Expanding Opportunities for Rural Communities to Get Quality Care

by Susan Hassmiller, PhD, RN, FAAN, Senior Adviser for Nursing, Robert Wood Johnson Foundation 

The full version of this post is on the Robert Wood Johnson Foundation’s Culture of Health blog.

I read recently in The New York Times about Murlene Osburn, a cattle rancher and psychiatric nurse, who will finally be able to start seeing patients now that Nebraska has passed legislation enabling advanced practice nurses to practice without a doctor’s oversight.

Osburn earned her graduate degree to become a psychiatric nurse after becoming convinced of the need in her rural community, but she found it impossible to practice. That’s because a state law requiring advanced practice nurses to have a doctor’s approval before they performed tasks—tasks they were certified to do. The closest psychiatrist was seven hours away by car (thus the need for a psychiatric nurse), and he wanted to charge her $500 a month. She got discouraged and set aside her dream of helping her community.

I lived in Nebraska for seven years, and I know firsthand that many rural communities lack adequate health services. As a public health nurse supervisor responsible for the entire state, I regularly traveled to small, isolated communities. Some of these communities did not have a physician or dentist, let alone a psychiatric nurse. People are forced to drive long distances to attain care, and they often delay necessary medical treatment as a result—putting them at risk of becoming even sicker, with more complex medical conditions.

Read the rest of Hassmiller's post on the Culture of Health blog.

Nurses Succeeding in Bone Marrow Biopsy Program

A nurse-led bone marrow aspiration/biopsy program is providing evidence that the use of procedurists is good for patient outcomes and good for clinical practice, according to a presentation at the Oncology Nursing Society’s 40th Annual Congress in Orlando, Florida. The presentation was titled Multidisciplinary Development of a Bone Marrow Aspirate and Core Biopsy Performed by Registered Nurses.

This use of nurse procedurists in bone marrow biopsies “demonstrates an innovative partnership for clinical practice, as recommended by the Institute of Medicine (IOM),” said Daravan Kao of the Seattle Cancer Care Alliance. The IOM’s landmark 2010 report, The Future of Nursing: Leading Change, Advancing Health, states that nurses “should practice to the full extent of their education and should be full partners in the redesigning of health care delivery,” Kao continued.

Registered nurses who participated in the bone marrow program maintained a 98 percent score, as rated by pathologists, for the quality of the samples they collected. Furthermore, there were no reported incidences of post procedure complications, Oncology Nurse Advisor reports.

A multidisciplinary team developed and implemented the biopsy program, which included didactic training, technical skills acquisition, and ongoing quality assurance.

States Benefit from Increased Autonomy for Nurses

States that allow Advanced Practice Registered Nurses (APRNs) to practice independently saw an improvement in health outcomes for patients and decreases in costs to Medicare and Medicaid, according to a study by researchers at the Missouri University Sinclair School of Nursing, Nurse.com reports.

The study, “Impact of Nurse Practitioners on Health Outcomes of Medicare and Medicaid Patients,” was published in the November-December issue of Nursing Outlook. Researchers analyzed previous studies with data on Medicare and Medicaid patients and found that states with full practice of nurse practitioners have lower hospitalization rates in all of the groups examined.

An INQRI-funded study, "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics,” found similar cost savings at retail clinics in states where nurses had more independence. The study, co-led by Joanne Spetz and Stephen Parente, found that visits to nurse-managed retail clinics were associated with lower costs, and the costs were even lower when Nurse Practitioners (NPs) practiced independently. The researchers 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.

INQRI Brief: Non-Physicians Can Address Primary Care Shortage

A pending primary care shortage may be best addressed by implementing promising strategies that fully utilize non-physician health care professionals in new systems of care, according to a new research brief co-authored by INQRI Co-Directors Mary Naylor and Mark Pauly with Janet Weiner.

With approximately 30 million people expected to gain coverage through the Affordable Care Act (ACA), demands on primary care services will no doubt grow. The brief, Primary Care Shortages: It’s More Than Just a Head Count, examines how the ACA will affect the delivery of primary care, and reviews recent research on the primary care shortage and possible strategies to address it.

The brief outlines several strategies that show promise for addressing these demands. Among them is ACA’s investments in health professional education and training to increase the number of primary care providers, including nurse practitioners and physician assistants. Other models, like retail clinics could ensure that more people can access primary care services, particularly in rural areas.

Ultimately, allowing health care providers to practice to the full extent of their education and training is central to increasing access to primary care, the authors write.

An article on the brief from RWJF’s December 2014 Sharing Nursing’s Knowledge is available here.

Supreme Court Ruling in Federal Trade Commission Case Will Have Broad Implications for Scope of Practice Regulations

By Joanne Spetz, PhD

Last week, the U.S. Supreme Court heard arguments in North Carolina State Board of Dental Examiners v. Federal Trade Commission (FTC), a case that will have significant implications for scope of practice regulations across the country.   At the center of this case is the “state-action doctrine,” which provides immunity from federal antitrust liability for certain state-mandated activities. In this case, the FTC had filed a complaint regarding the Board’s efforts to stop non-dentists from offering teeth whitening services. The North Carolina Dental Board asserted state-action as a defense. The case centers on how the Board operates and whether its operations fall under the state-action doctrine. The FTC believes that the board, which is comprised mainly of practicing dentists, exceeded its authority and its actions were a private effort to eliminate competition from non-dentists – a violation of anti-trust law. The Board believes it is acting as a regulatory body to ensure consumer safety.

Last spring, the 4^th Circuit Court of Appeals agreed with the FTC; the Board appealed to the Supreme Court. This case gives the Supreme Court an opportunity to decide whether health professions boards in general, which are usually established by state legislatures but whose members are private actors, fall under the state-action doctrine. If the Supreme Court sides with the FTC, it could have a significant impact on the capacity of dental, medical, nursing, and other boards to regulate health care services, especially when a compelling public safety argument cannot be made.  The Supreme Court’s decision also could provide clear guidance to states in how their boards can be appointed and function in order to adhere to anti-trust law. To follow the case’s history, look here. 

This same issue was addressed last June at an FTC public workshop in Washington, DC, titled, “Examining Health Care Competition.”  The workshop topics included professional regulation of health care providers, health care delivery innovations such as retail clinics, health information technology, health care quality, and price transparency. The meeting room was full for most of the two-day event, but attendance appeared greatest for the first session, “Professional Regulation of Health Care Providers,” for which I was one of the presenters. 

The session did not address any specific legal action related to health professions regulation, focusing instead on providing an overview of several important aspects of health professions regulation.  Barbara J. Safriet, JD, LLM, a Visiting Professor of Health Law and Lewis and Clark Law School, discussed the history of health professions regulation and the potential for legal collusion and hindrance of competition. Morris Kleiner, PhD, from the University of Minnesota, discussed health professions regulation in the context of professional regulation in general. He noted that health professions boards are often based at the same agencies as many other professions’ boards, so a single organization is charged with overseeing physicians, nurses, cosmetologists, pet groomers, and myriad other professions. Gail Finley of the Colorado Hospital Association discussed particular challenges that state faced regulating nurse anesthetists, and the battle between physicians and nurses regarding safe anesthesia care in rural communities. I discussed the impact of scope of practice regulations for licensed practical/vocational nurses on the demand by hospitals and nursing homes – we found that in states with stricter regulations, there is lower demand.

The FTC published a Policy Perspective paper in March 2014 on “Competition and the Regulation of Advanced Practice Nurses.”  The paper’s authors reviewed the rationale for establishing scope of practice regulations, noting that there are valid reasons to control scope of practice, even if it might reduce competition. However, they wrote: “…the FTC staff has consistently urged state legislators to avoid imposing restrictions on APRN scope of practice unless those restrictions are necessary to address well-founded patient safety concerns. Based on substantial evidence and experience, expert bodies have concluded that ARPNs are safe and effective as independent providers of many health care services within the scope of their training, licensure, certification, and current practice. Therefore, new or extended layers of mandatory physician supervision may not be justified.”

Unsurprisingly, there is great interest in the Supreme Court case throughout the health care industry. Among the entities that have filed amici briefs, are the American Dental Association, Federation of State Boards of Physical Therapy, American Association of Nurse Anesthetists, Association of Dental Support Organizations, Cato Institute, Pacific Legal Foundation, National Governors Association, California Optometric Association, and Public Citizen, and 23 states.  A decision is expected next year.

Joanne Spetz is a professor at the Philip R. Lee Institute for Health Policy Studies and associate director of research strategy for the Center for the Health Professions at the University of California, San Francisco.

Expanding Scope of Practice for NPs could save California nearly $2 Billion

Over the next 10 years, California could improve patients access to health care and save $1.8 billion in medical costs if nurse practitioners (NPs) were allowed to practice to the full extent of their education and training, according to a new report from the Bay Area Council Economic Institute funded by the Robert Wood Johnson Foundation and AARP. INQRI grantee Joanne Spetz contributed to the report.

According to the Council, with 3.3 million more Californians having access to health insurance under the Affordable Care Act, allowing NPs to practice independently from doctors is "one of the most effective steps" the state could take to meet the expected increase in demand for primary care providers, FierceHealthcare reports. Expanding scope of practice would increase the number of NPs practicing by 24 percent and would also allow more currently medically underserved communities to gain access to care.

The report reveals that full practice authority for NPs is associated with lower costs for common procedures and does not decrease quality of care: "In states with limited NP practice authority, the average cost for a preventative care visit can be as much as $16 higher than in states with full practice authority. We estimate scope of practice reform in California would save $1.8 billion in the cost of preventative care visits alone over the first ten years."

• The Council's report is available here.
• A statement on the report from the California Association for Nurse Practitioners is available here.

The INQRI-funded study "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics” was co-led by Spetz and Stephen Parente.

INQRI in the News

The Healthcare Economist blog provides an analysis of the INQRI-funded study "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics."

The author notes that allowing Nurse Practitioners (NPs) to practice independently reduces health care costs, compared with requiring supervision by a physician. The study found that “when NPs were allowed to practice independently, the cost savings of retail clinic episodes were even greater than when they could not practice independently.”

The study was co-led by Joanne Spetz and Stephen Parente.

Are Retail Clinics the Future of Health Care?

In "How Our Faith in Supermarkets, Nurses and Pharmacists Can Drive Health," health economist Jane Sarasohn-Kahn reports that two of the most trusted industries are supermarkets and hospitals and two of the most trusted professions are nursing and pharmacy. She also reports that "who we trust has a huge influence on who we engage for health."

Sarasohn-Kahn posits that this confluence will mean that self-care, particularly using retail clinics and seeking healthy products and advice in retail settings will become increasingly important and may be the best major drivers of health in our nation.

Her conclusion dovetails with the findings two studies funded by INQRI and published in Health Affairs earlier this year. One, led by Joanne Spetz at the University of Cailfornia, San Francisco, found that increasing use of retail clinics in which nurse practitioners provide primary care and practice independently, can dramatically reduce health care costs - by as much as $810 million in 2015, if those clinics account for 10 percent of outpatient primary care visits.

The other, led by David Auerbach of RAND and funded in part by the Donaghue Foundation, found that increasing the number of and the use of models of health care delivery that rely on nurse practitioners or physician assistants as primary care providers could offset the expected primary care physician shortage in 2025.

One thing is certain, there are many options for expanding access to health care and serious thought must be given to increasing the use of nurse practitioners and physician assistants as primary care providers in a range of settings.

INQRI In the News

New guidelines from the Joint Commission highlight the key role of nurses in preventing central line-associated bloodstream infections (CLABSIs), Infection Control Today reports. "Nurses are on the front lines and can take advantage of their constant contact with patients and other caregivers to explain infection control techniques and help health facilities develop and enforce standards of care that have been proven effective against CLABSI," said INQRI grantee Patricia Stone, PhD, MPH, RN.  She is also quoted in Long-Term Living,  Advanced Healthcare Network for Nurses, and Becker’s ASC Review.  

The health care system must ready itself for the influx of newly insured patients resulting from the Affordable Care Act, and advancing the role of nurses may be one way of addressing a potential physician shortage, according to an MSNBC.com article. The Institute of Medicine’s "Future of Nursing Report" is quoted in the article: “Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.”

A Reuters Health article profiles the INQRI-funded study "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics" and quotes co-lead investigator Joanne Spetz. "It appears there are cost savings when those nurse practitioners are allowed to operate autonomously in the retail clinic settings," Spetz told Reuters Health.

Policy Research to Inform Discussion on Scope of Practice

Alex Hoyt, PhD, RN, a Massachusetts General Hospital Institute of Health Professions School of Nursing Assistant Professor is using his recently awarded RWJF grant to bring policy research to the political debate over nurse practitioners’ (NPs') scope of practice. Dr. Hoyt was recently awarded a $250,000 grant via the Future of Nursing National Research Agenda initiative.

Dr. Hoyt plans to study the influence of regulatory changes on the NP workforce over time, how organizations interpret state practice regulations, and how these factors impact cost, quality, and access to care.

Click here to learn more about this impressive work.

ANA Recommends APRNs be Included Providers in Plans on Insurance Exchanges

The American Nurses Association (ANA) has recommended to the Centers for Medicare & Medicaid Services (CMS) that health insurers looking to offer plans on state health insurance exchanges include a certain number of advanced practice registered nurses (APRNs) in their network of health care providers for the plans to qualify. Given the millions of uninsured and underinsured individuals that seek primary care through these exchanges and the fact that research continually demonstrates that APRNs provide safe, high quality patient care, the ANA maintains that private insurers should not continue to exclude APRNs from their networks of providers.

To learn more, check out this recent story on the Advance for Nurses site.

New Human Capital Blog Post Regarding the Shortage of Primary Care Providers

A recent issue of the New England Journal of Medicine features two examples of policy analysis focused on the implications of expanding nurse practitioners' scope of practice relative to primary care, as well as an editorial addressing the same. Dr. Linda H. Aiken, a member of the INQRI National Advisory Committee and a Research Manager supporting the Future of Nursing: Campaign for Action, discusses these pieces in a new blog post on RWJF's Human Capital blog.

Click here to read Dr. Aiken's post and share your comments.

Article: States with Least Restrictive Regs on NP Practice Have Largest Increase in Primary Care Delivered by NPs

In a new Health Affairs article, Yong-Fang Kuo and colleagues present recent findings which demonstrate that states with the least restrictive regulations on nurse practitioner (NP) practice experienced the largest increase in the number of patients seen by NPs.  Further, the team found that between 1998 and 2010, the number of Medicare patients receiving NP-delivered care increased fifteenfold.  The authors suggest that relaxing restrictions on NP practice could increase the use of NPs as primary care providers, which could then reduce the shortage of primary care providers we are currently seeing across the country.

For more information, please read the article on the Health Affairs website.

A Broader Role for the Federal Trade Commission in Regulating APRN Nursing Scope of Practice

By Safiyyah Okeye, BSN, RN, Jill Vanek, BSN, MSN, and Julie Fairman, PhD, RN, FAAN 

The 2011 Institute of Medicine (IOM) report “Future of Nursing: Leading Change, Advancing Health” pointed out that because nursing scope of practice regulations vary across states, and because there is little rationale for these variations, the federal government, through the Federal Trade Commission (FTC) and the Antitrust Division of the Department of Justice, “is well situated to promote effective reforms [related to regulation of APRN scope of practice] by collecting and disseminating best practices from across the country and incentivizing their adoption.”  

The IOM recommended that the FTC and the Department of Justice review existing and proposed state regulations related to advanced practice registered nurses (APRNs) to identify those that limit competition without contributing to the health and safety of the public, and urge such states to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.  

Created in 1914 to promote consumer protection by eliminating and preventing anticompetitive, unsafe, or deceptive business practices, the FTC is the logical agency to address scope of practice laws. The FTC’s responsibility is to promote competition, inform consumer choice, and protect consumer safety. All are directly related to APRN scope of practice regulations, including those mandating physician supervision and oversight of APRNs when there is not “a compelling consumer protection rationale” for doing so. That includes evidence justifying restrictions on APRNs’ ability to provide health care services that could override the public interests with regard to choice, cost or competition. 

Marketplace Health Care: The Nurse Practitioner Will See You Now

 

This Marketplace podcast by Dan Gorenstein looks at the role of nurse practitioners as approximately 30 million Americans gain health insurance under the Affordable Care Act.

Listen to/read the podcast here.

New Jersey Nurses... APNs Sharing the Burden

Last week, we shared the first in a two part series on nursing in New Jersey published on New Jersey Spotlight.

The second part of the series was recently published and discusses the way that advanced practice nurses (APNs) can ease the burden on primary care physicians when they are given the ability to put all of their training into practice.  The article explains how APNs can assume many of the tasks typically done by doctors when given the freedom to act.

Click here to check out the story.

National Midwifery Week

As noted in the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, many states have not made changes to their scope-of-practice regulations to allow certified nurse midwives to see patients and prescribe medications without a physician's collaboration or supervision.

In honor of the IOM committee's recommendation to remove scope-of-practice barriers, we celebrate National Midwifery Week this week.

This event was created by the American College of Nurse-Midwives (ACNM) to celebrate and recognize its members. This year, ACNM is using a new public awareness initiative, Our Moment of Truth™: A New Understanding of Midwifery Care, to build the midwife brand across the country.

Click here for a list of actions you can take this week to commemorate the event. 

Solving Many of the United States' Primary Care Challenges

With the Affordable Care Act being upheld earlier this summer, there will a large flux on individuals with insurance coverage that require primary care. As many of our previous blog posts have already discussed, there is already a primary care provider shortage and this shortage is expected to grow even further after 2014.

The most recent Charting Nursing's Future, published by the Robert Wood Johnson Foundation, highlighted how nurses can help solve many of primary care’s most pressing challenges, including access and cost.

Gene Steuerle, writing for his own blog, The Government We Deserve, also focused on the role of nurses in reducing costs while providing the same level, or even better care than physicians for many basic services. Mr. Steuerle, who is a renowned economic and tax expert, argued that the current primary care provider shortage is a result of an uncompetitive industry unwilling to relinquish control over services that many non-physicians have the training and education to provide.

Finally, a collaborative group of scholars published a thorough article in the New England Journal of Medicine, highlighting how our health system can reduce costs while improving care. The utilization of nurses and other allied health professionals was highlighted by the authors as an integral piece of reforming our broken health system.

Report: Higher Payments Are No Cure For Doctor Shortage

Earlier this week, Jordan Rau, reporting for Kaiser Health News, detailed a recent report by the Institute of Medicine that recommended that Medicare should not raise reimbursements to lure practitioners to rural areas. The panel of experts suggested that instead of raising reimbursements, Medicare should provide payment for the use of telemedicine, in addition to supporting the expansion of scope of practice laws in restrictive states. By promoting the use of advanced practice nurses, the IOM believes it is possible to close the primary care physician gap using the existing workforce and network of resources currently available.

To read more about the report, click here.

Advanced Practice Nurses Attempting to Make A Significant Impact in Michigan

Yesterday, Alexandra Wilson Pecci, of HealthLeaders Media, discussed the current push by Advanced Practice Registered Nurses (APRNs) in Michigan to allow APRNs to practice to the full extent of their education and training by supporting a State Senate bill that would define APRNs as, "individual practictioners". Ms. Pecci conducted interviews with MaryLee Pakieser MSN RN BC-FNP, president of the Michigan Council of Nurse Practitioners (MICNP) and Joanne Pohl, PhD, ANP-BC, FAAN, FAANP, Proffessor Emeritus, The University of Michigan School of Nursing and MICNP member, both of whom testified before Michigan's Health Policy Committee to discuss the importance of passing this legislation.

To read the full interviews with MaryLee Pakieser and Joanne Pohl, click here.