There is a very useful paper in the Journal of Health Economics** that looks at what happens to primary care when nurse practicioners (NPs) are allowed by a state to practice to edge of their license without direct physician supervision nor sign-off requirements.
there is a statistically and economically significant increase in the share of adults reporting that they have a usual source of care when NPs gain full independence. We estimate that NP full independence leads to a 3.6% increase relative to the baseline value of this variable….
Our results indicate that allowing NPs to practice and prescribe drugs without physician oversight increases medical care for underserved populations and reduces emergency room use for conditions responsive to primary care. Previous estimates do not consider this source of cost savings, suggesting that NP full independence may reduce costs by more than 0.6 to 1.3%. We show that removing the administrative burden of oversight and supervision from NPs and physicians is a greater source of these effects than the long-term impact of the law change on primary care provider supply. We find that changing NP scope-of-practice laws slightly increases the labor supply of the vast majority of primary care providers, making NP independence a potential policy tool for this purpose.
Licensing requirements for medical professionals is a state level decision and responsibility. It is a political choice for states to either maintain strong restrictions on NP and Physician Assistant (PA) labor practices or to allow their non-doctor practicioners to practice to the edge of the license and training. This paper’s evidence suggests that allowing NPs to work to the edge of their license has the opportunity to lower net costs through the combination of lower reimbursements for NP services compared to MD/DO and potentially avoiding some emergency room visits. Furthermore, it also suggests that the increase in competition as well as lower administrative burdens have primary care MD/DOs shift their time away from paperwork and towards patients.
This is a type of fight that can be won at the state level without regard to the national political debate. If you live in a restrictive state, it is a baby step towards a better system, but a step that is worth taking.
** Traczynski, J., & Udalova, V. (2018). Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes. Journal of Health Economics. doi:10.1016/j.jhealeco.2018.01.001
tom
David, I am completely clueless about much of this stuff. How can one find out how restrictive one’s state is (MI in my case) on NPs and PAs?
Jim Bales
@tom: Let me echo Tom, Is there an easy way to find out if my state (MA) is restrictive or not?
Barbara
@tom: @Jim Bales: What I have learned is that states with true access issues for a significant percentage of their residents — Alaska, New Mexico, Wyoming — tend to be much more open to innovation in the state regulation of professional practice. They are less likely to adopt rigid regulations of telemedicine, for instance, and more likely to permit a greater scope of practice for paraprofessionals of all kinds. States where health care personnel tend to concentrate — California and Florida, for instance — worry much more about the propensity of lightly regulated professionals to commit fraud or provide suboptimal care. One of the current flash points is permitting trained dental assistants to provide a greater range of dental services, because the shortage of dentists is particularly concerning for children living in rural areas.
Here are a few links:
https://www.bartonassociates.com/locum-tenens-resources/nurse-practitioner-scope-of-practice-laws/
https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment#michigan
https://www.kff.org/other/state-indicator/physician-assistant-scope-of-practice-laws/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
https://www.kff.org/other/state-indicator/total-nurse-practitioners/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
Betty Cracker
Interesting study — thanks for sharing it! A registered nurse anesthetist I know tells me what they’re allowed to do is similarly subject to state regulations. She also tells me the strength of the MD lobbying organization in the state pretty much dictates the regulatory environment.
Barbara
@Betty Cracker: One of the issues that comes up a lot is that it’s hard to write practice laws for categories like nurse anesthetists who are highly trained in a very narrow range of medical practice, without permitting them to exceed the limits of their training. “General prescriptive” authority would mean the authority to prescribe for any person for any condition for any kind of drug. Even states like Alaska that permit a greater range of services to be carried out by nurses, PAs, etc., tend to have narrowly drawn scope of practice definitions.
dr. bloor
“Can,” in theory, but as someone who has advocated for psychologists at the state level re: scope of practice, I can assure you the pushback from well-monied interests will invariably be fierce. One person’s “increased efficiency” is another’s “irresponsible deregulation.”
BurntOutDoc
I would agree that licensure laws are often irrational, and need lots of fixing. I live in a poorer southern state, and last year lots of out-of-state PAC money (? Koch brothers) was funneled through the AARP to target the legislature with any bills that lowered licensure requirements in ANY occupation, whether well-considered or not. Our instate resources were quickly over-run, and a bill granting nurse practitioners expanded privileges passed without adequate vetting. The nursing board is WOEFULLY underfunded and understaffed, and is unable to provide any meaningful oversight or assistance to nurses who would like to use these privileges effectively. As a physician, when I am practicing “at the edge of my license”, I view that as a time when I need to be extra careful. But in a state with limited medical resources and far too few specialists available to help out when things go poorly, both physicians and nurses are easily overwhelmed and are putting patients at increased risk of poor outcomes. Changes in scope of practice without adequate resources makes my job more difficult every day.
David Anderson
@dr. bloor: more importantly one man’s increased efficiency is a lot less blow and fewer hookers for the protected incumbents….
Not saying it is easy just plausible
oclday
MDs are worried about money of course and they have an irrational fear of being sued if they “supervise” NPs and PAs. They are often quite uninformed about this. So this has always been a sticking point. As hospitals begin to hire more midlevels to cover ERs and as in patient providers this may become easier because of their ability to lobby. As a CNM in MN we have always been independent practitioners and recently NPs and PAs have gotten the same privilege. I can’t specifically speak to other midlevels however CNMs have better outcomes with low risk women than any type of MD at a lower cost, higher patient satisfaction, and less litigation.. We prefer to refer to working to the top of our license rather than the edge–would hate to fall off!
Daddio7
It is great to finally see discussions on how to lower medical costs instead of the constant bleating for more funds to pay the exorbitant costs baked into our system. My wife got her nursing license two years ago. She supply’s home care for severely disabled children on Medicaid. There is a shortage of nurses willing to do this, she works 60 hours a week and gets constant requests to work extra shifts. She attended a pilot program at a state sponsored tech school for free. She even got a $2600 grant for expenses. The course consisted of online study and class room time. The community collage program cost about $10,000 and some for profit schools cost over $25,000! I am a Conservative but medical training should be free for any qualified person who wants it.
I love my male PA, He believes what I tell him and proscribes the best medications and treatments for my problems. To bad our political parties are too hide bound to compromise and do what is best for us citizens.
dr. bloor
@Daddio7:
Dear sir, wanting something near and dear to you for free while letting the Invisible Hand of the Market smack everyone else around is the very essence of conservatism.
Barbara
@Daddio7: Well, it isn’t quite free is it? Medical training should be rethought, but there is simply no way to pretend that society does not expend a lot of money to support that training, even when the trainees are wracking up debt during the course of that training.