Healthforce Center Associate Director of Research Joanne Spetz, PhD, was interviewed for a nursing website (onlinefnpprograms.com) about her research on policies, politics and nursing practice that affect nursing leaders across the country. Below are excerpts from that conversation.
Question: In your research, what were some of your principal findings in terms of the impact of expanded Advanced Practice Registered Nurse (APRN) scope of practice on patient access to health care and patient health outcomes?
Answer: One study looked at advanced practice nursing care at retail health clinics and found that scope-of-practice laws for nurse practitioners limit cost savings. We found that visits to retail clinics were associated with lower costs per episode, compared to episodes of care that did not begin with a retail clinic visit, and the costs were even lower when NPs practiced independently. We concluded that eliminating restrictions on NPs’ scope of practice could have a large impact on the cost savings that can be achieved by retail clinics. We published our findings in Health Affairs, and it was one of the few papers at that point that had really looked at whether these scope of practice regulations were costing more money.
Another study that we did was with the Office of the Assistant Secretary for Planning and Evaluation, which is part of the US Department of Health and Human Services. We did an analysis of Medicare claims data, some analyses of the National Sample Survey of Nurse Practitioners, and site visits in four states about the practice environment for nurse practitioners. We discovered that when scope of practice is less restricted, NPs are more likely to practice in rural areas, which was not surprising. We also found that there are many other policies that can impede nurse practitioners from practicing to the full extent of their knowledge.
I did a site visit in New Mexico, and learned that NPs had issues prescribing medication-assisted therapy for opioid abuse. Until just last year, Nurse practitioners were not allowed to prescribe medication-assisted treatment; which was a huge problem in New Mexico, where opioid abuse had reached crisis levels. These were federal policies–so even though we were visiting states with independence for NPs, such as New Mexico and Washington State, we were still hearing that these federal laws were in the way. NPs are now allowed to prescribe medication-assisted therapy, thanks to the Comprehensive Addiction Treatment and Recovery Act, which was passed last year.
We also found that the local culture and the culture of the medical establishment matter. There are a number of hospitals and medical centers that, for no rational reason anyone could articulate to me, do not allow NPs to admit or round on patients. There were also rural communities we visited with medical facilities that would not let nurse midwives deliver babies.
The results illustrated the fact that you can have independent scope of practice, but that it doesn’t mean federal and local community forces do not get in your way. Local organizations, stereotypes and policies can inhibit NPs and physician assistants from doing what they need to do to meet the needs of the population.
One of the principal conclusions we drew from the findings described above was that the state laws are not enough to guarantee that the population will have sufficient access to the care they need.
Question: In your own research and your review of the existing literature on APRN scope of practice, have you encountered any findings that have indicated a qualitative difference between the quality of care when it is administered by an APRN practicing independently versus a physician or a physician-supervised APRN?
Answer: Has any study shown that physician oversight of APRNs improves quality of care and yields better safety or quality? No, not at all. There is no evidence that these scope of practice regulations improve quality or safety for patients.
Now, in terms of whether an NP can provide better quality care than a doctor, in general, the research would indicate that the quality of care is pretty equal. You can find different studies that have slightly different results, and the devil is always in the details, but I would say that on average, almost every study finds high quality of care, high adherence to clinical guidelines, high evidence of appropriate prescribing and higher patient satisfaction with NPs relative to physicians.
One of my colleagues, Ulrike Muench, has been conducting a study where she looked at Medicare data, specifically at medication adherence. She found similar rates of medication adherence with patients seen primarily by NPs versus those seen primarily by physicians. She also had a study that looked at Health Care Costs Institute (HCCI) data and found that scope of practice regulations did not have any influence on medication adherence. There was no evidence that having these restrictions are beneficial.
The politics are complicated. It’s very hard to find a physician who individually does not have a tremendous amount of respect for and confidence in the NPs they have worked with. In fact, the original vision for NPs was for them to manage patient care in rural areas where there were no doctors. This vision was for them not to have supervising physicians dictating how they practiced. Many doctors have an incredible amount of trust for NPs, but their professional organizations circle the wagons and block NPs.
Follow the money for the real reason behind this.
There are a lot of issues around who is in professional power and who has control over financial resources in the health care system. The politics and the turf protection end up coming ahead of ensuring an adequate number of providers are available to allow patients to get the care they need. It’s really sad that the politics play out that way.
We’ve made a lot of progress, but still have so much work left to do.
There is a layer of politics that does not serve the best interest of our population, of our primary care needs for the future.
I applaud states like Nevada, which have modernized scope of practice policies for APRNs. While some states have had to make compromises — for example, Kentucky still requires NPs to work under a collaborative practice agreement for a few years before practicing independently — the trend is still net positive.
About Joanne Spetz: Dr. Joanne Spetz, PhD is the associate director of research at Healthforce Center at UCSF. In addition, Dr. Spetz is a professor at the Philip R. Lee Institute for Health Policy Studies, Department of Family and Community Medicine, and the School of Nursing at UCSF. Dr. Spetz’s research focuses on the economics of the health care workforce.