Nurse practitioners hemmed in by scope of practice laws and payment policies

As the debate around using nurse practitioners to stem the predicted physician shortage continues to heat up, a new policy brief from the National Institute for Health Care Reform points to barriers that are preventing the fullest use of NPs.

The report, released in February, found that state scope of practice laws and payment policies are two of the biggest challenges to expanding care provided by nurse practitioners.

Scope of practice laws regulate how nurse practitioners can practice, including whether or not they can prescribe medications, create treatment plans or work without physician oversight. States vary widely in their regulations, but according to the report, 25 states require some oversight by a physician for all of these services. The report looked at six states – Arkansas, Arizona, Indiana, Maryland, Massachusetts and Michigan – to see how these regulations impacted the use of nurse practitioners in primary care.

Study authors found that requiring oversight by a primary care doctor prohibits many nurse practitioners from working in more rural areas where there is often a dearth of providers. Respondents in the report also said it was a challenge to find physicians to collaborate because doctors may not receive compensation.

While scope of practice laws often receive the most attention, it was really a combination of those and payment challenges that were inhibiting practice, said Tracy Yee, a co-author of the study.

"A misconception is that the solution or silver bullet for expanding provider capacity would be to liberalize scope of practice regulations," she said. "States need to also look at their Medicaid programs because they have control over that."

Yee said some states, like Arizona, have independent practice laws, but nurse practitioners can't sustain a practice because they can't get reimbursed. One solution would be for Medicaid and private payers to allow nurse practitioners to be reimbursed directly or be listed as preferred providers.

Tay Kopanos, vice president of governmental affairs for the states at the American Association of Nurse Practitioners, said the study's findings are similar to what her organization has seen.

"When nursing organizations would go forward to adopt rules and regulations, there has always been this friction point between medicine and nursing," she said.

But there has been some movement in scope of practice regulations. She said there are 12 states with bills this legislative session that would move toward full practice authority.

And only a small handful of states, including Utah and Arkansas, don't recognize nurse practitioners in their Medicaid program.

"I am hopeful that there is an awakening that healthcare isn't owned by one profession," Kopanos said. "But it is the strength of multiple disciplines providing care for patients in multiple settings that will be good for patients."