NPs could improve access to care, but practice expansions remain controversial

Allowing nurse practitioners full practice authority may help diversify the workforce and increase access to primary care, according to experts, but there are many factors in the benefit-risk balance to consider.

April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, president of the American Association of Nurse Practitioners, told Healio that the United States’ 355,000 nurse practitioners (NPs) work in every health care setting and can perform a variety of services, including ordering, supervising and interpreting diagnostic tests; prescribing medications and other treatments; diagnosing and treating both acute and chronic conditions; and managing overall care.

“NPs bring strength to the health care workforce and maximize our nation’s potential to meet patient needs. This is our key role, from my perspective,” Kapu said. “Approximately 88% of NPs are prepared in primary care, but you can also find NPs specializing in mental health/psychiatric care, cardiology, oncology, acute care and many more.”

NPs may help address racial health disparities

A recent study conducted by Alicia Plemmons, PhD, an assistant professor in the department of general business at West Virginia University, and colleagues explored how granting NPs full practice authority (FPA) might affect the racial and ethnic composition of the NP workforce and the communities they serve. FPA is a model of regulation that allows NPs to perform all of the responsibilities for which they are trained.

Plemmons and colleagues wrote that the nursing workforce has a higher representation of people from underrepresented racial and ethnic populations than physicians, and a health care workforce that is diverse is linked to higher patient satisfaction and improvements in quality of and access to care. They hypothesized that allowing FPA could attract NPs “to states where they have autonomy,” which could subsequently increase representation in the health care workforce and improve care overall.

Using CMS data, the researchers looked at practitioners enrolled in Medicare from 2014 to 2020 and the Medicare populations that they served. Additionally, they identified active licensing information for NPs when they merged the data with the NPI for all licensed practitioners.

They found that Black and Asian NPs served more Black Medicare beneficiaries after receiving FPA; Black NPs in FPA states served nearly 3% more Black Medicare beneficiaries than those in non-FPA states. The finding is significant given that multiple studies have found that patients of underrepresented racial and ethnic groups prefer providers who share their backgrounds, Plemmons said in a press release.

“Full practice authority is a costless way of helping communities of color address health care access disparities,” she said.

Debate

Kapu said that allowing NPs FPA would provide both more freedom to choose a health care provider and expanded care access.

“AANP strongly supports legislation that gives patients full and direct access to NPs. We are not alone,” she said. “In fact, the majority of health consumers support policies and legislation that remove barriers to NP practice and strengthen patient choice in the selection of a health care provider.”

Patients have full, direct access to NPs in the Washington, D.C., and 26 states — five of which are the healthiest states in the nation, Kapu noted.

“In the remainder of states, outdated licensure laws reduce or restrict patient access to NPs. In fact, the five least healthy states in the nation all restrict NP practice,” she said. “AANP supports legislative solutions to enact FPA in these states so patients receive full and direct access to high-quality, accessible NP-provided care. In fact, two out of three patients support legislation for greater access to NP services.”

However, allowing NPs FPA is not a universally popular idea. The AMA has fought scope of practice expansions for more than 30 years. It said its “state and federal advocacy efforts have safeguarded the practice of medicine by opposing NP and other non-physician professional attempts to inappropriately expand their scope of practice.”

In fact, the AMA has “secured over 100 state legislative victories stopping inappropriate scope expansions of nonphysicians” since 2019, according to the organization.

The AMA provided a statement to Healio that said it “strongly supports physician-led team-based care where all members of the team use their unique knowledge and valuable contributions to enhance patient outcomes.”

“Nurse practitioners are valuable members of this team, but they are not a replacement for physicians,” the AMA statement said. “Removing physicians from the care team results in higher costs and lower quality of care. Moreover, patients want and deserve care led by physicians.”

The AMA cited a recent survey in which 95% of patients said it was important for a physician to be involved in their diagnoses and treatment.

“That is why the AMA opposes inappropriate scope expansions and will continue to defend patient access to physician-led care,” the statement said.

Healio Primary Care Peer Perspective Board Member Alan Dow, MD, MSHA, FACP, the Ruth and Seymour Perlin Professor of Medicine and Health Administration and assistant vice president of health sciences for interprofessional education and collaborative care at Virginia Commonwealth University, said that advanced practice providers like NPs “are key members of the health care team, and we need them to practice at the top of their licenses to meet the needs of our patients and our communities.”

“That being said, physicians come out of residency more ‘practice-ready’ than nurse practitioners who don’t have as extensive practice-based training as physicians,” he told Healio. “More NPs are completing post-graduate fellowships, which are great but still uncommon and poorly funded. We need more of these types of programs.”

Education

Physicians usually undergo 4 years of medical school and an additional 3 years of residency, typically undergoing 10,000 to 16,000 hours of clinical training.

NPs usually have 500 to 720 hours of clinical training and are required to complete a master's or doctoral degree program, Kapu said, “and have advanced clinical training beyond their initial professional registered nurse (RN) preparation.”

“NP preparation differs from some other health professions,” Kapu said. “NP education is based on standardized national competencies set by the National Organization of Nurse Practitioner Faculties. All NP programs are nationally accredited and accountable to the U.S. Department of Education. It is a rigorous, competency-based framework.”

Before being accepted to a NP program, prospective students must earn an RN license and a bachelor’s degree in nursing — a prerequisite that Kapu said ensures students beginning their education “are already independent clinicians who are managing patients, delivering medications and adjusting treatments.”

“NPs must demonstrate they have integrated this prior knowledge and skill and do not progress or graduate simply based on hours spent in rotation,” she said. “In addition to the clinical content, NP education incorporates course work for leadership and management of health care teams and interprofessional care coordination.”

Because NPs rely on on-the-job training early in their careers, Dow said that “physicians and other system leaders need to find ways to assess when a nurse practitioner is truly capable of independent practice.”

“I don’t like relying on an arbitrary number of years to define competence and independence, but that’s been the practice for both physicians and other health care providers,” Dow said.

When it comes to handling complex cases, Kapu said that “half a century of research definitively demonstrates that NPs provide high-quality primary, acute and specialty health care services across the life span and in diverse settings, including NP-owned practices.”

Dow said that, though NPs can become very skilled in their areas, physicians are ultimately better equipped to manage the most complex cases.

“Nurse practitioners learn to engage physicians when a case is complex, much like how physicians engage subspecialists with complex cases. For any individual provider, it’s about knowing what you know and knowing what you don’t know,” he said.

Health care shortage

The Association of American Medical Colleges estimates that, by 2034, there will be a shortage of between 17,800 and 48,000 primary care physicians in the United States. Additionally, recent data from the Health Resources and Services Administration show that, as a whole, the U.S. has less than half of the PCPs its citizens need; about 99 million people are in a primary care professional shortage area.

Kapu said that NPs are “solutions to our health care access crisis.” Data from the U.S. Bureau of Labor Statistics lists NPs as the fastest-growing profession of the next decade, with a projected 46% increase by 2031.

“It’s time for all states to allow NPs to practice to the fullest extent of their education and clinical training,” Kapu said. “America’s patients need access to the high-quality care that NPs are uniquely positioned to provide.”

Dow agreed that NPs could help the shortage in the health care workforce.

“The bottom line is that we need more frontline health care providers, so safely expanding the practice authority of non-physicians makes sense,” Dow said. “Physicians, in turn, need to understand how best to collaborate with non-physicians to make their work more efficient and more impactful. Done well, physicians can spend their time on the more complex patients and, even though they might see fewer total patients, they might see their overall salaries grow.”

However, according to the AMA statement, “multiple studies confirm changes to scope of practice laws have not increased access to care in rural or underserved areas.”

“We need to look at real solutions that work to improve access to care, including coverage and payment of high-quality telehealth, increased funding for graduate medical education, and support of physician-led care teams,” the AMA said.

The AMA also noted that the organization “is actively working to alleviate a maldistribution of physicians that is responsible for shortages in many states.” The AMA supports various methods that help ease shortages, according to the statement, such as:

• increasing residency slots to train physicians in medically underserved areas;
• developing programs to help inactive and retired physicians re-enter clinical medicine; and
• expanding medical class sizes and the number of U.S. medical schools.

“The AMA is committed to improving the health of the nation and that includes ensuring physicians can continue to put patients first, lowering health care costs and enhancing health care quality,” the statement said. “We believe the health care system benefits from physician-led team-based care in which all health care professionals work together in a collaborative fashion to improve the overall health of the patient.”

References:

• AAMC report reinforces mounting physician shortage. https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-physician-shortage. Published June 11, 2021. Accessed Feb. 8, 2022.
• America’s health rankings. https://www.americashealthrankings.org/explore/annual. Accessed Feb. 10, 2023.
• AMA national survey: patient sentiment on scope of practice. https://www.ama-assn.org/system/files/ama-scope-of-practice-stand-alone-polling-toplines.pdf. Accessed Feb. 10, 2023.
• AMA successfully fights scope of practice expansions that threaten patient safety. https://www.ama-assn.org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threaten. Accessed Feb. 10, 2023.
• Health workforce shortage areas. https://data.hrsa.gov/topics/health-workforce/shortage-areas. Accessed Feb. 8, 2022.
• Plemmons A, et al. SAGE. 2023;doi:10.1177/15271544221138047.
• U.S. Bureau of Labor and Statistics. https://www.bls.gov/ooh/fastest-growing.htm. Accessed Feb. 8, 2023.
• WVU study shows marginalized communities benefit when states permit nurse practitioners to provide primary care. https://www.eurekalert.org/news-releases/976889. Published. Jan. 17, 2023. Accessed Feb. 8, 2023.