A federal agency is urging state lawmakers to think twice before putting new restrictions on advanced practice registered nurses (APRNs), a move that proponents say will help increase consumer access to health care.
In March, the Federal Trade Commission (FTC)—the government agency that works to protect consumers and prevent anticompetitive business practices—released a policy paper that warns that barriers to APRN practice could reduce the kind of free-market competition in the health care industry that benefits consumers. “Even well intentioned laws and regulations may impose unnecessary, unintended, or overbroad restrictions on competition, thereby depriving health care consumers of the benefits of vigorous competition,” the paper states.
APRNs, it adds, play a “critical role” in alleviating shortages of primary care providers and expanding access to health care for medically underserved populations. Expanded APRN scope of practice, it concludes, is “good for competition and American consumers.”
It’s good for business, too, says Micah Weinberg, PhD, senior policy advisor at the Bay Area Council, a business-sponsored public policy advocacy organization in San Francisco. Access to health care is critical for workers and communities, he says. “If we don’t have healthy communities, we don’t have healthy consumers, and we won’t have a healthy workforce.”
Historically, physicians have operated under an extremely broad legal definition of their scope of practice, according to Barbara Safriet, JD, LLM, a visiting professor of law at Lewis & Clark Law School in Portland, Ore. Nurses have, as a result, had to “carve out” the right to perform certain roles and functions, and they have had different results in different states, she writes in a landmark report on the future of the nursing profession that was released in 2010 by the Institute of Medicine (IOM).
This has led to what Safriet calls a “crazy quilt” of state laws that “makes no logical sense.” In some states, she notes, APRNs are “permitted to examine patients, order and interpret laboratory and other tests, diagnose and treat illness and injury, prescribe indicated drugs, order or refer for additional services, admit and attend patients in a hospital or other facility, and get paid directly” for their services. But in others, they face a litany of restrictions on these practices. The difference, she adds, has to do with state-level politics rather than the capabilities of nurses.
The FTC report buttresses national efforts to remove barriers to APRN practice to improve health and health care. That is a key recommendation of the IOM report, which serves as the foundation of the Future of Nursing: Campaign for Action, a collaborative effort of the Robert Wood Johnson Foundation (RWJF) and AARP that is working to transform health care through nursing.
“This is yet another piece of evidence in support of the APRN cause,” Weinberg says.
Catherine Dower, JD, health policy and law director at the Center for the Health Professions at the University of California at San Francisco, agrees. The report is especially valuable, she says, because it comes “from a highly respected entity ... that doesn’t have a vested interest in one side or another.”
There is opposition to expanded APRN practice. The American Medical Association (AMA) opposes lifting restrictions on APRN practice because leaders say it will compromise the quality and safety of care and will not solve the physician shortage problem. “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,” AMA board member Rebecca Patchin, MD, said in a statement in response to the IOM report.
The new FTC paper, however, cites the IOM report and other evidence showing that APRNs provide “safe and effective care within the scope of their training, certification, and licensure.” It is entitled Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses.
‘Competition Controls Costs’
The FTC has long promoted competition in the health care industry because it helps to control costs, improve quality, spark innovation, and expand access to services and goods, according to the paper.
In the last three years, the FTC has issued competition advocacy comments about proposed changes to APRN regulations in Massachusetts, Connecticut, West Virginia, Louisiana, Kentucky, Texas, and Florida. “As agency staff issued advocacies regarding individual state requests for comment, it was felt that a policy paper would help inform the agency’s consideration of future requests, stakeholders in those states, and others, and the larger policy discussion within which those advocacy requests are made,” FTC spokesman Frank Dorman said.
Dower called the paper a “bold step” but said it isn’t surprising “given the smaller steps they’ve taken over the past several years.”
The paper, she hopes, will discourage legislators from enacting new laws that unnecessarily limit APRN practice.
The trend has been going in the opposite direction, with states slowly taking steps to loosen restrictions on APRN practice, Dower notes. Still, APRN restrictions are in place in many states. Only 17 states and Washington, D.C., for example, allow nurse practitioners (NPs) to practice to the top of their competence, according to the American Association of Nurse Practitioners.
Furthermore, there’s always the potential for reversals, added Joanne Spetz, PhD, professor and associate director for research strategy at the Center for the Health Professions at the University of California at San Francisco.
“Historically, there’s been a fear that if you open up scope-of-practice legislation, you actually could end up with something worse than you started with,” she says, citing a bill introduced last year in California that initially was designed to expand NP practice but was amended during the legislative process so that it may have led to more restrictions. The bill died in committee.
“The FTC document sets the stage when legislators take on these issues,” Spetz said. “It gives them much more of a justification to prevent a backslide.”