Photo courtesy Seattle Municipal Archives

A new study finds loosening practice restrictions on North Carolina nurse practitioners, nurse midwives and nurse anesthetists could save hundreds of millions annually.

By Rose Hoban

If lawmakers in Raleigh would undo some of the restrictions on nurse practitioners, nurse midwives, nurse anesthetists and other “advanced practice” nurses, it could solve the state’s primary care provider shortage and provide at least $433 million in savings to the health care system in North Carolina, according to a new economic analysis by Duke University economist Chris Conover that was released last week.

In the study, which was commissioned by the North Carolina Nurses Association, Conover calculated that widening the “scope of practice” for advanced practice nurses would create, conservatively, at least 3,800 jobs statewide, generating tax revenues of more than $20 million and ease the shortage of primary care providers.

Conover headshot
Chris Conover, Image obtained from Conover’s twitter account

“There’s always a concern whether regulation has struck the right balance,” said Conover, a noted conservative economist. “This is an instance where we may have tipped over into overregulation.”

In an interview with North Carolina Health News, he argued there’s no good justification for the current extent of regulation.

“Our work would suggest that states like North Carolina consider lightening the regulatory burden on advanced practice nurses, resulting in a more competitive market and all the ancillary effects that would mean,” Conover said.

The study is only the latest salvo in a turf war that’s been playing out for years between advanced practice nurses and physicians over the role of the nurses and whether they require “supervision” by physicians.

And the tussle over scope of practice has played out in the legislature as nurses lobby to have regulations loosened, such as an effort in the 2013 session to lift supervision requirements from nurse-midwives. During the same time period, physicians sought to impose more restrictions on nurse anesthetists by tightening supervision rules.

Turf wars

What’s at issue is the ability for the nurses to diagnose, prescribe medications and offer treatment to patients, independent of a physician.

Advanced practice nurses typically have a bachelor’s degree in nursing, have practiced for at least several years and then completed master’s-level work to qualify to perform advanced tasks. These include delivering babies in uncomplicated births; administering anesthesia for routine surgeries; and managing primary care tasks for patients, such as routine screening and treatment of relatively straightforward problems such as colds and infections.

“I think with the entire changing of the health care landscape, with the implementation of the Affordable Care Act and with the graying of our population, all of that is beginning to push the utilization of health care resources up,” said Dennis Taylor, who works as a surgery and trauma nurse practitioner in Charlotte. He also chairs the commission on nurse practitioners for the N.C. Nurses Association.

“Advanced practice nursing is best positioned to assume a lot of that care that can be delivered in a safe, quality fashion to citizens without some of the regulations that are currently imposed,” Taylor argued.

Currently, supervision for advanced practice nurses does not mean that a physician stands over a nurse’s shoulder as he – but more often, she – delivers care. Instead, in North Carolina it means that advanced practice nurses have contractual agreements with physicians who occasionally review patient charts, practice standards and the delivery of care.

Practice restrictions for nurse practitioners. Green states indicate the ability for NPs to practice independently. Red states are where the law restricts  practice, requiring NPs to have supervision or management by physicians in order to practice. Map courtesy American Association of Nurse Practitioners
Practice restrictions for nurse practitioners. Green states indicate the ability for NPs to practice independently. Red states are where the law requires NPs to have supervision or management by physicians in order to practice. Map courtesy American Association of Nurse Practitioners

While physicians and advanced practice nurses often work under the same roof, the supervising physician does not always have to reside or practice in the same county as the advanced practice nurse.

This was noted to lawmakers by nurse-midwives during hearings in the legislative interim between the 2013 and 2014 sessions. That committee eventually recommended lifting the supervision restriction and allowing independent practices once those nurses had finished 2,400 hours of work under a physician’s supervision.

Dozens of states, including Alaska, Maine and Arizona, allow nurse practitioners to practice completely autonomously, while all southeastern states impose some level of restrictions on NPs. Similar patterns of restriction exist for nurse midwives and nurse anesthetists.

A study group convened by the national Institute of Medicine and chaired by former Department of Health and Human Services Sec. Donna Shalala found little reason to continue to restrict the practice of advanced practice nurses.

“We have invested in the education of these nurses; we set the standards of that training as part of state law and state regulations,” Shalala said during a 2012 interview. “So why are we on the other hand restraining that training when the evidence is that people can do the work, and that you get better health outcomes as a result?”

The first recommendation made in the 2010 final IOM report was to remove scope of practice restrictions on advanced practice nurses.

Nurse anesthetist Sharon Pearce wears her CRNA pin during the nurse anesthetist advocacy day at the General Assembly in February. Photo credit: Rose Hoban
Nurse anesthetist Sharon Pearce wears her CRNA pin during the nurse anesthetist advocacy day at the General Assembly in February. Photo credit: Rose Hoban

”All of the evidence is that nurse practitioners can do extraordinary things of very high quality and free up physicians to do other things that they were trained for,” Shalala said.

In 2012, authors of a report issued by the not-for-profit Physicians Foundation noted in its discussion of the safety and quality of nurse practitioners that “the research literature shows, without exception, that within their areas of training and experience, nurse practitioners provide care that is as good as or better than that provided by physicians.”

The Physicians Foundation report, titled “Accept No Substitute,” cites some critiques of the studies on advanced practice nurse quality. But the authors note that “state medical society executives we spoke with expressed concern that they had very little hard data and few, if any, empirical studies with which to refute the growing body of research presented by non-physicians and their advocates – research that tends to show that their clinical outcomes are at least as good as those of physicians.”

The Physicians Foundation report outlined strategies to be used by state medical societies to maintain restrictions on practice, which includes continuing to emphasize that doctors are “safer” and provider “higher quality of care.”

And in presentations to lawmakers at the General Assembly, physicians have argued that the supervision requirement is dictated by the need to protect patient safety.

Tainted analysis?

When presented with the study, several health care lobbyists at the General Assembly compared the study, which was sponsored by the state’s largest nursing association, to those commissioned by the tobacco industry that showed smoking isn’t harmful.

“I’m sure there will be people who will criticize studies sponsored by drug companies,” Taylor retorted. “Then they’re verified by outside sources, as I’m sure that other outside sources will look at this one to validate its authenticity.”

A spokeswoman from the North Carolina Medical Society said her organization would not comment on Conover’s study. And Julie Henry, a spokeswoman for the North Carolina Hospital Association said that hospitals support the current state law that “allows nurses to practice at the top of their license with physician supervision.”

Conover said his goal was not to argue the evidence on whether nurses can practice safely.

“Doctors are not going to say they’re worried about their pocketbooks. They’ll frame it as a patient-quality concern,” he said. “But the empirical evidence doesn’t support that.”

Conover said he aimed only to calculate the economic benefit of independent practice.

For example, nurse practitioners who bill Medicare receive about 85 percent of what physicians receive for the same care. Similar care paid for by insurance companies can be as low as half the cost of physician-billed care.

“We say that the greater use of advanced practice nurses would result in at least 3,800 new jobs and an increase in economic output of half a billion dollars annually,” Conover said. “Annual health system savings could be in excess of $400 million. Those are significant impacts.”

“There’s a limited amount of money out there, and physicians have done a great job of maintaining professional authority and controlling the health care system,” said Joanne Spetz, a health economist at the University of California, San Francisco, who studies the economics of nursing. “This idea of trying to protect the profession is essentially protecting the money.”

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