States (and DC)Allowing Nurse Practitioners Full Autonomy |
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Bills in Connecticut and Kentucky failed to pass this year after fierce opposition from state medical organizations. Lawmakers in both states vow to offer similar measures next year. New York lawmakers proposed a bill granting full independence to NPs this year, but it was never scheduled for a hearing.
Democratic Assemblywoman Maggie Carlton, the lead sponsor of Nevada’s scope of practice law, said it took three legislative sessions and six year before “we could get the right people to talk about the right topics at the right time.”
Carlton said she has “faith in nurse practitioners that they will practice up to the top of their license, and when they get there, they will refer to the next level of care just like a general practitioner refers to a specialist.”
Filling a Void
According to the federal Health Resources and Services Administration, or HRSA, at least 55 million Americans live in areas with an inadequate supply of primary care doctors. Massachusetts has the most primary care doctors per capita; Mississippi has the fewest.
The nation would need more than 15,000 additional providers to meet the target ratio of one primary care practitioner for every 3,500 residents, according to HRSA, a gap that cannot be filled with physicians.
The Association of American Medical Colleges predicts a worsening shortage ahead. In the next 10 years, as one-third of all doctors retire, there will be 90,000 fewer doctors than needed to serve the nation’s aging population. Half of the shortage will be in primary care.
Nationwide, 117,000 physicians practiced family medicine in 2012, according to the Kaiser Family Foundation; 134,000 nurse practitioners practiced primary care, according to the American Association of Nurse Practitioners. Last year, only 1,916 U.S. medical school graduates, or about 12 percent of the total, went into primary care residency programs, according to the nonprofit research group National Resident Matching Program. Nursing school graduates who went into primary care totaled 11,764 in 2012, about 84 percent of all NP graduates.
But will relaxing state NP licensing laws improve patient access to care? A study reported this month in the journal Health Affairs says yes. The authors found that between 1998 and 2010, as more states relaxed licensing laws, the number of patients receiving care from NPs increased by a factor of 15.
Physician Objections
The American Medical Association and other physician groups argue that NPs lack the same level of medical training — four years of medical school plus three years of residency compared to four years of nursing school plus two years of graduate schools for NPs. The gap in training, the doctors insist, means that NPs cannot safely provide the same services as doctors.
Research tells a different story. Studies have shown that primary care provided by nurse practitioners has been as safe and effective as care provided by doctors. A 2010 report from the Institute of Medicine points to 50 years of evidence confirming that conclusion.
Supporters point out that doctors, particularly those in private practice, have a financial incentive to limit nurses’ independence. Often carrying heavy medical school loan debt, doctors are loath to see money diverted to competing health care services. The Federal Trade Commission has weighed in on several state battles over scope of practice, arguing that physician groups have no valid reason for blocking such laws other than to thwart competition.
Supporters also argue that the practice of family medicine has changed in the past 20 years, making the training and skills of NPs even more appropriate for the job. In the earlier days of family medicine, doctors treated a wide variety of illnesses, set bones and performed minor surgery. Today, most spend their days treating common colds, managing diabetes, hypertension and other chronic diseases, and diagnosing and referring patients to specialists.
Another change is the way primary care doctors are paid. As an increasing number of physicians join large practices or work for hospitals, some predict that they will be less concerned about whether they are losing business to nurse practitioners. A recent study from The Physicians Foundation, a nonprofit advocate for practicing doctors, reported that one state medical society director said that 60 percent of his members were now employed by large institutions or practices, and they did not oppose expanding nurse practitioners’ scope of practice. “The independents are still very vocal,” he said.
*Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.
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