Cost of Barriers

Regulations or licensing laws of health care providers were developed in the past to obtain legislative recognition and protection of practice authority of the provider. Physicians were the first group to seek legislative recognition with broad definitions written about their authority.

As other health care providers sought out licensure laws, such as nursing, they were seen as claiming the ability to do tasks already included in the implicitly exclusive medical practice acts. This dynamic has fostered a view of scope of practice that is conceptually faulty, potentially damaging and adds costs for the consumer seeking care. (NCSBN, 2009).

Restrictive barriers placed on APRNs reduce access to care and are associated with poor outcomes for Missourians who are Medicare and Medicaid beneficiaries.  The poor outcomes cost the taxpayer through increased treatment costs. (Oliver, Pennington, Revelle, & Rantz, 2014).

The Missouri Foundation for Health reported in 2011 that fully utilizing APRNs in Missouri would result in a savings of $1.2 billion over the next ten years.

A study by the Rand Corporation (2015) reported that total spending in states with complete independent prescriptive authority for APRNs was still slightly lower than in those with no independence, which could reflect lower prices in the independent states because of fewer restrictions on care. (I will send you report to put on site). Emergency room visits tend to drop when APRNs have full practice as increased access leads to more office-based primary care visits and checkups. Traczynski and Udalova (2013) also validated that states that allow nurse practitioners greater freedom from physician oversite results in increased frequency of routine checkups.

A 2013 study (Spetz, Parente, Town, & Bazarko) looking at the cost savings of retail clinics staffed by nurse practitioners found that costs per episode were higher in states that did not allow independent APRN practice. The costs associated with the retail clinic visit were lower than costs for care provided in other settings, such as physician offices. Analysts predicted that the growth of retail clinics will account for 10% of all primary care visits 2014.

An overlooked factor reported on by Conover and Richards (2015), is the economic benefits to the state where the APRNs have less restrictive practice. Their analysis of APRNs in North Carolina revealed that the state economy would benefit from substantial increases in economic output and employment while also seeing increases in tax revenue.

Physicians who are required to practice under the current Missouri rules related to APRNs, experience loss of income when they perform the supervisory duties required in Missouri instead of providing direct care.

Conover, C., & Richards, R. (2015). Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina. Nursing Outlook, 63, 585-592.

Martsolf, G., Auerbach, D., & Arifkhanova, A. (2015). The impact of full practice authority for nurse practitioners and Other advanced practice registered nurses in Ohio. Published by the RAND Corporation. Sponsored by the Ohio Association of Advanced Practice Nurses.

Oliver, G.M., Pennington, L., Revelle, S., & Rantz, M. (2014). Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nursing Outlook, 62(6), 440-447.

Spetz, J., Parente, S., Town, R. & Bazarko, D. (2013). Scope-of-practice laws for nurse practitioners limit cost savings that can be achieved in retail clinics. Health Affairs, 32(11), 1977-1984. doi: 10.1377/hlthaff.2013.0544

Traczynski, J. & Udalovay, V. (2013). Nurse practitioner independence, health care utilization, and health outcomes. Department of Economics, University of Hawaii at Manoa.

Barriers of Practice

What are some of the Barriers to Care for APRNs in Missouri?

Missouri Advanced Practice Registered Nurses (APRNs) have one of the most restrictive practice environments in the United States through its use of Collaborative Practice Arrangement. When regulations are unnecessary, they are barriers to health care access. These barriers are costly and can impede access to high quality and safe care for APRN patients.

BARRIER

Collaborative Practice Arrangement

• Missouri APRNs must enter into a collaborative practice arrangement with a physician in order to practice in the state of Missouri. This unnecessary regulation leads to barriers that hinder access to quality care for Missourians.  **This was kept in place during the COVID emergency orders**

Result of Barrier Reductions:

Removing the Collaborative Practice Arrangement would allow APRNs to practice to the full extent of their training and education like they do in 22 other states.

BARRIER

The collaborative physician must be located within 75 miles of the APRN

• Eighty percent of Missouri counties are considered physician shortage areas and only ten percent of new physicians are going into rural primary care. Many new physicians are not willing to practice in rural, underserved areas. This limits APRNs’ ability to practice tremendously, as a collaborating physician may not be available within the geographic restriction. 

Result of Barrier Reductions:

Removing the 75-mile rule requirement would increase access to APRN care in both rural and urban underserved areas.

BARRIER

A physician is limited to collaborating with only up to 6 full-time equivalent APRNs, PAs, or APs.

• Also, APRNs are required to practice in the same location as the collaborating physician for one month prior to practicing at a separate location. If the collaborator changes, this process must be repeated. During this time, the APRN’s availability to see patients is restricted to the location of the new collaborative physician.

 Result of Barrier Reductions:

APRN practice and patient access to care would not be hindered by the availability of a physician collaborator.

BARRIER

An APRN is not allowed to prescribe any medications unless the collaborating physician allows such prescriptive privileges within the collaborative practice arrangement.

• If the APRN is delegated prescriptive authority by the collaborative physician, the APRN may prescribe non controlled substances and is limited on prescribing controlled substances. Patients with acute and/or chronic illnesses often require medication treatment. Restrictions associated with APRN prescriptive authority for controlled substances result in limited patient access to legitimately needed medications.

 Result of Barrier Reductions:

APRNs would be able to provide all indicated prescriptions for patients and allow appropriate treatment. The Missouri State Board of Nursing will be solely responsible for promulgating rules and requirements for continuing education, including pharmacology.

BARRIER

If the APRN provides services to a patient for other than an acute self-limited or well-defined condition, the patient is to be examined and evaluated by a physician within two weeks (Collaborative Practice Rule).

• This creates the burden of an extra visit, extra charges, loss of wages, and a time constraint for the patient. In the majority of practices, it is not feasible to reschedule the patient with the collaborating physician within two weeks.  The collaborating physician (or other designated physician) must be immediately available for consultation.  If the collaborating physician or designee is unavailable (vacation, on leave, etc.), patient services cannot be provided by the APRN.

Result of Barrier Reductions:

Patient access to the appropriate health care provider would reduce cost for the patient.

BARRIER

When the APRN practices at a separate site from the collaborator, the collaborating physician shall be present at that site at least once every two weeks to review the APRN’s services and to provide medical services.

• A physician must review 10% of APRN charts and 20% of the charts when a controlled substance prescription has been given.

 Result of Barrier Reductions:

Improved interdisciplinary collaboration as indicated by the patient’s needs and provider assessment.   Telecommunication allows for real time collaboration when on-site collaboration is difficult or impossible.  Patient access to care would not be interrupted due to infringement on physician time in completing APRN chart review requirements.

Safety

Numerous studies demonstrate that APRNs have increased patient satisfaction, increased patient compliance, and equal patient outcomes for care provided by APRNs versus physicians to similar patients. Yet the AMA continues to publish unsubstantiated reports questioning the safety of APRN practice.   The Journal of Medical Licensure and Discipline has published many articles that the malpractice claims on APRNs are dramatically fewer than those compared to MDs and DOs.

Benefits to Missouri Citizens if barriers to APRNs are permanently removed:

• Many of these barriers were removed during the COVID19 Emergency Order. Access to care was increased and there were no reports of misuse or abuse by APRNs to the Missouri Board of Nursing while the barriers were not in place
• Broader access to healthcare in all areas, including rural and urban underserved areas in Missouri.
• Increased APRN availability will increase overall number of healthcare providers to care for a growing number of patients and an aging population.
• APRNs will be able to provide assistance anywhere in the state of Missouri in the event of an emergency such as during the COVID 19 state of emergency. This is in contrast to the events after the Joplin tornado. APRNs from across the state were not able to provide care to storm survivors due to practice restrictions imposed by Missouri collaborative practice regulations.
• Prescriptions will be labeled with the correct APRN provider, decreasing the confusion by patients and pharmacies.
• Diagnostic tests will be ordered by and reported to the correct APRN provider, thus decreasing the potential for delayed evaluation and treatment.

In a time when healthcare services access is most needed, excessive regulations negatively impact APRNs. Despite the declining primary care physician access in all states, states with more restrictive laws may have a more marked shortage, as nurse practitioners may not be in a position to alleviate the shortage of primary care.

Nurse Practitioner Cost Effectiveness

• Nurse Practitioner Cost-Effectiveness (American Association of Nurse Practitioners, 2013)
  • Nurse Practitioners (NPs) are a proven response to the evolving trend towards wellness and preventive health care driven by consumer demand. A solid body of evidence demonstrates that NPs have consistently proven to be cost-effective providers of high-quality care for almost 50 years. Examples of the NP cost-effectiveness research are described below.
• Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians (Health Services Research, December 27, 2015)
  • New Health Services Research study by Perloff et al. found that after controlling for other factors, Medicare costs for patients of NPs were more cost-effective than for physicians’ patients: 29% less for E&M; 18% for inpatient visits; and 11% less for office visits! The researchers noted that “the possibility of different practice styles between the two groups of clinicians” may be at work here. The study demonstrates NP cost-effectiveness.

(Perloff, J., DesRoches, C. M. & Buerhaus, P. (2015). Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Services Research. doi: 10.1111/1475-6773.12425)

Nurse Practitioner Clinical Effectiveness

• Quality of Nurse Practitioner Practice (American Association of Nurse Practitioners, 2013)
  • Nurse practitioners (NPs) are high quality health care providers who practice in primary care, ambulatory, acute care, specialty care, and long-term care. They are registered nurses prepared with specialized advanced education and clinical competency to provide health and medical care for diverse populations in a variety of settings. A graduate degree is required for entry-level practice. The NP role was created in 1965 and over 45 years of research consistently supports the excellent outcomes and high quality of care provided by NPs. The body of evidence supports that the quality of NP care is at least equivalent to that of physician care. This paper provides a summary of a number of important research reports supporting the NP.
• Nurse Practitioners and Primary Care: Federal and state laws and other policies limit how these professionals can help meet the growing need for primary care. (Robert Wood Johnson Foundation’s HealthAffairs, Health Policy Brief, October 25, 2015)
  • This brief examines the policy proposals for allowing nurse practitioners to practice to their full potential and the accompanying debate.

Research about Quality of Care

One of the common arguments heard from opponents of reducing restrictive APRN licensure laws is the claim that care provided by APRNs would result in decreased quality.

Early research has revealed that the quality of care provided by APRNs is comparable with that of physicians and that APRNs were better with patient communication and management of chronic health conditions (U.S. Congress Office of Technology Assessment, 1986).

Ongoing research has shown that APRNs consistently provide *quality* care. No published studies have demonstrated adverse outcomes from care provided by APRNs.

Below are later articles reporting on health care outcomes of APRNs:

Case for Removing Barriers to APRN Practice (Robert Wood Johnson Foundation, March 2017)