On March 14, California lawmakers rejected a popular plan to give all state residents government single-payer healthcare. This action frustrated Democratic activists, who have increasingly rallied behind dramatic reforms. But with millions unable to afford insurance and one in five Americans living in a community with a shortage of primary care right now, perhaps California policymakers should look to the example of states like Pennsylvania, which are examining more basic reforms. PA legislators are considering the simple idea of allowing nurse practitioners (NPs) to do what they are already trained to do.
Early in January, the Federal Trade Commission (FTC) submitted comments supporting Pennsylvania H.B. 100. The proposed bill eliminates a requirement that experienced NPs be in a collaborative practice agreement with a physician. Requiring practicing NPs to be supervised by a physician unnecessarily limits NP effectiveness and restricts patient access to primary care.
In its comments, the FTC quotes a study estimating the Pennsylvania bill would generate around $6.4 billion in healthcare savings over ten years, as well as increase the state supply of NPs by 13 percent. But, though it is receiving bipartisan support, experience from other states shows that the legislative fight will be difficult.
Proposals like H.B. 100 are nothing new. Every year, advocates for better healthcare urge their states to consider legislation expanding NP scopes of practice––the range of duties NPs are legally allowed to perform without physician oversight. The idea is to let NPs perform the tasks they are trained to perform independently, giving them more freedom to practice in areas that need it the most.
However, these expansion efforts are often unsuccessful. In the 2015-2016 legislative session, there were 68 state bills introduced by state legislatures relating to NP scope of practice. Only nine passed.
One reason giving NPs more freedom under the law is such an onerous task is because physician associations lobby heavily against it. These are special interest groups, representing only a small number of physician specialists, who are threatened by the prospect of competing with NPs. They argue that NPs simply do not have as much training as physicians and thus cannot be trusted with more independence.
While it is obviously true that NPs do not have as much training as physicians, this is no reason to keep them from work that they are more than qualified to perform. Around 85 percent of NPs are trained in primary care, and 77 percent currently deliver primary care. Meanwhile, only one-third of active physicians specialize in primary care. By letting NPs work to the full extent of their training, physicians are freed up for tasks only they have the specialized training to perform.
Unfortunately, many states like California refuse to enable access to more care for more patients. Thanks largely to scope of practice restrictions and an oversupply of specialist physicians, nearly half of the appointments fielded by specialists in the United States are for routine follow-up or preventative care—the types of appointments NPs could very well handle. This gross inefficiency balloons healthcare costs. Patients with NP primary care providers cost 11 to 29 percent less than the patients with a physician primary care provider.
Opponents of scope of practice expansion fear giving NPs more freedom is dangerous for patients. While well-intentioned, these fears are unfounded. Nearly two dozen states already allow NPs to prescribe medication and operate their own practice without physician supervision, to no disastrous effect.
In some of these states, like Alaska and New Hampshire, NPs have had full license authority since the 1980s. Far from seeing adverse outcomes, states that let their NPs work freely have seen better access to primary care. Better access to primary care, many studies suggest, leads to generally healthier populations and lower healthcare costs.
States that let their NPs work also see equivalent outcomes in patients cared for by physicians and those cared for by NPs. One report aggregating results from 37 different peer-reviewed studies published between 1990 and 2009 thoroughly corroborates this finding. It concludes that patient outcomes in satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure, and mortality are all similar under independent NPs and MDs.
Physicians need not oppose the push for lower healthcare costs and increased access. Though legislation like H.B. 100 aims to end mandatory collaborative practice agreements, it does nothing to discourage the natural collaboration physicians and NPs engage in all the time. Independent NPs still write referrals and consult specialists. They are also still regulated by nursing boards, a check that ensures NP practice standards will remain rigorous and safe.
Considering that physicians spend nearly two-thirds of their time doing paperwork, they should breathe a sigh of relief when red tape is cut. For them, NP independence means more time with patients. It also means less time worrying about being held responsible for any malpractice NPs commit under the physicians’ limited watch.
With rising costs and limited access to primary care, states cannot afford to have any healthcare professionals on the sidelines. Before considering dramatic solutions like adopting a single-payer system, state legislators should first try fully utilizing their health workforce. They should ignore the pleas from special interest groups, and let their nurse practitioners work.
Christian Barnard is a Young Voices Advocate and a policy researcher based in Boston, MA. Follow him on twitter @CBarnard33.