The Future of Nursing Leading Change, Advancing Health (2011) / Chapter Skim
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H Federal Options for Maximizing the Value of Advanced Practice Nurses in Providing Quality, Cost-Effective Health Care
H Federal Options for Maximizing the Value of Advanced Practice Nurses in Providing Quality, Cost-Effective Health Care
Pages 443-476
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From page 443... ...
These well-trained providers -- including nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists -- can and do practice across the full range of care settings and patient populations. They have proven to be valuable in both acute and primary care roles, and as generalists as well as specialists.2 By professional training as well as by regulatory and financial necessity, they have emphasized coordinated and cost-effective care, and they have tended more than other providers to establish practices in traditionally underserved areas.
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From page 444... ...
wide variety of skill levels and roles, and nursing practice routinely takes 3 Louisiana State Board of Medical Examiners: Statement of Position, "Interventional Pain Manage ment Procedures Are Not Delegable," June 2006. 4 Social Security Act § 1819(b)
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From page 445... ...
Even though master's-level education and national certification are now uniformly required for APN licensure, 5 5 For a recently adopted uniform framework for APNs, see APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee (2008)
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From page 446... ...
Their traditional approach of blend ing counseling with clinical care, and coordinating health services as well as appropriate community resources in support of patients, could be a model for policies that seek a more optimal balance of providers prepared to meet the needs of the American public. Regulatory Barriers to the Full Deployment of APNs Current Impediments in the Regulatory Environment For health care providers of all types (other than physicians)
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From page 447... ...
Depending on the jurisdiction, these restrictions may preclude or limit the authority to prescribe medications, admit patients to hospitals or other care facilities, evaluate and assess patients' conditions, order and evaluate tests and procedures, and the like. To illustrate the pervasive and detrimental variations embodied in many state licensure statutes and regulations, consider the following example.
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From page 448... ...
Examination and Treatment • She may not treat chronic pain (even at the direction of a supervising physician)
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From page 449... ...
In sum, this practice environment for APNs echoes the conclusion of a previous Institute of Medicine report, which succinctly described the current regulatory framework for health care providers as "inconsistent, contradictory, duplicative, outdated, and counter to best practices" (IOM, 2001)
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From page 450... ...
That being so, the scopes of practice for APNs (and other health professionals) are exercises in legislative exception making, a "carving out" of small, politically achievable spheres of practice authority from the universal domain of medicine.
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From page 451... ...
State-based Licensure and the All-Encompassing Medical Practice Acts Historical development The United States was one of the first countries to regulate health care providers, and physicians were the first practitioners to gain legislative recognition of their practice. By the early 20th century, each state had adopted a so-called "medical practice act" that essentially claimed the entire human condition as the exclusive province of medicine.
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From page 452... ...
In this way, the pervasive medical practice acts "exert a gravitational force that 6 Rev. Code Washington §18.71.011 (1)
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From page 453... ...
. To be clear, the medical practice acts of every state authorize a licensed medical doctor to undertake virtually any kind of medical or health intervention.
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From page 454... ...
Indeed, the point was neatly (if inadvertently) made by the Louisiana State Board of Medical Examiners in the pain-management Statement of Position referred to in the Introduction: The Board's opinion is not and cannot be altered by representations that a par ticular CRNA [Certified Registered Nurse Anesthetist]
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From page 455... ...
Thus, though the public is increasingly familiar with provider titles such as nurse practitioner, nurse-midwife and nurse anesthetist, it is still "doctor" who "knows best." As the prominent medical sociologist Eliot Freidson has noted, "health services" as understood in the United States "are organized around professional authority, and their basic structure is constituted by the dominance of a single profession [medicine] over a variety of other, subordinate occupations."9 This construct, which underpins the continued centrality of "doctor" and "physician" in the popular culture, prevents the public from forming an accurate perception of the many and diverse types of essential health care providers and their spheres of competence.
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From page 456... ...
Legislative Inertia, "Scope of Practice Fatigue," and Organized Opposition to Change Many states have recognized the evolution of APNs' education and training, as well as their documented practice abilities. In those states, APNs' licensure laws have been reformed in two important ways: first, they have been revised to eliminate requirements that APNs enter into formalized practice relationships with physicians (including practice agreements or protocols and physician supervision or direction)
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From page 457... ...
• The American Medical Association has adopted and continued to re affirm resolutions which direct the organization to pursue, "through all appropriate legislative and other advocacy activities,"12 measures designed to − "oppose the enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state's requirement for medical licensure,"13 (a position that may seem unremarkable until one remembers that, under the medical practice acts, everything is "the practice of medicine") ; − "oppose any attempt at empowering non-physicians to become un supervised primary medical care providers and be directly reim bursed";14 and − support physicians who oppose efforts by alternative providers to ob tain increased medical control of patients by legislatively expanding 11 Finocchio et al., 1998, hereinafter, the Taskforce Report.
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From page 458... ...
17 In furtherance of its long-standing opposition to APN independent practice (including prescribing authority) and direct payment, the AMA, in concert with six national medical specialty societies and several state medical associations, formed a coalition named the Scope of Practice Partnership (SOPP)
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From page 459... ...
First, they are intended to be considered "by State medical boards and legislative bodies when addressing scope of practice initiatives relating to persons without a license to practice medicine"19 -- in other words, to everyone other than physicians, whose scope of practice is seemingly assumed to be not only universal but inviolable and eternal. Second, the underlying assumption of the preeminence of medicine is made explicit by the prefatory statement that "All discussions about changes in scope of practice should begin with a basic understanding of the definition of the practice of medicine and recognition that the education received by physicians differs in scope and duration from other health care professionals.
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From page 460... ...
. Healthcare practice acts need to evolve as healthcare demands and ca pabilities change." • "Overlap among professions is necessary.
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From page 461... ...
, which noted that "a major challenge in transitioning to the health care system of the 21st century envisioned by the committee is preparing the workforce to acquire new skills and adopt new ways of relating to patients and each other." Among the approaches recommended by the IOM Committee was a modification of "the ways in which health professionals are regulated to facilitate the needed changes in care delivery. Scope-of-practice acts and other workforce regulations need to allow for innovation in the use of all types of clinicians to meet patient needs in the most effective and efficient way possible." This approach led to the recommendation that research be pursued "to evaluate how the current regulatory and legal systems .
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From page 462... ...
. • In a comprehensive analysis of the need for a national, coordinated health workforce policy, the Association of Academic Health Centers found that "Inconsistencies in scope of practice laws engender numerous chal lenges." The report went on to add that "lack of national uniformity in scope of practice limits health professionals' mobility and practice," and that "many professionals and policymakers believe that the appropriate response to workforce shortages is to expand the scope of practice of various health professionals.
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From page 463... ...
The analysis went on to note that, as reported by clinic representatives, the "most powerful state regulatory tools af fecting their operations are the scope of practice regulations that govern nurse practitioners and [physician assistants] ." "These kinds of regula tions can greatly affect the cost structure of retail clinics and may affect where retail clinics locate, their staffing, and their hours of operation." The report concluded that many states have chosen not to regulate these clinics directly, but rather have relied on existing health care provider regulations and market forces to decide the fate of these clinics, with one ‘most notable exception'": "often in response to physician groups, states have increased physician oversight of non-physician practitioners who work at retail clinics [emphasis added]
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From page 464... ...
2 5 T his latter option is important because retail clinics are staffed principally by nurse practitioners. 26 Although the RAND report included PAs and NPs in this policy option, I have omitted references to PAs from this summary, both because my focus is on APNs, and because the regulatory scheme for PAs is fundamentally different than that for APNs, in that, though individually licensed, their scope of practice in all states is determined by delegation by a required supervising physician.
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From page 465... ...
, corresponding to the subset of conditions commonly treated at retail clinics." For the upper bound of savings, they assumed that these providers could provide care for these six conditions "as well as for all general medical examinations and well-baby visits." Even given these narrow treatment parameters, the potential savings in Massachusetts over a 10-year period ranged from a lower bound of $4.2 billion to an upper bound of $8.4 billion. The authors also noted that the higher savings estimates were supported by a majority of the studies in the research literature, which confirm that NPs and PAs "can deliver care for a large fraction of diagnoses at equivalent quality and lower cost than physicians," that the "use of NPs leads to high levels of patient satisfaction," and that "NPs are more likely to provide disease prevention counseling, health education, and health promotion activities than are physicians." Quite tellingly, the factors that were identified as tending toward the lower savings range involved some of the common regulatory dysfunctions discussed earlier in this paper.
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From page 466... ...
"[R] esearch suggests that the supply of NPs is influenced both by scope of practice and reimbursement policies, and that a greater supply is available in states with more expansive scope of practice regulations." The detailed analysis contained in the RAND report confirms and amplifies the fundamental conclusion reached by an ever-growing cohort of health care policy analysts: many of the most promising efforts to improve our health care delivery system will have to reckon with the debilitating regulatory restrictions currently imposed on providers' practice parameters.
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From page 467... ...
for all regulated health providers, with more uniform educational preparation and scope-of-practice provisions for each profession. A variation on this scheme could be what one might call "shared direct licensure," in which the federal government would establish a uniform scope of practice for each profession, while retaining the current role of state licensure boards in performing credentials evaluation and verification, disciplinary functions and continued competence assessments.
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From page 468... ...
There are a number of steps that could be taken now to advance this agenda. Articulate National Priorities and Raise Public Awareness: the "Bully Pulpit" National priorities Through an Executive Order or other appropriate vehicle, the federal government could declare that the highest and best utilization of health care providers is a national priority, consistent with the goal of promoting wider access to quality care in cost-effective ways.
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From page 469... ...
statutory authority for annual state reports and assessments of Medicaid and SCHIP, the Secretary of HHS and/or the Administrator of CMS could require the Governor and/or Director of Medicaid/SCHIP of each state to submit an annual report that: • specifies how any of their state's health care provider practice acts and regulations impose restrictions not included in the preferred model framework, and • documents the justifications for these continued restrictions. A compilation of these reports could be posted on the HHS and CMS and other appropriate websites and could be distributed to associations such as the National Council of State Legislatures and the National Governors' Association, as well as to public advocacy groups.
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From page 470... ...
to ensure that impermissible anti-competitive measures are not enacted. The need for such monitoring is confirmed by the recent FTC29 evaluations of proposals in Massachusetts and Illinois and Kentucky, which revealed that several such provisions (including limitations on advertising, differential cost-sharing, more stringent physician supervision requirements, restrictions on clinic locations and physical configurations or proximity to other commercial ventures, and limitations on the scope of professional services that can be provided which do not apply to the same credentialed professionals in comparable limited care settings)
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From page 471... ...
Among other provisions affect ing APNs, this would require a revision of the current CMS "Opt-Out" regulation31 for conditions of participation for anesthesia services in hospitals, critical access hospitals, and ambulatory surgical centers. Under the current regulation, even in states whose licensure laws do not require physician supervision of certified registered nurse anesthetists, CMS will not pay for an "unsupervised" CRNA's fully competent and authorized services unless the Governor of that state, after conferring with the Boards of Nursing and Medicine, certifies to the CMS that s/he has found that "it is in the best interests of the state's citizens to opt-out of the current federal physician supervision requirements, and that the opt-out is consistent with state law." • CMS should encourage state Medicaid programs to cover health care services provided by retail or convenient care clinics.
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From page 472... ...
While policy makers and other public advocates move forward with efforts to remove many of the large-scale impediments resulting from the dynamics previously discussed, there are immediate steps that can be taken improve the practice context for APNs. Several specific examples follow: • The CMS should ensure that APN practices, including Nurse-Managed Health Centers, are eligible to receive subsidies under the ARRA of 2009/stimulus funds for adoption of the Electronic Health Records sys tems currently being developed by the Health Information Technology Policy Committee, or any other HIT initiatives.
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From page 473... ...
In sum, the fundamental flaws in the regulatory framework that I have described are real, and they rob us as a nation of the full range of care options that our health care providers are capable of offering. This is particularly true of
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From page 474... ...
:1. APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee.
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From page 475... ...
Washington, DC: Association of Academic Health Centers.
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