The Federal Trade Commission (FTC) recently issued a policy paper urging state legislators to carefully evaluate proposals that limit nurse practitioners’ scope of practice. Nurse practitioners (also known as Advanced Practice Registered Nurses, or APRNs) are registered nurses who have been both educated and received specialized training beyond the requirements for a registered nurse. Notably, the FTC paper concluded that expanding the scope of APRN practice would create more competition in the health care sector – helping to control costs, improve quality, promote innovation, and expand access to care.
The FTC relied heavily on an Institute of Medicine (IOM) report issued in 2011, which indicated that state restrictions on APRNs vary widely for political reasons that have little to do with an APRN’s education and training or patient safety concerns. Building on this report, the FTC recommended state legislators and policymakers focus on the following factors when evaluating APRN scope of practice limitations:
• Patient access to safe and effective health care is of critical importance.
• State licensure requirements should focus on services APRNs can safely and effectively provide based on their education, training, and experience.
• A lack of compensation in the health care industry can have serious health and safety consequences, particularly in medically underserved areas.
• Effective collaboration between APRNs and physicians does not always require direct physician supervision.
• Scope of practice limitations should be narrowly tailored to address well-founded health and safety concerns, and should not be more restrictive than patient protection requires.
• Safety and quality evidence should be carefully scrutinized to determine if legitimate safety concerns exist and if so, whether physician supervision requirements or other regulatory interventions are likely to address them.
According to the American Association of Nurse Practitioners, only 19 states and the District of Columbia allow for full independent APRN practice, including the ability to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments and prescribe medications. Restrictions in the remaining states may limit or prohibit an APRN’s authority to prescribe medications, admit patients to hospitals, assess patient conditions, and order and evaluate tests.
Further, many states require an APRN to have a supervisory relationship or written collaborative practice agreement with a physician in order for the APRN to practice. For example, Missouri is one of the most restrictive states for APRN practice. In Missouri, an APRN must work under a collaborative practice agreement with a supervising physician. The physician must practice on-site with the APRN for a minimum of one month, after which certain geographic restrictions apply. After the one-month period is complete, additional restrictions regarding on-site follow-up patient care and chart reviews come into play.
Despite pushback from state medical associations, support for expanding APRN scope of practice appears to be growing as a means to address primary care physician shortages, particularly in medically underserved areas. The FTC policy paper provides more food for thought for state legislators considering these issues, and suggests that reductions in state restrictions on APRN scope of practice are only a matter of time.