Patients Slowly Gaining Access to Care Provided by Advanced Practice Registered Nurses

    • January 15, 2014

In the summer of 2009, Susan Delean-Botkin, a nurse practitioner (NP), faced a conundrum: Maryland law required her to get a physician to sign a patient’s death certificate, but the doctor whose signature she needed was nowhere to be found. He had literally “gone fishing.”

Facing a 24-hour deadline to get the physician’s signature, Delean-Botkin, MSN, CRNP, past president of the Nurse Practitioner Association of Maryland, did not give up. She got in her family’s whaler and began a search on the Choptank River, a tributary of the Chesapeake Bay. She eventually found the doctor on the river, got his signature, and headed back to her office.

Delean-Botkin told that story later that year to state legislators while testifying in support of a bill designed to loosen restrictions on advanced practice nursing. The tactic worked; in 2010, Maryland replaced its requirement for lengthy collaborative agreements between NPs and physicians with less cumbersome “attestation statements” that identify a physician who is willing to collaborate when clinically necessary but do not require physician signatures.

The new law has made a “huge” difference, Delean-Botkin said. “This has eliminated the terrible situations where a physician would die, retire, or leave the state, and the patients were abandoned because the NP could not practice without the specific collaborating physician in place,” she said. “NPs can now open practices and serve larger patient populations. This has helped with the primary care shortage in Maryland.” 

Other states have also taken steps to unleash advanced practice registered nurses (APRNs) from restrictions in recent years.

In 2013, Nevada removed a requirement that APRNs work under the supervision of physicians and expanded their prescriptive authority. Rhode Island enacted legislation that expands the type of medications APRNs can prescribe. In Utah, state Medicaid officials agreed to recognize and reimburse NPs for primary care services for beneficiaries. Oregon’s governor signed a law that allows NPs and clinical nurse specialists to dispense prescription drugs. And in Iowa, the state Supreme Court ruled that NPs can supervise fluoroscopy, a high-tech X-ray, without physician supervision.

In 2012, a Colorado appeals court ruled that certified registered nurse anesthetists (CRNAs) can provide anesthesia services to Medicare patients without physician supervision at certain health care facilities, and Massachusetts passed a law allowing certified nurse midwives to write prescriptions and order and interpret tests and therapeutics.

In 2011, North Dakota scrapped a requirement that NPs work in collaboration with physicians, and Kentucky became the 17th state to exempt certain health care facilities from the requirement that CRNAs practice under physician supervision.

Picking Up Steam

Changes like these suggest that the national movement to empower APRNs and improve patient access to care is picking up steam, according to Donna Shalala, PhD, FAAN, president of the University of Miami in Florida and former head of the U.S. Department of Health and Human Services. “The movement and the change [are] real,” she said in a recent speech at the Institute of Medicine (IOM).

In 2010, Shalala served as chair of the Committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing at the IOM, which released a report in 2010 that called for a transformation of the nursing profession, including the removal of barriers to nursing practice. Enabling nurses to practice to the full extent of their education and training will increase access to care and improve the quality and safety of care, the Committee said.

There is opposition. The American Medical Association has opposed efforts to grant more power to APRNs. “A physician-led team approach to care, with each member of the team playing the role they are educated and trained to play—helps ensure patients get high quality care and value for their health care spending,” the group said in response to the IOM report on the future of nursing. “Increasing the responsibility of nurses is not the answer to the physician shortage.”

But leading health experts disagree. “To those who say these barriers have to do with quality and patient safety, I say ‘Nonsense,’” Shalala said. “If we want evidence-based medicine, then we have to apply the evidence to that question. And the evidence is there: Nurses with first-class training can do all the things we need them to do, and we need them to work up to their training.”

Patients will be the ultimate beneficiaries of a reformed practice landscape, noted Susan Hassmiller, RN, PhD, FAAN, RWJF’s senior adviser for nursing. “When antiquated laws prevent highly educated nurses from doing all they are trained to do, patients wait needlessly for prescriptions they need, get their test results—and thus their follow-up care—later than necessary, and many do not learn the best ways to avoid and manage their diseases,” she wrote in a post on the RWJF Human Capital Blog.

The American Nurses Association’s senior policy fellow of nursing practice and policy, Andrea Brassard, PhD, FNP-C, FAANP, agrees. “When APRNs are prevented from practicing to their full capacity by unnecessarily burdensome supervision requirements, patients and their insurers incur unnecessary delays and increased costs.”

Carmen Alvarez, PhD, RN, NP-C, CNM, the Julio Belber Postdoctoral Fellow in the Department of Health Policy at the George Washington University in Washington, D.C., also agrees. A few years ago, Alvarez performed an assessment on a patient at a community health center in Michigan who was filing for asylum in the United States. Alvarez identified the patient as a victim of female genital mutilation, which can serve as grounds for a successful asylum claim.

A few weeks later, though, Alvarez was notified that her assessment wasn’t valid because it lacked the signature of a physician, a legal requirement in the state. The patient was forced to make a repeat appointment for the same visit with a physician, which added to the time and cost associated with care and delayed the patient’s application for asylum, Alvarez said.

Restrictions on advanced nursing practice, Alvarez added, have the potential to undermine efforts to expand access to care. “We already have a shortage of primary care providers,” she said. “How is expanding health insurance helpful if patients can’t get in to see anyone?” Restrictions, she added, “definitely limit people’s options.”

After the IOM report was released, RWJF and AARP came together to launch the Future of Nursing: Campaign for Action, which aims to ensure that everyone in America can live a healthier life, supported by a system in which nurses are essential partners in providing care and promoting health. Freeing nurses to practice to the top of their licenses is a key goal of the campaign, especially as the nation’s population ages and as millions more people gain access to health care insurance coverage under the Affordable Care Act.

“Public opinion has actually shifted” in support of the movement to expand nurses’ scope of practice, Shalala said. “We’ve got editorial board support, and a lot of leaders ... have written reports and taken a stand. And I believe we’re going to see a lot more progress before all is said and done.”

John Rowe, MD, a professor in the department of health policy and management at Columbia University Mailman School of Public Health, agreed. It is “now becoming clear that nursing will succeed in the effort to eliminate barriers to full scope of practice” he said in a speech last year to the American Association of Colleges of Nursing.

Nurses’ Practice Still Restricted

Still, many consumers lack unfettered access to care provided by APRNs.

At the federal level, Medicare does not allow APRNs to authorize patients for home health services or initial hospice care without a physician’s certification, a requirement that critics say delays needed care and may result in hospitalizations that could have been avoided.

Two-thirds of the states (33), meanwhile, do not allow NPs to practice without physician supervision. And even in states that do, NPs aren’t always able to practice independently. Some insurers are declining to accept nurses with advanced degrees into their credentialed networks as primary care providers, according to a recent story on Kaiser Health News, and others are limiting NP practice to rural areas.

“All patients in all settings should have access to nurses, no matter where they live,” Brassard said. “Just because an APRN moves to another state, she or he doesn’t forget what they know how to do.”

Efforts to empower APRNs have also suffered some recent defeats. In California, for example, a bill that would have enabled NPs to practice without physician supervision died in the state Legislature last year. State legislators are likely to consider the issue again in 2014.

But proponents are optimistic about overall prospects. “I’m very encouraged,” Brassard said. “APRNs are very persistent patient advocates.”