Full Practice Authority for Nurse Practitioners - IngentaConnect

Nurs Admin Q Vol. 41, No. 1, pp. 86–93 c 2017 Wolters Kluwer Health, Inc. All rights reserved. Copyright

Full Practice Authority for Nurse Practitioners Deborah Dillon, DNP, RN, ACNP-BC, CCRN, CHFN; Faye Gary, EdD, RN, FAAN Implementation of the Affordable Care Act (2010) enabled more than 30 million people to have new access to primary care services. On the basis of current utilization patterns, demand for primary care providers is expected to grow more rapidly than physician supply. This imbalance is expected to worsen, as the aging population requires more health care resources. In addition, more patients are requiring critical care services and physician numbers are not keeping with this growing need. Restrictions on resident physician practice hours have impacted inpatient care as well. Revisiting outdated state practice laws, and considering Full Practice Authority (FPA) for nurse practitioners (NP), is needed for improving access to care while creating greater flexibility for development of patient-centered health care homes and other emerging models of care delivery. Currently, 21 states and the District of Columbia have adopted FPA for NPs, with 15 more states planning legislation in 2016. Allowing FPA and Prescriptive Authority (PA) enables NPs to become more efficient and effective patient care team members. However, physician resistance to FPA and PA presents barriers to implementation. Key words: Affordable Care Act, Full Practice Authority, nurse practitioners, scope of practice

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ULL PRACTICE AUTHORITY (FPA), as defined by the American Association of Nurse Practitioners (AANP), is “the collection of state practice and licensure laws that allow for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including the ability to prescribe medications—under the exclusive licensure authority of the state board of nursing.”1 In some states, such as South Carolina and West Virginia, Prescriptive Authority for Schedule II medications2 and the inability to order home health services significantly limit nurse practitioner (NP) practice (Figure). The Institute of Medicine

Author Affiliations: University of Virginia School of Nursing, Charlottesville (Dr Dillon); and Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Gary). The authors declare no conflict of interest. Correspondence: Deborah Dillon, DNP, RN, ACNP-BC, CCRN, CHFN, University of Virginia School of Nursing, 225 Jeanette Lancaster Way, PO Box 800782, McLeod Hall, Charlottesville, VA 22908 ([email protected]). DOI: 10.1097/NAQ.0000000000000210

(IOM)* made the recommendation in its 2010 landmark report, The Future of Nursing, that scope-of-practice barriers should be removed to allow advanced practice registered nurses (APRNs) to practice to the full extent of their education and training.3 In early 2014, the Federal Trade Commission recommended that states take caution when considering proposals to limit the practice authority of NPs, citing evidence of a reduction in both competition and benefits to health care consumers that result from such laws.4 As of August 2016, 21 states and the District of Columbia permit NPs to diagnose, treat, and prescribe medications without physician oversight.5 The support of FPA is endorsed by the AANP and the American Nurses Association. The American Association of Retired Persons supports FPA, with additional recommendations to states to amend current scope-of-practice laws and regulations to allow nurses and APRNs

*

The IOM is now known by its new name the National Academy of Medicine.

86 Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Full Practice Authority for Nurse Practitioners

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Figure. The 2015 nurse practitioner state practice environment. From American Association of Nurse Practitioners.

to perform duties for which they have been educated and certified.1,6 Additional health policy and consumer advocacy organizations support removing scope-of-practice barriers.

These groups include, but are not limited to, the National Governors Association, Bipartisan Policy Center, and the Josiah Macy Foundation.1

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2017

RATIONALE FOR AUTONOMY The Patient Protection and Affordable Care Act expanded health coverage for millions of Americans and increased the demand for primary care providers.7 One strategy to increase the number of primary care providers is to expand the role of NPs.8 This resulting increase in primary care settings will improve patient accessibility and decrease wait times to see a provider. In a 1981 analysis (reconfirmed in 1986), the United States Office of Technology Assessment concluded from its examination of NP care and practice patterns that NPs perform as well as physicians in all areas of primary care delivery and health outcomes.9,10 NPs are positioned to effect positive change in health care and new models of health care delivery. The AANP has documented a body of literature that supports the position that NPs provide care that is safe, effective, patient-centered, timely, efficient, equitable, and evidence-based.11 NPs, practicing to the full extent of their licensure and training, can be a valuable resource for inpatient settings by providing the same consistent, evidence-based, equitable, safe, and patient-centered care.3 Although NPs historically have been employed in primary care, the development of the acute care nurse practitioner role in the mid-1990s has placed NPs in inpatient care roles as a tactic to meet coverage needs and quality directives.12-14 One of the largest driving forces for this move to NP inpatient care has been the human resource shortage in critical care medicine. The restriction of resident physician practice hours (as a result of changes in graduate medical education) has reduced the number of care providers in the hospital setting.15 As the American population continues to age, there is a resulting increase in need for hospital services. While NPs in outpatient settings focus on access to care and decreased wait times, NPs practicing in the inpatient setting focus on length of stay and intervention outcomes. Care coordination and transitions of care are extremely important to positive

outcomes of hospital care, for all patients, regardless of age.6 FPA for NPs enables them to provide patients with direct access to the full services that NPs can provide. Table 1 outlines the benefits of FPA according to the AANP.1 FPA should have a favorable impact on physician practices by freeing up physician time currently utilized for authorization of prescriptions and medical treatments. In addition, improving access to care and decreasing office wait times (by adding NPs) improve patient satisfaction. BARRIERS TO FULL PRACTICE AUTHORITY Interprofessional barriers In 2012, the American Academy of Family Physicians (AAFP) issued a report cautioning against creating what its members describe as a 2-class system of health care, one that is physician-led and another led by “lessqualified health professionals.”16 The AAFP took issue with NPs and FPA. Although it acknowledged the valuable role played by advanced practitioners in the health care team, it asserts that NPs “cannot fulfill the need for a fully trained physician.” According to AAFP Board Chair, Roland Goertz, MD, MBA, adding independent practice for NPs was not the right model with which to move into the future of health care.16 Unfortunately, the report contained multiple incorrect statements regarding the NP’s education preparation and ability to arrive at an initial patient diagnosis. Dr Bobbie Berkowtiz, Dean of the Columbia School of Nursing in New York City, agreed that “the report was flawed and that it didn’t use data to back up its statements.”17 The AANP responded with a press release and announcement at that time and stated, “AAFP’s position was directly contrary to the recommendations of the IOM and the National Council of State Boards of Nursing” as well as “being contrary to the requirements set forth by the National Committee for Quality Assurance (NCQA), URAC, and The Joint Commission.”18



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Table 1. Benefits of FPAa FPA Benefit to Patient Care

Method/Rationale

Other Considerations

Improved patient access

Delivers care to underserved and rural areas Allows increased service to an aging population

Streamlined care delivery making more efficient

Provides direct patient access to providers Removes delays in care when dated regulations requires a physician signature prior to initiation of medications or diagnostic testing Avoids duplication of services and billing costs related to physician oversight Reduces repetition or orders, office visits, and other care services Allows patient access to health care provider of their choice

Addresses primary care provider workforce shortage Addresses change in Graduate Medical Education duty-hour requirements Assures timely access to care

Decreased cost

Protects patients’ right to choose

Medicare payments to NPs are at 85% of the physician fee schedule This is in alignment with many of the commercial payers Removes constraint on the practice of one health discipline in a regulating relationship with another profession

Abbreviations: FPA, Full Practice Authority; NP, nurse practitioner. a Adapted with permission from AANP materials.

Despite 40 years of evidence to the contrary, the AAFP report made the misleading statement that NPs misdiagnose, miss obvious and potentially life-threatening problems, or make prescribing errors.19 Multiple studies comparing NP outcomes with those of physicians have demonstrated either no difference between MD and NP providers or evidence of a reduction in morbidity and mortality under NP care.20-22 In addition, Dr Kenneth Brummel-Smith, Chair of the Department of Geriatrics at Florida State University College of Medicine, has stated, “There simply is a ton of evidence that physicians often do not do a good job of prescribing (controlled drugs) and very little evidence that nurse practitioners do a bad job.”19

Insurance payer barriers In addition to physician barriers placed by physicians and physician groups, FPA faces barriers from the insurance payer market. Commercial health plan reimbursement varies, and there are those that do not recognize NPs as primary care providers. Frequently, payer policies are linked to state practice regulations and licensure.23 Reimbursement issues are often associated with scope of practice. Federal and state barriers Federal barriers, such as those imposed by the Social Security Act,24 which governs Medicare and Medicaid, were written in 1965.


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Those recommendations were made in Medicare/Medicaid documents, which were implemented in the very early years of the NP professional development. The Act often refers to the word physician as the only health care provider. The Act, although revised many times since the 1960s, has had some relevant portions changed, but many remain that give permission to physicians and only to physicians to provide care. The Act still states that a physician must direct the care of hospitalized patients. The Centers for Medicare & Medicaid Services (CMS) requires for outpatient services (Medicare Part B) incident-to billing to be rendered under the physician’s name and number. This requirement also includes that the physician must establish the initial plan of care as well as be periodically involved in the patient’s plan of care. The CMS requires that hospitalized Medicare patients be “under the care of a doctor of medicine or osteopathy” (481.12).25 The CMS requires the admission to be certified. This certification is required for hospital inpatient coverage and payment under Medicare Part A and may be signed only by one of the following: (1) a physician who is a doctor of medicine or osteopathy, (2) a dentist in the circumstances specified in 42 CFR 424.13 (d), or (3) a doctor of podiatric medicine if his or her certification is consistent with the functions he or she is authorized to perform under state law.25 These payment barriers are sometimes used to justify hospitals and medical staff bylaw limitations to NP admitting privileges as well as practice within the hospital environment. Changes at the federal level have not kept up with current access to care issues and delivery models. Modernizing and updating state nursing licensure laws to meet current practice and population health care needs are essential in this process. Removing current collaborative practice requirements would enable full benefit of NP services in hospitals, nursing homes, home health care, and hospice environments.

ACCESS TO CARE An analysis of the 2008 Medicare administrative data showed that NPs were more likely than physicians to serve a younger, more female, and less frequently white population of beneficiaries. They were also more likely to serve individuals with a disability as well as the vulnerable populations that are dual eligible for Medicare and Medicaid.26 Traczynski and Udalova’s27 analysis of Medical Expenditure Panel Survey found that, after NPs were granted FPA, reports of satisfaction rose significantly in both appointment availability and ease of traveling to appointments. Currently, in communities where underserved and vulnerable populations reside, when collaborating physicians leave the area, NPs, without FPA, are left without an ability to continue care for these patients. In other words, loss of a physician leads to loss of access to NP providers for at least a period of time. A new physician provider may take months to recruit and then may need time to establish state licensure. In the interim, patients must locate another provider or go without care. They may also choose a more expensive care option, such as use of a local emergency department, which drives up medical costs. COSTS AND BENEFITS Multiple studies have demonstrated the cost-effectiveness of NPs. One of the largest studies was published in the 2000 Journal of the American Medical Association.5,28 This randomized clinical trial evaluated patients over a course of care and treatment. At 6 and 12 months, it was found that both resource utilization and patient health care status were the same for patients treated by either primary care NPs or physicians. A 2-year follow-up study confirmed that, where NPs had the same authority, responsibilities, productivity, administrative requirements, and patient population as their physician colleagues, patients experienced equivalent


Full Practice Authority for Nurse Practitioners health care results: “No differences were identified in health status, physiologic measures, satisfaction, or use of a specialist, emergency room or inpatient visits.”28 Costs associated with increased length of stay and hospital complications have been reduced after the addition of an NP to clinical service.29 A reduction in use of inpatient resources through a consistent application of evidence-based practice (EBP) guidelines in the ordering of diagnostics, treatments, and medications has also been demonstrated when NPs have joined the care team.27-29 This has resulted in associated cost savings via reduced complications and lengths of stay.27-29 Multiple studies related to specific clinical challenges, such as catheter-related bloodstream infection, surgical care improvement, and hospital-acquired complications, have demonstrated the positive impact of NPs in the standardization of EBP guidelines and quality of care.29-31 NPs have been cited as being influential in reducing costs related to adherence to EBP guidelines in decreasing avoidable complications.30-32 Research in both the primary care and inpatient settings have demonstrated the benefits of NP practice. Cost reductions have also been demonstrated in both practice settings when utilizing an NP provider. There is now 50 years of excellent outcomes and higher

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quality of care provided by NPs of evidence supporting the role of NPs in both primary and acute care settings.1,11

STRATEGIES FOR SUCCESS Most current discussions on the urgency for increasing FPA address barriers to care access and utilization. The evidence points to FPA as a valuable strategy for this country to streamline care and make care delivery more efficient while decreasing cost. FPA also enables patients to choose the health care provider of their choice.1 Despite evidence, and the country’s need to provide experienced, quality care, some policy makers have been slow to remove barriers to FPA. One tactic for helping policy makers feel more comfortable with change that enables FPA is to develop a “transition period” before NPs are able to practice independently.33 During this transition, an NP must work under the guidance of a physician. This requirement is part of legislation enacted by Connecticut, Minnesota, Nebraska, and New York this year. States vary in the clinical practice hours required to reach independent practice (ranging from 2000 to 4000). While there is no evidence support the “best” number of hours, in one case, the governor of Nebraska vetoed a bill that would have

Table 2. Strategies for Removing Barriers to APRNa Practiceb Communicate about the APRN role and the value of APRN care to stakeholders including patients Institute medic campaigns on the role of APRN care in patient care Conduct proactive lobbying to change restrictive APRN regulations Highlight and demonstrate the impact of APRN care at the institutional and national levels Demonstrate the value of APRN care by implementing innovative models that leverage APRN skills, knowledge, and experience Make APRN role visible by identifying contributions of APRNs Educate health ministries, administrative entities, credentialing committees, and medical staff about the practice of APRNs to assist in updating hospital bylaws Encourage patients/consumers cared for by APRNs to advocate for them as competent providers Disseminate/publish/present on exemplars in collaborative models that have demonstrated quality and safety improvements a The

authors are accepting advanced practice registered nurse (APRN) used in this table in reference to the nurse practitioner. b Adapted with permission from Robert Wood Johnson Foundation, 2013; Brassard and Smolenski.8


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required 2000 clinical practice hours before transition to independent practice, stating he would support legislation that mandated a minimum of 4000 clinical hours.33 Research supporting the ideal clinical practice hour requirement as well as the specific minimum hours required is needed. Proponents of advanced practice FPA recognize that it may be necessary to get support for legislative and regulatory changes (Table 2). SUMMARY It is time to move forward with FPA for NPs. Changes in health care delivery initiated because of the Patient Protection and Affordable Care Act, as well as support from the IOM and other national organizations, provide unprecedented support for this. NPs are well situated to provide care in both the primary and acute care settings. Removing barriers to practice will empower NPs to effect positive change in our struggling health care system, in addition to providing additional access to care for minorities and underserved patient populations. Despite significant resistance, the AANP “believes that there is a pendulum swing toward FPA. The Board of Directors has set a goal that 90 per cent of states will have FPA licensure by 2020.”5(p99) Approval of FPA has taken a state-bystate approach due to individual state boards

of nursing requirements. Different approach strategies have met with varying degrees of success. While the case for increased access to care for the underserved has convinced legislatures in some states, the transition to clinical practice hour requirement has been successful in others. The state-by-state approach is costly and labor-intensive and delays the implementation of a national policy that would benefit patients. The Veterans Administration has proposed a systemwide adoption of FPA that would supersede individual state regulations.34 This adoption of FPA would allow “increased access to care, decreased variability throughout the Veterans Administration System, and ensure continuity of the highest quality of care for all the nation’s veterans.”34 Monitoring the progress of this legislation may help provide direction and additional strategies for successful changes in licensure regulation. Understanding the goals and outcomes of FPA by all practitioners, administrators, and legislators would aid in hastening the next health care transition for all NPs and patients. The IOM, in its Future of Nursing Report, states, “The current conflicts between what APRNs can do based on their education and training and what they may do according to state and federal regulations must be resolved so that they are better able to provide seamless, affordable, and quality care.”3

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