Nurse Practitioners and Full-Practice Authority: Insight from the States, Opportunity Amidst COVID-19

In an effort to combat the COVID-19 pandemic, states across the country are suspending or waiving collaborative practice agreement requirements for nurse practitioners (NPs). Collaborative practice agreements are made with a physician and specify permissible tasks such as the types of medical conditions NPs can treat and what procedures NPs are permitted to perform. Currently, twenty-eight states require NPs to enter into such agreements that place them under the direct supervision of a physician as a part of a patient care team. How much NPs are required to pay the supervising physician depends on a variety of factors. Changes to the current laws raise questions about the necessity of such restrictions on the practice authority of NPs and will surely spark more debate on the topic in the months ahead. Even after the crisis subsides, there is still a need to address the growing physician shortage and rising healthcare costs. NPs are well positioned to meet these needs.

To gain some insight on the current practice environment across the country and the debate over NPs’ practice authority, I sat down to speak with Taynin Kopanos, DNP, NP, the vice president of state government affairs at the American Association of Nurse Practitioners. Below are excerpts from our interview. They have been lightly edited for clarity.

There are significant differences in training requirements for registered nurses and nurse practitioners (NPs). Can you explain those differences?

The majority of nurse practitioners have over six years of formalized classroom and clinical education before they become licensed as a nurse practitioner. Admission to an NP program requires that an applicant already hold a four year bachelor's degree in nursing and be licensed as a registered nurse. So, NPs begin their graduate education with skills in physical assessment, interpreting diagnostic test results, evaluating patients, determining appropriate treatments, and evaluating the effects of those treatments. Graduate NP education is then able to build on that platform both in the classroom and in didactic clinical settings to develop advanced skills, such as diagnosing health conditions and prescribing medications

The Mercatus Center recently prereleased its Healthcare Openness and Access Project (HOAP) 2020 Index to give policymakers ideas on how to stretch their healthcare resources. The authors echo the sentiment of many other researchers like myself and recommend adopting full practice authority (FPA) licensure laws. As a nurse practitioner, how would you define full practice authority?

I think it's helpful to provide a framework for what we mean when we talk about licensure authority. Practice authority is an individual's legal permission from a state to practice their profession. So very much like an individual has a driver's license that gives them state permission to drive a car, your license authority as a professional, is based on that legal permission from a state.

At AANP we define FPA as the legal permission for a nurse practitioner to evaluate patients, to diagnose, to order and interpret diagnostic tests, and to initiate and manage treatments (i.e., prescribing controlled substances) under the exclusive authority of the nurse’s license regulated by the state board of nursing. Currently, 22 states and DC have FPA licensure laws. In the remaining states, nurse practitioners are required to have an external contract (or a permission slip if you will) from a physician or an outside entity to give them the legal permission to practice their profession and provide those services to patients. It sets up an unnecessary regulatory barrier between a patient and a healthcare provider.

AANP is actively calling on governors across the country to allow NPs to adopt FPA. Why should states make this a priority to combat COVID-19?

Reflecting on local response efforts after major disasters like Hurricane Katrina and Hurricane Sandy, AANP knew that the country’s existing licensure format would be problematic in the nationwide response to COVID-19. So, we went out early calling on governors to waive existing limitations to ensure outdated laws would not hamstring the ability to provide care for patients.

One of our members summed the situation up really well saying, 'It is easier for me to go serve in another state than it is to volunteer in my own community.'

So far, five states have issued Executive Orders that have fully suspended the requirement for external contracts for nurse practitioners. That has made a difference. Unfortunately, we continue to hear from our members in states where the regulatory contract has yet to be waived. For some, their current primary workplaces have closed down and they are willing to volunteer. Other members are willing to serve on the front lines either in a different capacity as a nurse practitioner or as a screener, but because their existing contract with a physician doesn’t explicitly grant permission to do so, or their physician collaborator is not willing to authorize that, those NPs are left on the sidelines. One of our members summed the situation up really well saying, "It is easier for me to go serve in another state than it is to volunteer in my own community." With a nationwide emergency like COVID-19, we need to prioritize efforts to remove those roadblocks so clinicians who are in those communities can meet their neighbors' needs.

When the crisis subsides, why are states with FPA better positioned to deliver more care at a lower cost?

Helping our country recover economically will require us to address deficiencies in the healthcare system. When you look at head-to-head analyses on states that have full practice authority and those that don’t, you see a track record over several decades that states with FPA do better at lowering costs. For example, a 2014 study that looked at head-to-head Medicaid rates found states with full practice authority had lower hospitalizations, lower re-admissions, and improved healthcare status for Medicaid beneficiaries. In addition, healthcare economists found that full practice authority states have the ability to utilize their healthcare workforce more efficiently by reinvesting the time of physicians and nurse practitioners took to meet regulatory hoops into patient care⁠—helping boost productivity and drive down costs.

On the flip side, studies have shown states without FPA have higher costs of care for routine things like well-child exams. The outcomes and safety are the same as states with FPA, but the cost is higher. There are also regulatory costs. In 2017, South Dakota adopted full practice authority partly because the state could save $70,000 a year in regulatory oversight costs just by moving towards a more modernized licensure. As states look to improve the economics of healthcare, licensure reform really should be a top priority.

So you mentioned South Dakota's enacting a significant reform. Have there been other states that have been essentially laggards and not taking any action? And are there any other states recently besides South Dakota that have enacted significant reforms on this front?

We have seen Western states primarily take the lead in moving forward, and that trend goes back more than three decades. South Dakota was the last state to enact full practice authority followed by Guam. Before COVID-19 disrupted the 2020 state legislative schedules, several states had legislation for full practice authority under consideration.

We consistently see some of the most challenges in the Southeast. It's also one of the regions that needs the most assistance. When we look at the metrics around healthcare outcomes, healthcare costs, and rising disease burden for chronic diseases, those are the states that could benefit the most from moving forward with licensure modernization.

Is there any evidence that granting FPA reduces the quality of care patients receive? This is often a concern that opponents raise when they’re arguing against moving towards full practice authority.

Safety and quality of care is a paramount issue for nurse practitioners, the nursing community, and health professionals as a whole. There is absolutely no evidence to support that concern. There have been several hundred studies conducted over the course of four decades, and no study has ever found safety or quality concerns for nurse practitioners. In fact, the opposite has been true. The majority of studies find that healthcare outcomes and safety are similar between nurse practitioners and physicians and other healthcare providers who deliver the same types of services.

If FPA does not reduce quality, then what is stopping states from granting nurse practitioners FPA?

I think it really boils down to two factors. One is an outdated perception of who can deliver healthcare and the second is a very clear market participant with a vested interest in maintaining the status quo. Those two factors are a challenges to overcome. Outcomes and cost data really suggests that moving towards full practice authority is a way to improve healthcare access, improve quality of life, and decrease healthcare expenses.

Eight of the top ten states in the HOAP Index are full practice authority states, whereas seven of the 10 bottom ranked states have licensure restrictions.

Seven of the top ten states in the United Health Foundations 2019 America’s Health Rankings report are full practice authority states. All ten of their lowest ranked states restrict or reduce the regulatory permission of an NP to practice their profession. The Mercatus Center’s HOAP Index rankings also echoes these findings. Eight of the top ten states in the HOAP Index are full practice authority states, whereas seven of the 10 bottom ranked states have licensure restrictions. Across the board, no matter what the metric, states that limit patient choice and restrict the ability for people to practice their profession are not coming out well for cost, quality, access or health for their residents.

Would you like to share any closing thoughts?

As we determine how to best improve health outcomes and improve our economy, we should take some of the lessons that we've learned from the last several decades as well as the last couple of months with COVID-19. Licensure reform is a bipartisan way to advance our healthcare system. Both the current and prior administration issued reports saying we needed to remove licensure barriers to improve healthcare access and control costs. This is a low hanging fruit. It is a no-cost, no-delay, no-risk-to-patients way to improve healthcare and healthcare services in our country.

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