FTC Report on APRN Practice Demands Our Attention

May 2, 2014, 9:00 AM

Margo Brooks Carthon, PhD, APRN, is an assistant professor in the School of Nursing at the University of Pennsylvania and a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar.

The Federal Trade Commission (FTC) created quite a stir when it released a recent report in support of expanded scope-of-practice (SOP) regulations for advanced practice registered nurses (APRNs)1. Why after all, would the FTC—an agency charged with protecting consumers—take an interest in the regulatory woes of nurses?

Because unnecessary restrictions on APRN practice have the potential to undermine competition in the health care market and impede consumer access to care. That, at least, is the conclusion of the FTC, which released a policy paper making that argument in March entitled Competition and the Regulation of Advanced Practice Nurses.

The FTC aims to prevent unfair methods of competition and unfair, deceptive acts or practices in (or affecting) commerce. Overly restrictive SOP regulations on APRNs may be an example of anti-competitive conduct, the FTC argues, because they may prevent nurse practitioners (NPs) and other APRNs from entering the health care market as providers of care that patients need.

The report also argues that while SOP policies may be intended as a form of consumer protection, they may have the opposite effect. Decades of research link APRNs to safe, high-quality, and cost-effective care. That extensive body of evidence makes it difficult to support the many restrictive SOP regulations that are in place in many states.

The major question the report tackles is: “Do current SOP laws and regulations impair competition?”  Competition, it argues, is good for the health care market, as it is for the larger economy, because it can spur improved quality and help contain costs. While the authors of the report do not necessarily advocate for a single uniform model or standardization of SOP regulations, they are in favor of less restrictive regulations, particularly in light of the distributional problems in the supply of health care professionals.

Health care provider shortages are a real concern, especially for individuals living in primary care deserts. These individuals (many of whom are low-income and on Medicaid) are among the 65 million people living in areas that lack sufficient numbers of health care providers. The FTC report, coupled with other research, has linked states with excessive SOP regulation to barriers in accessing primary care2.

The FTC report also contends that excessive supervision and collaboration requirements may undermine access to care. Restrictive collaboration regulations can take a number of forms. Some states, for instance, require that NPs practice within a certain distance of a collaborating physician. Other states limit the number of NPs physicians can supervise. These regulations differ from state to state, often with no clear safety or quality data to support them. It is easy to see how such requirements could present a challenge in some rural or urban communities, where the nearest doctor can be many miles away.

The FTC report also argues that restrictive collaborative practices turn physicians into “gatekeepers” who control access to the market. Such practices may exacerbate the projected health care “bottleneck,” in which demands for health care outpace the supply of providers—and that, the report argues, is anti-competitive.

Current projections indicate that the supply of APRNs will nearly double between 2008 and 2025, from 128,000 to 244,0003. Many APRNs will enter primary care practice in communities with high proportions of Medicaid beneficiaries. At the same time, a 2008 survey demonstrated that a mere 2 percent of medical students were interested in careers in general practice4. Scarce health provider resources and the projected increase in consumer demands as a result of the Affordable Care Act (ACA) requires regulatory practices that are tailored to meet well established health and safety concerns. Regulations, according to the FTC report, should not be more restrictive than necessary.

The FTC report makes a timely entrance into the current debate over how to transform our health care system. It charges that fixed or mandatory supervision requirements may constrain innovation—a concept that is central to the transformation in health care that is envisioned by the ACA. Patient-centered medical homes for example, are a fixture of the ACA. These medical homes aim to provide comprehensive primary care that is evidence-based, high-quality, and holistic5. While the ACA defers to states to determine if APRNs can lead health care teams, based on state SOP regulations and laws, it states that they should not be prevented from leading primary care teams.

The American Academy of Family Physicians recently recommended that patient-centered medical homes be led by physicians6. The position laid out in the 2014 FTC report asserts the opposite; it argues that health care organizations that employ APRNs should have the flexibility to determine their own protocols for the use of APRNs. These protocols should be based on the needs of the consumers and the expertise and skills of providers. APRNs, prepared at the master’s or doctoral levels, are required to hold national certification and to demonstrate an interest in providing primary care services in medically underserved communities.

Moreover, while the educational pathways between physicians and APRNs differ, the outcomes associated with their care do not. Study after study has demonstrated that APRNs provide safe, high-quality, cost-effective care. In addition, recent surveys suggest that a majority of consumers are open to being seen by NPs or physician assistants, and some even state a preference for seeing these types of providers over physicians7,8.

If increased access to care, cost savings, and improved quality are what consumers need and want, then there are many reasons that we should pay attention to the recent FTC report.



1. Gilman, D.J., Koslov, T.I.  (2014). Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses. Retrieved from the Federal Trade Commission Website: http://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced-practice-nurses/140307aprnpolicypaper.pdf

2. Kuo, Y. F., Loresto, F. L., Rounds, L. R., & Goodwin, J. S. (2013). States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Affairs32(7), 1236-1243.

3. Auerbach, D. I. (2012). Will the NP workforce grow in the future?: New forecasts and implications for healthcare delivery. Medical care50(7), 606-610.

4. Hauer, K. E., Durning, S. J., Kernan, W. N., Fagan, M. J., Mintz, M., O’Sullivan, P. S., ... & Schwartz, M. D. (2008). Factors associated with medical students' career choices regarding internal medicine. Jama300(10), 1154-1164.

5. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4105, 2717. (2010).

6. American Academy of Family Physicians.  (2012).  Primary Care for the 21st Century: Ensuring a Quality, Physician-led Team for Every Patient.  Retrieved from: http://www.aafp.org/dam/AAFP/documents/about_us/initiatives/AAFP-PCMHWhitePaper.pdf

7. Dill, M. J., Pankow, S., Erikson, C., & Shipman, S. (2013). Survey shows consumers open to a greater role for physician assistants and nurse practitioners. Health Affairs32(6), 1135-1142.

8. Aiken, L.H.  (2013, October 3).  Consumer Preferences Toward Non-Physician Providers.  [Weblog comment].  Retrieved from: http://ldi.upenn.edu/voices/2013/10/03/consumer-preferences-toward-non-physician-providers  

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