Expanded APRN Scope Will Aid Patient Access

Aine Cryts

August 09, 2021

A new Delaware law giving nurse practitioners more practice authority is being praised by the profession's national organization, but state doctors are skeptical of its real impact.

Delaware has joined 23 US states, the District of Columbia, and two US territories in allowing advanced practice registered nurses (APRNs) to provide care to patients independently of physicians. Proponents of the law, signed on August 4 by Delaware Governor John Carney, say that its passage will increase access to care for patients and reduce healthcare disparities. The law's critics say that its passage won't improve access to care for patients in rural areas, where the need is greatest. The law took effect upon receipt of the governor's signature.

The increased scope of services provided by APRNs includes advanced assessment, diagnosing, prescribing, and ordering, per the Delaware law. Included in this category of clinicians are certified nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and clinical nurse specialists.

The law also stipulates that nurses providing these services have a basic nursing education; licensure as a registered nurse; graduation from or completion of a graduate-level APRN program accredited by a national accrediting body and current certification by a national certifying body in the appropriate APRN role; and at least one population focus.

"As our state contends with a heightened need for healthcare, this law represents a necessary and positive step toward removing roadblocks that impede equitable access to high-quality care," Sharon Baptiste-Brown, MSN, APRN-BC, an American Association of Nurse Practitioners (AANP) state representative for Delaware, said in a statement. She added that the law will help the state meet patients' needs while "increas[ing] future capacity by attracting [nurse practitioners] to the state."

Matthew Burday, DO, president of the Medical Society of Delaware, which represents the state's physicians, acknowledges that APRNs are valued members of the healthcare team. However, he told Medscape the law's passage won't result in improved care access for patients as APRNs tend to practice in urban areas, not in rural areas where the shortage of healthcare providers is most acute.

Burday points to a 2013 study that showed 85% of APRNs practice in metropolitan counties, while approximately 6% practice in remote rural counties. Delaware is similar to other states in practice distribution among APRNs, he says.

As of January, Delaware has no critical access hospitals or rural health clinics, according to the Rural Health Information Hub. The state has four Federally Qualified Health Center sites, which receive federal funding to provide primary care services in underserved areas outside of urbanized areas, and two short-term hospitals located outside of urbanized areas.

Aging Population, Retiring Physicians Driving Physician Shortage

Passage of the Delaware law is an attempt to increase residents' access to healthcare. Two factors are driving the physician–patient mismatch: older patients and retiring physicians, according to a 2020 study by the Association of American Medical Colleges (AAMC). It's projected that there will be 139,000 fewer physicians than needed in 2033, per the AAMC study.

A 2021 IHS Market Ltd study, found that, after adjusting for demographics, socioeconomic factors, and the prevalence of disease and health risk factors, physician demand is projected to be the most acute in the Southern and Western regions of the United States between 2019 and 2034. The study was conducted on behalf of AAMC.

The American Medical Association is "actively working to alleviate a maldistribution of physicians that is responsible for shortages in many states," says a spokesperson. Some of those efforts include increasing residency slots to train physicians in medically underserved areas and developing programs to help inactive and retired physicians re-enter clinical medicine.

"We believe the healthcare system benefits from physician-led, team-based care in which all healthcare professionals work together in a collaborative fashion to improve the overall health of the patient," said an AMA spokesperson.

Numbers of Licensed NPs, Physicians On the Rise

There are more than 325,000 nurse practitioners licensed in the United States, per AANP. Nearly 89% of nurse practitioners are certified in an area of primary care, and more than 96% of nurse practitioners prescribe medications; nurse practitioners in full-time practice write approximately 21 prescriptions each day. A 2020 study published in Health Affairs found that, from 2010 to 2017, the number of nurse practitioners more than doubled from approximately 91,000 to 190,000. This increase was seen in every region of the United States.

A 2018 census of US physicians conducted by the Federation of State Medical Boards (FSMB) found that there were 985,026 physicians with MD and DO degrees licensed to practice; that's a net increase of 16% since 2010. The expansion in the number of medical schools and students during the past 20 years is driving the increase in physicians, according to FSMB.

The AANP championed the passage of the Delaware law; the Diamond state became just the second this year to enact Full Practice Authority. Massachusetts took this step at the beginning of the year.

"We are encouraged to see other states looking to modernize their laws, eliminate healthcare disparities, and increase healthcare access and choice for patients by fully engaging the [nurse practitioner] workforce," said April Kapu, DNP, APRN, president of AANP, in a statement.

"Full Practice Authority is the authorization of nurse practitioners to evaluate patients, diagnose, order, and interpret diagnostic tests, and initiate and manage treatments — including prescribe medications — under the exclusive licensure authority of the state board of nursing," according to the AANP.

Aine Cryts is a veteran health IT and healthcare writer based out of Boston.

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