By Gayle Bennett, contributing writer for the Journal of ASPR
It’s no secret that the United States is in the midst of a primary care physician shortage, due mainly to demographics (aging baby boomers) but also to the increase in insurance coverage through the Affordable Care Act.
The U.S. Department of Health and Human Services Health Resources and Services Administration predicts a shortage of 20,400 primary care physicians by 2020, while the Association of American Medical Colleges estimates a shortfall of between 12,500 and 31,100 primary care physicians by 2025.
What’s also well known is that nurse practitioners (NPs) can help alleviate this shortage. But NPs, like other advanced practice registered nurses (APRNs) — nurse anesthetists, nurse midwives, and clinical nurse specialists — have varying degrees of authority, depending on the state they work in. APRNs with full-practice authority can practice and prescribe independently, though they still collaborate with physicians. APRNs with reduced or restricted scope of practice require physician oversight to varying degrees, depending on individual state regulations.
There is a slow but steady movement to grant APRNs full practice authority, but this is a state decision made in state legislatures. However, in states where APRNs can practice to their full education, recruiters and health systems have increased flexibility to create collaborative care models that meet patient demand while taking into account the supply of medical professionals in various areas.
The state-by-state push
The National Council of State Boards of Nursing (NCSBN) supports full-practice authority for APRNs. NCSBN has created the Campaign for Consensus to help states align their APRN regulations so that they can practice independently with appropriate education, licensure, and certification.
According to Maureen Cahill, associate for nursing regulation at NCSBN, on the whole, states are 82 percent of the way to uniformity in their laws regarding APRNs. Thirteen states are at 100 percent implementation of the consensus model. This uniformity, according to NCSBN, would help health care practitioners understand the preparation, training, and scope of practice of the APRNs they are working with.
In 2015, NCSBN also created the APRN Compact, which allows an APRN to hold one license with the ability to practice in other compact states. “Both the consensus and the compact create uniformity in the way that people are prepared to practice, and then they are regulated in the same way,” Cahill says.
Meanwhile, the American Association of Nurse Practitioners (AANP) is pushing states to pass full-practice authority licensure laws for NPs. Currently, 21 states meet AANP’s definition of full-practice authority, and seven of those states did so in the last five years, says Taynin Kopanos, vice president of government affairs for AANP.
“In the 2015 legislative session, Maryland and Nebraska both passed full-practice authority legislation,” Kopanos says. “We are seeing already, one year out, that hospital systems and provider practices are better able to see more patients and are making strides for greater efficiency. And, we’re seeing new clinics open in areas where patients had not had health care access before.”
The effect on staffing models
Lotoya Henry is a physician and advanced practice recruiter for Holy Spirit—A Geisinger Affiliate in Camp Hill, Pa. She recruits physicians and APRNs for the hospital and the over 30 out-patient family medicine facilities Holy Spirit owns. The Pennsylvania legislature is currently considering a bill to grant NPs full-practice authority.
“The physician positions are so hard to fill,” Henry says. “So if I’m able to recruit an APRN and place that person there, that would give us more candidates.”
Cahill echoes this point. “Health systems and hospitals own a lot of practices now, and it’s in their best interest that they get the full performance from everyone.”
MEDNAX is a national health solutions partner specializing in neonatal and other pediatric services, anesthesia, maternal-fetal, radiology, pediatric cardiology and other physician and management services.Debra Sansoucie, vice president of the company’s Advanced Practitioner Program, sees how full-practice authority can be an extension of the collaborative care model supported by MEDNAX.
“As scope of practice restrictions change in the various states, we do have more flexibility to create unique staffing models that meet the needs of our patients,” Sansoucie says. “It allows us to have hospital relationships in which we can provide services with our advanced practice nurses without a physician in close proximity.” She emphasizes, however, that all advanced practice providers working for MEDNAX have a collaborative relationship with a physician, though they may not work side-by-side on a daily basis.
Kopanos notes that when states update nurse licensure laws, they are often retiring restrictions and activities, such as meaningless chart reviews, that take NPs and physicians away from spending time with patients. “Physicians and group practices in health care settings are realizing that modernizing licensure reform frees them up,” she says. “They are no longer having to focus on meeting an arbitrary regulatory requirement. They can really deploy their health care teams and workforce in a way that’s more efficient for their system and better capable of meeting their patient care needs.”
In May, the U.S. Department of Veterans Affairs proposed a rule to grant full-practice authority to APRNs working for the VA. “The purpose of this proposed regulation is to ensure VA has authority to address staffing shortages in the future,” said David Shulkin, VA under secretary for health, in a VA press release.
The group most consistently opposed to modernizing ARPN licensure laws is physicians. Cecelia Smith, director of advanced providers at Indiana University Health Physicians, understands their reticence, and she thinks there are concrete ways to address it. Indiana has modified restrictions for APRNs; they must have a collaborative-practice agreement with a physician to prescribe.
Smith believes that states granting full-practice authority need to mandate board certification and institute a limited collaborative-practice agreement with a physician during an APRN’s first six months or year of practice. “There are ways to make this more palatable for the physicians groups that maybe don’t fully understand what full prescriptive authority would mean or how to come to terms with that and feel more comfortable,” she says.
Henry, the recruiter with Holy Spirit, has worked with her medical director and quality director to help them understand how an increased scope of practice for NPs can help physicians spend more time with patients and have a better work-life balance, among other benefits. “That was my first step, getting the medical director on board and our quality person on board. So when they go out to talk to the doctors, they can help sell that.”
Sansoucie notes that while some physician associations still oppose full-practice authority for APRNs, “On the individual physician level, I would say they are understanding more that full-practice authority would allow us to be better partners.”