Nurse Practitioners and the Primary Care Shortage

Mar 20, 2013, 9:00 AM

In light of concerns about the nation’s shortage of primary care providers—which is likely to be exacerbated as health reform takes effect—many have argued that nurse practitioners (NPs) can help increase capacity. But because state laws about NPs’ scope of practice vary widely, in some places NPs may not be able to help fill the gap and satisfy demand for primary care services.

A new report from the National Institute for Health Care Reform examines the scope-of-practice laws and payment policies that affect how and to what extent NPs can provide primary care. The report examines laws across six states (Arkansas, Arizona, Indiana, Maryland, Massachusetts and Michigan) that represent a range of restrictiveness. The National Institute for Health Care Reform is a nonprofit, nonpartisan organization that conducts health policy research and analysis.

Rather than spelling out specific tasks NPs can perform, scope-of-practice laws generally determine whether NPs must have physician supervision. Requirements for documented supervision—collaborative agreements—are seen “as a formality that does not stimulate meaningful interaction between NPs and physicians,” according to the report. Collaborative agreements can limit how NPs are used in care settings or prohibit them from acting as the sole care provider, and can limit NPs’ range or number of practice settings, which can have serious consequences for underserved rural communities, the report says.

Payer policies can also discourage NPs from practicing to the full extent of their education and training. “Many NP respondents reported that payer policies had more of an impact than [scope-of-practice] laws on how and where they can practice,” the report says. “However, research has found that the level of restrictiveness in state scope-of-practice laws appears to be associated with the level of autonomy granted to NPs through public and private payer policies.” Payer policies may also stop NPs from establishing their own practices—even if they are allowed under scope-of-practice laws—because of a lack of direct payment or low payment rates.

States should reexamine their scope-of-practice laws, and other laws and regulations that restrict the use of NPs in primary care settings, the report concludes, particularly in places where there is a shortage of providers or an imminent shortage. Policy-makers might also want to consider measures like “explicitly granting NPs authority as primary care providers under Medicaid or encouraging health plans to pay nurse practitioners directly.”

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.