The United States faces many health care challenges, including an aging and increasingly diverse population, more patients with more chronic conditions, soaring costs, and a shortage of providers. The shortage of primary care providers is likely to increase in 2014, when as many as 32 million more Americans will gain insurance coverage and become eligible for Medicaid under the Patient Protection and Affordable Care Act of 2010. The United States can address many of these challenges now by maximizing the use of advanced practice RNs (APRNs), who have graduate degrees and are authorized to examine, diagnose, and treat patients. However, outdated laws, regulations, and organizational policies keep APRNs and other skilled providers from practicing to the full extent of their education and training. These outdated barriers limit fully qualified nurses and others from expanding access to preventive and primary care.
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A major goal of the Future of Nursing: Campaign for Action, a joint initiative of the Robert Wood Johnson Foundation and AARP, is to eliminate barriers that restrict the ability of APRNs and others to provide primary care. The campaign has made incremental gains toward enabling nurses to practice to the full extent of their education and training, but more work remains to be done.
In 2011, the Institute of Medicine (IOM) published the evidence-based report The Future of Nursing: Leading Change, Advancing Health, which called for changes at the federal and state levels to enable APRNs to practice to the full extent of their education and training. The report noted that the ability of nurses to provide primary care is “hampered by the constraints of outdated policies, particularly those involving nurses' scopes of practice.”1 State laws determine whether APRNs can practice without physician oversight and prescribe medications. In 2012, 16 states and the District of Columbia permitted NPs to diagnose and treat patients and prescribe medications without a physician's involvement; 34 states required physician involvement to diagnose and treat or prescribe medications, or both.2
The American Medical Association and the American Academy of Family Physicians contend that because physicians attend school longer, APRNs should practice with physician supervision or collaboration to ensure patient safety.3, 4 However, studies demonstrate that consumers receive safe and effective health care from APRNs. Research shows no difference in outcomes of primary care delivered by an NP or a physician, including patient satisfaction, health outcomes, the number of prescriptions written, return visits requested, or referrals to other providers.5 A systematic review of APRN outcomes found comparable—and in some cases better—outcomes of care delivered by NPs, certified nurse midwives (CNMs), and clinical nurse specialists in collaboration with physicians, compared with care provided by physicians alone.6 In fact, no study establishes a basis for requiring physicians to supervise APRNs.7 There is no evidence that APRN care is better in states with more restrictive physician oversight. There is also no evidence that physicians make less money in states in which APRNs have an expanded scope of practice.8
The IOM committee carefully considered the role of nurses in realizing a transformed health care system and concluded that overly restrictive scope of practice regulations prevent APRNs from giving the care they were trained to provide. The committee didn't recommend that APRNs replace physicians, who receive more extensive and specialized training than APRNs, but asserted that all health care professionals should practice to the full extent of their education and training so that more patients may benefit.1 The report also emphasized that better patient care can come from an interprofessional cadre of health care professionals who practice together on a patient-centered team.
PROGRESS SO FAR
Changing laws and regulations that restrict APRNs and other skilled providers from practicing to the full extent of their education and training is both controversial and cumbersome: attempts to do so often face opposition from physician groups and must be made at the state, federal, and organizational levels. Nevertheless, the campaign has made progress and realized some victories in its first two years.
State laws. The campaign has recorded positive legislative changes in Massachusetts, North Dakota, and Maryland. In 2012, Massachusetts enacted a law that authorizes CNMs to issue written prescriptions and order and interpret tests and therapeutics.9 The law removed physician supervision language and simply requires CNMs to have relationships with obstetrician–gynecologists for consultation and referral. North Dakota removed a regulation in 2011 that required NPs to practice in collaboration with a physician,10 and Maryland replaced its collaborative agreement in 2010 with a one-page statement that simply names a physician that an NP will collaborate with when clinically necessary.11 These measures have the potential to increase access to care, particularly for underserved populations; improve health care outcomes; and reduce health care costs.7
The Federal Trade Commission (FTC), which is charged with preventing unfair restriction of competition, unfair methods of competition, and unfair or deceptive acts or practices in or affecting commerce, has issued rulings in eight states challenging limits to nurses' scope of practice: Alabama, Florida, Kentucky, Louisiana, Missouri, Tennessee, Texas, and West Virginia.12 In 2012, for example, the FTC weighed in on HB 951, a bill in Louisiana that would have removed a requirement that APRNs have a formal, written collaborative-practice agreement with a physician. The FTC concluded that “removing this requirement has the potential to benefit consumers by expanding choices for patients, containing costs, and improving access.”13 And in April 2012, Kentucky governor Steve Beshear exercised his option to exempt hospitals, critical access hospitals, and ambulatory surgical centers from the requirement that certified registered nurse anesthetists (CRNAs) be supervised by a physician. This made Kentucky the 17th state to opt out of physician supervision, resulting in increased consumer access to anesthesia and pain management services.14
In addition, Vermont and Massachusetts passed significant legislation that will enable NPs to sign patient forms, which should streamline care. The Vermont bill, HB 573, will enable NPs to sign forms whenever the signature of a physician is required.15 The Massachusetts bill, S 2400, will allow NPs to sign where a physician must sign, certify, verify, stamp, or endorse.9 Arizona,16 Connecticut,17 Idaho,18 Illinois,19 Iowa,20 Nebraska,21 and Pennsylvania22-24 passed more modest signatory bills that will allow APRNs to sign certain forms, which should increase access to care and may reduce costs.
Ohio passed SB 83–HB 206, a measure that will allow APRNs to prescribe schedule II controlled substances such as morphine, hydrocodone, and codeine under certain conditions and in certain settings.25 NPs can prescribe controlled substances in 48 states and the District of Columbia. APRNs in Alabama and Florida cannot prescribe any controlled substances.26
Federal law. The House of Representatives passed legislation27 at the end of 2011 that would allow APRNs and physician assistants to certify eligibility for federal workers' compensation and to diagnose and treat federal employees with job-related traumatic injuries—policies in line with the IOM report recommendations. Although this bill didn't make it out of Senate committee in 2012, it's anticipated that similar legislation will be introduced in the 113th Congress; as of this writing, it hadn't been.
Regulations. Inroads have been made in changing Medicare regulations that limit nursing scope of practice. AARP and a broad coalition of nursing organizations submitted comments to the Department of Health and Human Services (DHHS) on a proposed regulation to revise Medicare hospital conditions of participation, which detail clinical privileges, admitting privileges, and medical staff membership.28 Although the final regulation doesn't require hospitals to grant clinical privileges to APRNs, it ensures that APRN applications are reviewed.
In addition, the DHHS released a proposed regulation last June, updating the Medicare physician fee schedule, that contained two positive steps toward removing barriers to nursing practice.29 First, the regulation clarified that Medicare will pay for portable X-ray services ordered by APRNs. The current regulation can be interpreted to allow payment for those services only when a physician or osteopath orders them. Second, the regulation clarified that Medicare will provide direct reimbursement for chronic pain management services provided by CRNAs as allowed by state law. Several Medicare carriers (private insurance companies that process Medicare claims and make payments) had recently begun denying payment for CRNA-provided pain management services, arguing that only physicians can perform those services.
Organizational actions. The Department of Veterans Affairs (VA) has developed and submitted to the VA leadership a position paper supporting implementation of federal supremacy, a measure that would supersede states' medical staff laws and regulations to enable APRNs to practice independently within the Veterans Health Administration system.30
APRN Consensus Model progress. The National Council of State Boards of Nursing is working to reduce state-by-state variation in how APRNs are regulated in licensure, education, and practice through the APRN Consensus Model. The model calls for APRNs to be able to prescribe medications, order tests, and sign treatment forms without restrictive oversight and its associated cost. Only five states—Montana, New Mexico, North Dakota, Utah, and Vermont—fully conform to the model,31 although several states—California,32 Idaho,33 Maryland,34, 35 Massachusetts,36 and West Virginia37—passed legislation in 2012 to move them closer to it.
The campaign, through AARP's Center to Champion Nursing in America, will continue to work to implement specific IOM recommendations on the future of nursing related to scope of practice. At the federal level, the campaign is urging Congress to amend Medicare to allow APRNs to sign certification documents to enable patients to receive home health and hospice services. Currently, a physician must certify that a patient needs the services, which can delay care for homebound patients and result in hospitalization that could have been avoided had an NP been able to make the determination. Some physicians will charge NPs a fee to sign the forms; others won't certify the services unless they've seen the patient, requiring a homebound patient to travel to a physician's office, often by ambulance, resulting in delays and unnecessarily increasing health care costs.38
The campaign will continue to work at the state level to reform scope of practice laws and regulations to conform to the APRN Consensus Model. The campaign will also work at the state level to require third-party payers to directly reimburse APRNs in an effort to expand access to care and help contain health care costs. A recent report from the National Governors Association adds support to regulatory and reimbursement policy change.39
Enabling nurses to practice to the full extent of their education and training will help the United States to expand access to care and provide needed preventive and primary care services. The campaign will continue to seek to remove outdated barriers to care that prevent patients from receiving the care they need, when and where they need it.
1. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health
. Washington, DC: National Academies Press; 2011.
2. Phillips SJ. 25th Annual legislative update: evidence-based practice reforms improve access to APRN care Nurse Pract. 2013;38(1):18–42
5. Horrocks S, et al. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors BMJ. 2002;324(7341):819–23
6. Newhouse RP, et al. Advanced practice nurse outcomes 1990–2008: a systematic review Nurs Econ. 2011;29(5):230–50
8. Pittman P, Williams B. Physician wages in states with expanded APRN scope of practice Nurs Res Pract. 2012;2012:671974
9. Commonwealth of Massachusetts Senate. S2400. An act improving the quality of health care and reducing costs through increased transparency, efficiency and innovation. Boston 2012.
10. State of North Dakota Legislative Assembly. Senate bill no. 2148. An act to amend and reenact section 43-12.1-18 of the North Dakota century code, relating to prescriptive practice standards for advanced practice registered nurses. Bismarck, ND 2011.
11. State of Maryland Senate. SB 484. An act concerning state board of nursing—nurse practitioners—certification requirements and authority to practice. Annapolis, MD 2010.
12. U.S. Federal Trade Commission. Policy. Advocacy filings by subject: health care: health professions
15. State of Vermont General Assembly. Health; physicians; advanced practice registered nurses; nurse practitioners; signatures. Montpelier, VT 2011.
17. State of Connecticut General Assembly. Public act no.120197. An act concerning various revisions to the public health statutes. Hartford, CT 2012.
18. State of Idaho Legislature. Senate bill 1294. Medical consent and natural death act. Boise, ID 2012.
19. State of Illinois General Assembly. An act concerning transportation [Public Act 097-0845. HB5624 enrolled]. 2012.
20. State of Iowa General Assembly. SF2248. An act relating to the licensed professionals authorized to prescribe respiratory care services. Des Moines, IA 2012.
21. State of Nebraska Legislature. LB788. An act relating to the respiratory care practice act. Lincoln, NE 2012.
22. Commonwealth of Pennsylvania General Assembly. HB1610. An act establishing standards for preventing sudden cardiac arrest and death in student athletes; assigning duties to the Department of Health and the Department of Education; and imposing penalties. Harrisburg, PA 2012.
23. Commonwealth of Pennsylvania General Assembly. An act amending the act of June 29, 1953 (P.L.304, No.66), known as the Vital Statistics Law of 1953, further providing for death and fetal death registration information for certificates, for coroner referrals and for pronouncement of death by a professional nurse. Harrisburg, PA 2012.
24. Commonwealth of Pennsylvania General Assembly. SB1528. An act amending the act of June 15, 1982 (P.L.502, No.140), known as the Occupational Therapy Practice Act, further providing for definitions, for creation of board, for requirements for licensure, for practice and referral, for renewal of license and for refusal, suspension or revocation of license; and providing for impaired professionals program. Harrisburg, PA 2012.
25. State of Ohio General Assembly. HB 206. A bill to amend sections 3719.06, 4723.06, 4723.481, 4723.482, 4723.492, and 4723.50 and to enact section 4723.486 of the revised code to modify the authority of certain advanced practice nurses to prescribe schedule II controlled substances. Columbus, OH 2010.
26. U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control. Mid-level practitioners authorization by state. 2013.
27. Congressional Record. Federal workers' compensation modernization and improvement act [HR 2465]. Washington, DC: Government Printing Office 2011 H7908-16.
32. State of California Legislature. SB-1524 Nursing. An act to amend Sections 2746.51 and 2836.1 of the Business and Professions Code, relating to nursing. Sacramento, CA 2012.
33. State of Idaho Legislature. Senate bill No. 1273. An act relating to nurses; amending section 54-1401, Idaho code, to provde correct terminology; amending section 54-1402, Idaho code, to revise definitions, etc. Boise, ID 2012.
34. State of Maryland General Assembly. SB337. State board of nursing—nurses, nursing assistants, medication technicians, and electrologists—licensure and certification requirements. Annapolis, MD 2012.
35. State of Maryland Legislature. HB238. An act concerning state board of nursing—nurses, nursing assistants, medication technicians, and electrologists—licensure and certification requirements. Annapolis, MD 2012.
36. Commonwealth of Massachusetts General Court. Bill H. 3815. An act relative to enhancing the practice of nurse-midwives. Boston 2012.
37. State of West Virginia Legislature. SB572. An act replacing “advanced nurse practitioner” with “advanced practice registered nurse.” Charleston, WV 2012.
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