Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies

Laws Don't Affect Services Provided by Nurse Practitioners But Do Limit Practice Opportunities

News Release
Feb. 28, 2013

FURTHER INFORMATION, CONTACT:
Alwyn Cassil (202) 264-3484 or acassil@hschange.org

WASHINGTON , DC—While state scope-of practice laws don’t typically restrict what primary care services nurse practitioners (NPs) can provide to patients, the laws do affect practice opportunities for NPs and appear to influence payer policies, accordingto a new qualitative study by the Center for Studying Health System Change (HSC) for the nonpartisan, nonprofit National Institute for Health Care Reform (NIHCR).

Amid concerns about primary care provider shortages, especially in light of health reform coverage expansions in 2014, some believe that revising state laws governing nurse practitioners’ scope of practice is a way to increase primary care capacity. NPs are registered nurses trained at the graduate level, with a specialization in primary care, acute care or psychiatric/mental health nursing, sometimes with a focus on pediatrics, adult/gerontology or women’s health.

According to the study, state scope-of-practice laws vary widely in the level of physician oversight required for nurse practitioners, with some states allowing NPs to practice independently, and others limiting NPs’ authority to diagnose, treat and prescribe medications to patients without supervision.

The study, which included interviews with NPs and practice managers and physicians working in settings that employ NPs, examined variations in NP scope-of-practice laws in six states—Arkansas, Arizona, Indiana, Maryland, Massachusetts and Michigan, which represent a range of restrictiveness. For example, Arizona allows NPs to practice independently, while Arkansas requires direct physician supervision of NP diagnoses, treatment and prescribing.

States with more restrictive scope-of-practice laws were associated with more challenging environments for NPs to bill public and private payers, order certain tests, and establish independent primary care practices, according to the study.

“Scope-of-practice laws in and of themselves don’t appear to limit what primary care services patients can receive from nurse practitioners, but requirements for documented physician supervision do appear to impact where and how NPs can practice,” said Tracy Yee, Ph.D., HSC researcher and coauthor of the study with Ellyn Boukus, M.A., an HSC health research analyst; Dori Cross, an HSC research assistant; and Divya Samuel, a former HSC research assistant.

The study’s findings are detailed in a new NIHCR Research Brief—Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies—available online at www.nihcr.org/PCP-Workforce-NPs. Other key findings include:

• Both primary care physician and NP respondents reported that within a practice the degree of supervision typically evolves over time and varies by NP and physician. Even in restrictive SOP states, most NPs described having latitude to make clinical decisions, although with a greater level of documented supervision.
• Collaborative agreements, which  stipulate how a physician will supervise or monitor a nurse practitioner’s performance and competency, reportedly limit the range of practice settings for NPs in some states, with notable impacts on underserved rural communities. For example, in Arkansas, an NP explained, “We are tethered to physicians; we can’t go farther out into rural communities than physicians are willing to go to provide care because of the collaborative practice agreement requirement. The collaborating physician has to be available and accessible, and I wouldn’t want to collaborate with someone 200 miles away.”
• Many NP respondents reported that payer policies had more of an impact than scope-of-practice laws on how and where they can practice. Payers determine what services NPs are paid for, their payment rates, whether NPs are designated as primary care providers and assigned their own patient panels, and whether NPs can be paid directly.
• Restrictive scope-of-practice laws, in conjunction with strict payer policies, reportedly limit NPs to working as employees of physician practices, hospitals or other entities rather than in their own independent practices.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation's changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is affiliated with Mathematica Policy Research.