Primary Care: Expanding the Use of Nurse Practitioners
Introduction | Evidence of Quality Improvements | Evidence of Savings | Key Considerations | Further Resources | State-by-State Ratings
The Policy
State law that allows nurse practitioners to diagnose and prescribe without mandated physician oversight.
Introduction
There is a shortage of primary care physicians nationally and within the Medicaid program, yet studies repeatedly show that primary care reduces cost and increases quality for consumers.
Nurse practitioners can play an important role in expanding primary care capacity in the Medicaid program. Nurse practitioners (NPs), often called mid-level providers, are able to provide some aspects of primary care, complementing the work of primary care physicians. Nurse practitioners are nurses with advanced clinical training. They need fewer years of training than physicians making them a more immediate support to a stretched primary care workforce. Additionally, NPs reduce cost because their average earnings are half those of primary care physicians.
NPs are important for areas of the country that face severe primary care physician shortages - this shortage is particularly acute for rural areas and southern states where the patient-to-primary care physician ratio is higher and where fewer physicians are choosing to practice. Studies show that NPs are more likely to practice in these underserved areas than primary care physicians, increasing access for Medicaid patients and the uninsured.
Although NPs are trained to provide primary care, states differ in scope-of-practice guidelines. Scope-of-practice guidelines dictate what authority NPs have with their patients. Some states allow NPs to provide primary care, diagnose, and prescribe without physician oversight, while others have more restrictive scope-of-practice guidelines that require physician oversight and may limit NP practice and prescription authority. For example, Alaska allows NPs to diagnose and prescribe all medications without physician oversight while Missouri requires written documentation of physician involvement for NPs to diagnose and prescribe.
Expanding NP scope-of-practice strengthens primary care capacity. Greater NP autonomy increases consumer access to primary care while freeing up physicians to manage more complex patient cases. States can support consumer access to health care by passing legislation that eases restrictions on NP scope-of-practice.
Evidence for Quality Improvement
There is extensive research documenting nurse practitioner's ability to provide high quality care, resulting in similar patient outcomes to physician-provided care. Similarly, patients that see NPs report high levels of satisfaction.
Harnessing NPs can also help address a common barrier to care for Medicaid beneficiaries: the shortfall of primary care providers. The 2014 expansion of the Medicaid program, mandated by the Affordable Care Act, will enroll approximately 16 million new participants, many needing a primary care provider for the first time. Empowering NPs to diagnose and prescribe without physician oversight is one important tool in helping to ensure that there is an adequate primary care workforce to serve this new population, especially since NPs are more likely than MDs to treat patients in settings where provider resources are scarce.
Evidence for Savings
Studies show that a higher concentration of primary care physicians results in higher quality, lower cost care. One recent study shows that a 10 percent increase in primary care physician to patient ratio results in a 7 percent spending drop ($369) per Medicare beneficiary, on average. This suggests that increasing primary care capacity is a bridge to cost savings and better care.
Analysis of Massachusetts' data revealed that patient visits with nurse practitioners or physician assistants were, on average, 35 percent less expensive than physician visits. The authors estimated that expansion of nurse practitioner scope of practice laws in states could save between $4.2 billion and $8.4 billion over ten years for the state.
Key Considerations
Additional barriers to NPs serving as primary care providers: The Institute of Medicine (IOM) in its 2010 report The Future of Nursing recommends that states increase the scope-of-practice for NPs enabling them to be more effective primary care providers and practice to the full extent of their advanced educational training. The IOM outlines steps to remove barriers to NP scope of practice that includes regulatory and insurance barriers in addition to legislative barriers.
In addition to scope-of-practice restrictions, some states use multiple bodies to regulate NPs. For example, Georgia and 16 additional states, require both the nursing and medicine boards oversee NPs. Using two regulatory bodies creates a confusing oversight structure that it is inefficient. Legislators should consider adopting a simplified regulatory model such as the APRN Consensus Model. This IOM recommended model identifies the Board of Nursing as the sole regulatory body for nurses.
Political opposition: Another key consideration for states as they think about expanding scope-of-practice laws for NPs is potential opposition from the physician community. Many physician groups are opposed to expanding NP scope-of-practice citing concerns about overuse of specialty services and overall quality of patient care. Claims that NPs increase patient use of services through over-referral to specialists are unsubstantiated, and studies show that quality of patient care by NPs is comparable to quality of patient care by physicians. There must be a wider discussion about how the health care delivery system, as a whole, transforms to meet the needs of patients; this will involve more team care and shared responsibility.
Further Resources
Interactive Nurse Practitioner Scope of Practice Law Guide, Barton Associates
The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care, National Governors Association
Improving Access to Adult Primary Care in Medicaid: Exploring the Potential Role of Nurse Practitioners and Physician Assistants, Kaiser Family Foundation
State model for nurse practitioner regulation, National Council of State Boards of Nursing
Scope of Practice Laws in Health Care: Rethinking the Role of Nurse Practitioners, California Health Care Foundation
Controlling Health Care Spening in Massachusetts: An Analysis of Options, Rand Health
Access Care and Advanced Practice Nurses A Review of Southern U.S. Practice Laws, AARP
State-by-State Ratings
 Made the Grade
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 Room to Improve (?)
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 Miss the Mark
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