State regulations defining the scope of medical practice for nurse practitioners (NPs) vary widely and more restrictive states also seem to influence restrictive reimbursement policies, a study by the Center for Studying Health System Change has found.
Half of the states require physician oversight of NPs' diagnoses, treatment plans and prescribing, and seven states require physician oversight of NP for just prescriptions, while 18 states and Washington D.C. permit NPs to diagnose, treat patients and prescribe medications without physician oversight.
Along with physicians assistants and registered nurses, the ranks of NPs has been growing, with 56,000 practicing in primary care, mostly focusing on chronic and preventive care management rather than complex diagnoses, according to the Center's study, which was sponsored by National Institute for Health Care Reform, a nonprofit created by the United Auto Workers, Chrysler, Ford and General Motors.
According to the study, more or less restrictive nurse practitioner laws don't correlate either way with healthcare quality, and even in states with more restrictive laws, NPs surveyed say they feel they have latitude in clinical decision making. But growing demand for basic primary care has led to interest in expanding NPs' ability to work independently, as a recent National Governors Association report recommended.
Some states with traditionally restrictive NP laws are considering more liberal frameworks, such as Michigan and Massachusetts, whose post-health reform spike in primary care demand from newly insured patients may portend the next decade under the ACA.
In Michigan, NPs currently must have practice agreements with doctors, and have to work in the same facility as a physician if they're writing prescriptions for medications classified as potentially addictive. In Massachusetts, NPs are required to be supervised by a physician, who develops their care management plans and prescription guidelines.
In Indiana, NPs are reimbursed at 75 percent of the physician rate and they are required to have physician practice agreements and submit care management plans to the state. In Arkansas, NPs must have agreements with physicians and are compensated at 80 percent of the physician rate and limited to 12 visits per patient per year.
"We are tethered to physicians," one Arkansas NP told survey researchers. "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."
In 2010 Maryland changed its NPs regulations, requiring only a one page consultative agreement with a physician, rather than collaborative practice agreements. NPs in Maryland now can practice at any location and do not have to be supervised, with Medicaid reimbursements at 100 percent of the physician fee. Arizona law also gives NPs wide flexibility in their scope of diagnoses, treatment and prescribing, although they are reimbursed at 90 percent of the physician rate.
Nevada lawmakers are currently considering legislation that would let NPs practice without physician supervision.
"For the average family, it's going to increase access for people to get care," Matthew Khan, a family practice nurse practitioner and president of the Nevada Advancde Practice Nurses Association, told the Las Vegas Sun. "We are removing a barrier."
In most states, hospitals are permitted to create their own NP framework, while payer policies for NPs varies, often following state regulation.
Currently one-third of states do not explicitly allow NPs to be designated as primary care providers in Medicaid managed care networks, only letting them work as part of a care team. Revising NP regulations in Medicaid managed care plans "may be a more immediate and politically feasible way to expand effective utilization of NPs in primary care," wrote health policy researcher Tracy Yee and colleagues.
Medicare, meanwhile, places a number of requirements on NPs nationally -- for instance, prohibiting NPs from ordering home healthcare or durable medical equipment, regardless of whether they are the sole primary care provider. "Even in states that allow NPs to practice independently, such Medicare policies reportedly pose significant barriers to care delivery, making it difficult to practice without a collaborating physician," the Center's researchers wrote.
Proposals for expanding the role of NPs have been met with reluctance from some physicians groups. "Increasing the responsibility of nonphysician health care professionals beyond their education and training is not the answer to this shortage," Jeremy Lazarus, MD, president of the American Medical Association, said last year. "Training more physicians and nurses so patients have access to the quality care they need is the answer."