The U.S. health care system is fragmented and access to care is often limited. The federal government enacted the Patient Protection and Affordable Care Act (ACA) to decrease the cost of health care, improve its quality, and improve access to care through increasing the percentage of people who have health insurance. With approximately 30 million newly insured individuals projected to enter the health care market as a result of the ACA, the ongoing shortage of primary care providers has been receiving national attention. While other initiatives have been proposed, one possible solution would be to allow NPs to practice to the full extent of their training, unfettered by practice restrictions requiring physician oversight and limiting prescriptive authority.
NPs have a demonstrated history of providing competent, quality care that's cost-effective and results in positive health outcomes. However, state scope-of-practice limitations remain a barrier to full NP utilization. Federal intervention may be a way to remove these barriers. Although licensure and regulation of health care professionals are state responsibilities, the federal government has previously influenced state legislation and policy (on such issues as the legal drinking age through incentive programs to promote health and safety, for example).
Since some of the rules supporting the ACA are still under development, a rule could be introduced that would provide incentives to states with unrestricted NP practice. The incentives could be tied to graduate medical education (GME) funding. As an incentive, states with unrestricted practice acts could receive extra funding for NP education, thus helping them to bolster their ranks of primary care providers.
The program could be implemented by the federal government as a voluntary incentive program for individual states, with a national deadline to universal unencumbered NP scope of practice. Such a phased implementation process might meet with less medical lobby resistance. A relatively small portion of physician GME budget could seamlessly fund the incentive program, since disbursement processes are already in place. It's well known that educating one NP costs a fraction of what it costs to educate a physician and can be accomplished far more quickly. In fact, it's been estimated that from three to as many as 12 NPs can be educated at the same cost of educating one physician. If we shifted a small percentage of GME money to the incentive program for funding NP education, the return on investment would be substantial, with no drain on the federal budget, little loss to physician education, and a potential increase in the pool of available primary care providers.
As states allowing independent NP practice begin to see the benefits (improved access to health care and decreased health care spending), constituents in more restrictive states will become interested in changing practice laws. Legislators will be lobbied—if change doesn't occur through legislation, it may be enacted through the electoral process. Many states may in fact welcome the increased funding and potential for improved access to health care and change their laws relatively soon after the incentive program rules are released.
Implementation of greater participation and autonomy for NPs would positively affect the entire health care system and help us better meet Institute of Medicine quality care aims. Providers would be accessible (timely), provide a full scope of care (patient centered), provide quality care (safety), and improve patient outcomes (effective), while decreasing health care costs (efficient). Furthermore, removal of practice restrictions would ensure care for a greater percentage of patients, regardless of location (equitable). The time has come to allow NPs to take their rightful place in our health care system.