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.

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.

More Nursing Schools Focus on Interdisciplinary Care

A number of the nation’s top nursing schools now require students to participate in at least one interprofessional education course or activity, according to a “dashboard” report recently released by the Future of Nursing: Campaign for Action, an initiative of RWJF and AARP.

Experts have been calling for interprofessional education for decades, but more schools are now responding because requirements are being written into health professions accreditation standards, Barbara Brandt tells RWJF’s Sharing Nursing’s Knowledge (SNK) newsletter. Brant is head of the National Center for Interprofessional Practice and Education, a public-private partnership supported by RWJF, the U.S. Health Resources and Services Administration, and other organizations. While there is not yet any comprehensive data quantifying the number of interprofessional activities and courses offered nationwide, Brandt said that there is “no question” the number of schools requiring these types of activities is growing rapidly.

INQRI is credited in the SNK article for helping to foster interdisciplinary research and collaborative practice. The ongoing impact can also be seen in health journals, where the number of articles in 10 of the top health services research journals co-authored by a registered nurse (RN) is increasing dramatically, according to a supplemental dashboard indicator, which shows that articles co-authored by RNs jumped from 80 to 145 from 2010 to 2012.

“For much of history, physicians made the major care decisions,” INQRI Grantee Joanne Spetz said. “We need to start teaching nursing students that they bring a set of skills to the table that are unique and distinct, and add value to the skills provided by other professionals. That will help them develop good, collaborative relationships over time.”

Government Report Shows Increase of Nurse Practitioners in Primary Care

After declining for two decades, the rate of recently licensed nurse practitioners (NPs) joining the primary care workforce is moving upward, according to a new report from the Health Resources and Services Administration (HRSA).

According to the National Sample Survey of Nurse Practitioners, in 1992, 59 percent of graduating NPs worked in primary care, but that decreased to 42 percent between 2003 and 2007. The new survey, based on 2012 data, shows that 47 percent NPs who graduated since 2008 have entered primary care, Nurse Zone reports. Survey results also showed:

• 94 percent of that total NP workforce held a graduate degree in some field, 86 percent had a master’s degree in nursing, and 5 percent held a doctoral degree in nursing;
• 76 percent of the NP workforce maintained certification in a primary care specialty (family, adult, pediatric, or gerontology); and
• More than half of the NP workforce worked in ambulatory care settings, with nearly a third practicing in hospitals.

Two recent studies funded by INQRI found significant benefits of NPs working in primary care. The first, led by Joanne Spetz at the University of California, 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, 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.

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.

INQRI in the News

HealthLeaders Media highlighted the INQRI program, and the importance of nurses to quality of care, in its recent article “Interdisciplinary Care Starts with Respect for Colleagues.” Managing editor Alexandra Wilson Pecci writes that it is time to upend the hospital hierarchy, where power starts with physicians and flows down to nurses, particularly within interdisciplinary care. “Instead of this top-down hierarchy, I believe all branches of health care should function as equals,” Pecci said. “The responsibilities of nurses, physicians, pharmacists, and other members of the clinical care team are certainly different, but none is more or less important to patient care. All members of the team are needed for their own, particular skills.”

The new INQRI-funded study “Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics,” continues to receive media coverage, most recently on the Reuters Health Globalpost website.  The study is led by Joanne Spetz and Stephen Parente.

Bread, Milk, Pneumonia Shot: How Retail Clinics are Changing the Landscape of Healthcare

By Olga Yakusheva, Marquette University

When your child gets a sudden fever, it’s bad enough. When your child gets a sudden fever on a Friday night, it can be downright terrifying. You calm yourself with the thought that it is most likely nothing serious and can wait until Monday, all the while trying hard to push away the memory of that recent Sunday family trip to the ER for what turned out to be a simple ear infection.

Thankfully, these situations are becoming less frequent as more and more people get access to retail health clinics. Retail clinics, also called convenient care clinics, are small clinics located in pharmacies, grocery stores, and supermarkets, where a nurse practitioner (NP) or physician assistant will see you for a range of simple conditions (ear infections, cuts and small burns, and such), preventive care, or vaccinations. The clinics accept patients on a walk-in basis and are typically open after hours and on weekends. Most visits last about 15 minutes and prescriptions can often be purchased before leaving the store. Many clinics accept insurance, and some insurers now cover retail clinic services. Although a relatively new phenomenon in the US health care landscape, close to six  million patients visited retail clinic visits in 2009 alone, and an estimated 6,000 retail clinics or more will be operating in the US by the end of the year.

Along with convenience, retail clinics provide care at a lower cost. A study funded by INQRI and recently published in Health Affairs found that choosing a retail clinic for the initial visit can reduce the overall cost of care over the next two weeks by as much as $160-$220 per patient, and that these cost saving are greater where NPs are allowed to practice independently without a physician’s supervision. In addition to direct cost savings, having access to convenient care could lower costs by averting complications that may otherwise result when patients delay seeking care.

While currently accounting for less than 5% of all outpatient primary care visits, the share of visits to retail clinics is projected to increase more than two-fold by 2015. If the cost savings continue into the near future, the projected expansion of the retail clinic market could save our economy over $2 billion, and potentially much more if it were accompanied by a uniform expansion of NP scope of practice laws. Joanne Spetz, the lead author of the study, says that these findings “underscore … that when NPs practice to the full extent of their training, they can deliver highly efficient high-quality primary care.”

Critics of retail clinics bring up a number of potential drawbacks to wide adoption of retail clinics. These concerns include the possible erosion of existing patient-physician relationships, diminished continuity of care, over-prescription of medications (particularly antibiotics), and overall reduced quality of care. While existing studies show the quality of care provided at retail clinics to be similar to conventional primary care settings, the Spetz study did find that when NPs were allowed to prescribe, payments for prescription medications were slightly higher.

These concerns notwithstanding, the rapid growth of the retail clinic sector over the last decade tells us that they are meeting a growing consumer demand for convenient, high-quality affordable care. As health care policy changes under the Affordable Care Act continue to roll out, retail clinics will play an increasingly important role in alleviating growing pressures on our primary care system. In the meantime, we may all need to start getting used to the idea of putting routine tests and vaccinations on our grocery lists.

INQRI In the News

A new INQRI-funded study, which shows that retail clinics can reduce costs when Nurse Practioners (NPs) practice independently, is making headlines. The study, led by Joanne Spetz and Stephen Parente is in current issue of Health Affairs.

News media and blog coverage has included the Albuquerque Business Journal, which notes that New Mexico allows NPs autonomous practice. The study was also covered in The Lund Report and The Incidental Economist.

Additionally, the INQRI-coordinated study to examine whether public reporting laws are effective in encouraging hospitals to improve nurse staffing levels and improving patient outcomes is also receiving attention, recently being featured on News-Line.com.

INQRI Study Shows Retail Clinics are Convenient, Cost-Effective, Provide Quality Care

A new INQRI-funded study shows that retail clinics can reduce costs when Nurse Practioners (NPs) are allowed to practice independently, potentially by nearly $472 million or more in 2015.

Retail clinics are an increasingly popular option for people who need diagnosis and treatment for common, non-life-threatening conditions. NPs are the primary care providers in these clinics, which are located in a range of settings, including pharmacies, grocery stores and “big box” stores. First established in 2000, there are now more than 1,200 retail clinics nationwide.

The research team for the study was led by Joanne Spetz, professor at the Institute for Health Policy Studies and associate director for Research Strategy at the Center for the Health Professions at the University of California, San Francisco, and Stephen Parente, director of the Medical Industry Leadership Institute at the Carlson School of Business, University of Minnesota. The team compared claims data over a two-week period for 9,503 patients who visited retail and non-retail clinics from 2004 to 2007. Researchers compared costs in states that require NPs to be supervised by or collaborate with physicians, states that allow NPs to practice independently but not prescribe, and states in which NPs are allowed to practice and prescribe independently. The study is in the November issue of Health Affairs.

The researchers found that insurance claims over a two-week period were lower following retail clinic patient visits than after visits to other settings, such as doctor’s offices and emergency departments, for the same conditions. Insurance expenditures for retail patient visits were even lower in states that allow NPs to practice independently. Payments for prescriptions were slightly higher in states where NPs are allowed to prescribe, but that increase in cost was mitigated by the lower cost of an NP practicing independently.

Adjusted to 2013 dollars, the average two-week cost for non-retail clinic visits was $704, for retail clinic visits in states with no NP independence it was $543, and for retail clinic visits in states where NPs have independence in practice, it was $484. The average cost for retail clinic visits in states where NPs had independence in practice and prescribing was $509.

Retail clinics are projected to account for about 10 percent of outpatient primary care visits by 2015. The study’s authors projected that the cost savings realized from using retail clinics at that level would be $2.2 million. The savings would be increased by $810 million if all states allowed NPs to practice independently and by $472 million if NPs were allowed to practice and prescribe independently.

Read the study.