Advanced Nurse Practitioner Scope of Practice Issues
New York State needed an additional 1,200 physicians to address the shortage by 2012, according to a 2012 Haney’s survey by the Healthcare Association of New York State (Verdon, Ritchie, Marbury & Mazzolini, 2014). The scope of Certified Nurse Practitioner (CNP) practice is currently debated in some states. In New York State, the Nurse Practitioners Modernization Act will allow those nurses who have more than 3,600 hours of experience to treat patients without the supervising physician’s signed practice agreement (Farmer, 2014).This act will become law on January 1, 2015. This act may fill that void; however, various New York physician advocate groups continue to argue that patient safety will be compromised because of the gap in training of CNPs (Verdon et al., 2014).
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The United States (U.S.) health care system faces many challenges due to demographical, economic and political shifts. There are existing gaps in quality and accessibility of care and patient safety. U.S. population is aging rapidly and it is estimated that about 18 percent of the U.S. population will be 65 years old or older by 2025 (U.S. Census Bureau, 2012). With growing number of Medicare beneficiaries, there will be more demand for primary care providers. It is estimated that by 2020, the U.S. nation will require 40 percent more primary care providers (Hauer et al., 2008). U.S people 65 and older will have more than one chronic disease and physicians’ shortages will not meet the demands that are expected (Centers for Disease Control and Prevention, 2012).
The National Governors Association (NGA) reviewed of the literature and summarized that CNPs can reduce disparities in access to care, promote cost effectiveness through policy advancement, patient advocacy and the development of innovative models of care to improve patient care (NGA, 2013). The push for giving CNPs more autonomy continues with the shortage of primary care physicians on the rise. The American Academy of Family Physicians (AAFP) is not supporting the idea of allowing CNPs the full scope of practice without working under the physician’s supervision. One of the reasons cited is that family physicians have extensive training and education, which would ensure patients’ safety and provide the best quality of care (American Academy of Family Physicians, 2012). The scope of CNPs’ practice is currently debated in some states.
Researchers studied care provided by both nurse practitioners and physicians and showed that while quality of care was similar for both providers, patients’ results were same or better for NPs as compared to physicians (Bauer, J. 2010). In addition, it was found that nurse practitioners provide care at a lower cost as well as more disease prevention counseling, health education, and health promotion activities than physicians (Mehrota et al., 2009).
Another study which used data from the Association of American Medical Colleges’ Consumer Survey showed that consumers are open to the idea of obtaining medical care from NPs (Dill, Pankow, Erikson & Shippman, 2013). Compared to physicians, CNPs traditionally are reimbursed at a lower Medicare rate for delivery of the same services. Yet, while our healthcare desperately needs to reduce cost, it is estimated that a cost savings would remain, even if CNPs were to receive equivalent reimbursement, because they utilize fewer resources than physicians (Health Policy Brief, 2012).
In 2009, on average, it cost 20% less to visit a nurse practitioner than to visit a physician (Eibner, Hussey, Ridgely & Glynn, 2009). In Massachusetts, after the insurance reform was implemented, it was shown that the state could save from $4.2 to $8.4 billion over a 10-year period when nurse practitioners use was increased (Eibner et al., 2009).
Accountable care organizations (ACA), community and nurse-managed health centers, patient-centered medical homes success will require that CNPs have full scope of practice to have the ability to practice independently without restrictions (Fairman, Rowe, Hassmiller, & Shalala, 2011). Organizational barriers exist for reimbursements of care provided by CNPs. Notwithstanding that the quality and standards of preventing care established in the ACA are met by these providers, their current rate of reimbursement for Medicare services to residents in long term care (LTC) facilities is only 85 percent of the rate that physicians charge for the same services (American Association of Nurse Practitioners, 2013).
The unlimited contribution of CPNs will be even more important considering that with the implementation of the ACA, millions of newly insured Americans will seek the access to healthcare. Expanding the scope of practice of advanced practice nurses can possibly translate to an increased access to healthcare for many current and future patients, especially in underserved areas (National Governors Association, 2012).
There is a need for the uniform standards for practice and to eliminate the difference in the level of practice among CNPs from one state to another (NGA, 2012). The scope of practice will establish which activities are reimbursed by third party payers and will have direct impact on the independent practice of CNPs (NGA, 2012). When CNPs are required to collaborate or to be supervised by the physician, they are less likely to be selected by insurers and are unable to directly bill for the services they render (NGA, 2012). Instead, the bill for their services is coded under the physician’s provider number. If the requirement for physician involvement is dropped, CNPs would be allowed to be credentialed as providers and directly reimbursed for their services. This is also important if a physician moves or does not want to collaborate with a CNP.
Another issue related to scope of practice is the lack of universal, federal recommendations for mobility across states for practitioners involved in telemedicine. The significant discrepancy in CNP scopes of practice across states limits the ability of expert CNPs to work as consultants in a different state, which may limit the access of individuals to specialty consultations that may not be available locally. In their study of nurse migration, it was reported that nurses, including CNPs, move to states with less restrictive scopes of practice. Migration of CNPs may contribute to the shortage of primary care providers, especially in disadvantaged areas (Kalist, Spurr, & Wada, 2010). Nurses are restricted to certify in some state to do health care visits or stay in skilled nursing facilities, admit patients to hospitals or prescribe medications without physician’s supervision and because of that nurses move to less restrictive states, and from primary to specialist care, a resulting loss of access to care a lot of patients (Eibner et al., 2009).
With millions of people signing up for health care under the Affordable Care Act, the aging population and number of chronic illnesses growing, the demand for primary care services is projected to grow. NPs will play a significant part in expansion and shaping of health care delivery. The looming shortage of primary care practitioners can be alleviating by integrating into health care delivery primary care nurse practitioners and physicians assistants. Medical profession should have an active interest in advancing the role of NPs and making sure that the high standards of the profession are intact. While NPs should not be a replacement for doctors they should be allowed to practice to the full extent of their training. Relaxing the scope of practice laws that prevent nurse practitioners from playing the important role in providing basic primary health care services is the first step that should be undertaken.
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Verdon, D., Ritchie, A., Marbury, D., & Mazzolini, C. (2014). (Slideshow) Scope of practice debate in primary care spreads to 8 states. Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/midlevel-providers/slideshow-scope-practice-debate-primary-care-sprea?page=full
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