Reference no: EM132209759

Primary Care: Expanding the Use of Nurse Practitioners 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-ofpractice 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 scopeof-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 scopeof-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. 1. Applying what you have learned in the course thus far, describe how expansion of NP's scope of practice (or other mid-level providers) could address the current concerns of: healthcare workforce shortages, health insurance cost-containment, and the provision of prevention and curative services to under served populations in the U.S. 2. What steps need to be taken to make this proposal a reality? 3. How could stakeholders (federal and/or state government, institutions of higher education for these professions, the health insurance industry, others?) play a role in supporting the expanded scope of practice? 4. What barriers can you identify?