Answering Objections to Full Practice Authority for Mississippi’s Nurse Practitioners
Last Thursday, I published an article in the Clarion Ledger highlighting Mississippi’s worst in the nation physician shortage, our worst in the nation life expectancy and health outcomes, and how full practice authority for Mississippi’s nurse practitioners could be one solution to improve access to affordable, quality health care.
Despite the article being rather demure — heavy on studies and data compiled by reputable research institutions — the article drew a rather spirited response from a small contingent of people concerned about the quality of care delivered by nurse practitioners. Four primary objections emerged that warrant response.
Objection 1: Nurse Practitioners Are Not Properly Trained to Dispense Primary Care
Advanced Practice Registered Nurses (APRNs) describe a category of nurses that have obtained either a Master of Science in Nursing (MSN), which typically involves 2-3 years of additional education beyond that necessary to become a registered nurse, or a Doctor of Nursing Practice (DNP) degree, which involves even more training.
The APRN designation includes certified nurse practitioners (NPs), certified registered nurse anesthetist (CRNA), certified nurse-midwives (CNMs), and clinical nurse specialists (CNPs). Most who ultimately pursue an advanced nursing degree do so after years of clinical experience as a registered nurse — meaning that they have thousands of hours of real-world handling of patients under the supervision of physicians before ever seeking an APRN certification. Nurse Practitioners’ training includes the assessment of patients, ordering and interpretation of diagnostic and laboratory testing, prescribing medication and non-pharmacological treatment, and coordination of care with other providers. Upon completion of training, NPs must obtain national board certification.
Objection 2: Relying on Nurse Practitioners for Primary Care Will Lead to Negative Outcomes or Two-Tiered Care
To answer this objection requires assessing the purpose of primary care, existing data on primary care supplied by NPs, and cost-benefit analysis of an environment in which nurse practitioners share some of the load of providing primary care with primary care physicians. versus an environment where the responsibility for primary care falls wholly on primary care physicians.
THE PURPOSE OF PRIMARY CARE
It is important to start with an understanding of the role of primary care in the larger health care ecosystem. Primary care providers serve three important roles that we all know from our experience with them. First, they identify and treat minor health problems like the common cold, flu, bacterial infections, cuts, etc. Second, they monitor and treat chronic conditions like hypertension or diabetes. Third, they serve as a first point of contact for health concerns that warrant specialization — a health coordinator that knows when to seek additional input and from whom.
Because of the nature of primary care, the risks associated with improper treatment are substantially lower. This is reflected in the fact that while primary care providers experience the highest volume of patients, they experience some of the lowest rates for malpractice claims — fractions of what higher risk, lower volume specialties like neurosurgery experience. The biggest risk in primary care is not acute malpractice, but the cumulative risk of inaccessibility.
NURSE PRACTITIONERS’ CURRENTLY PROVIDE PRIMARY CARE INDEPENDENT OF PHYSICIANS
In all fifty states, including Mississippi, NPs are legally authorized to prescribe medication. In nearly all states, including Mississippi, NPs can provide primary care without the presence of a physician. In Mississippi, there are approximately 7,000 licensed NPs, 5,600 of which supply primary care. This puts the current ratio of NPs to primary care physicians (PCP) in Mississippi at 2:1.
If you’ve gone to a clinic in recent years for primary care, you have likely been treated by an NP, in many cases without ever seeing a physician. This is particularly true if your method of payment for primary care is Medicare or Medicaid, where NPs are accepting new patients at a much higher rate than primary care physicians. The idea of nurse practitioners filling a void in delivering primary care to underserved populations is not a theoretical concept. It’s already happening. We have millions of positive patient experiences across Mississippi and the broader country to demonstrate the value added by nurse practitioners.
MISSISSIPPIANS ARE MORE AT RISK WITHOUT NURSE PRACTITIONERS’ PROVIDING PRIMARY CARE
We know that the biggest risk with primary care is not that of acute malpractice, but inaccessibility. We also know that Mississippi has the worst physician shortage in the country. The National Institute of Health predicts that Mississippi will need 3,709 new physicians by 2030 to close its gap. This is a task of near mathematical impossibility, given that a full third of our existing pool of 5,714 active physicians is nearing retirement age.
Concern that reliance on nurse practitioners to help fill the primary care gap yields a two-tiered society seems to ignore the reality that NPs are already doing heavy lifting and that large swaths of people would go without any primary care if they weren’t. There is no evidence of statistically significant quality differentials in the primary care provided by PCPs and NPs. But, even if there were some decline, there is a more significant delta between NP provided care and no care at all. That is to say that in the real world, the two tiers that develop are not between those treated by PCPs versus NPs, but those treated versus those without access to care at all.
Objection 3: Granting Full Practice Authority is a Roll of the Dice that Will Harm Patients
In twenty-two states and the District of Columbia, NPs have “full practice authority.” This means that they are not required to be in a collaborative agreement with a physician to provide care commensurate with their training. Mississippi would not be an outlier, but an established trend adopter, if it chose to recognize full practice authority.
At present, NPs in Mississippi have to enter into a collaborative agreement with a supervising physician. These collaborative agreements do not require that NPs work in an office with a physician or that they consult with a physician in real-time while treating a patient. Many clinics across Mississippi are already independently run by NPs. Instead, physicians offering supervision under the collaborative agreement are required to review as little as ten percent of an NPs charts once a month. This means that when you get treated for a cold by an NP, there is a 1 in 10 chance that a doctor will look at your treatment, and this review could occur weeks after you were seen (and recovered). In exchange for this audit service, NPs are required to pay their supervising physician an average of nearly $2,000/month.
Of course, some physicians provide more than the bare minimum in the course of their collaborative agreements. The argument goes that this “check” helps to ensure the proper standard of care is maintained. But in twenty-two states without this requirement, there is no statistically significant indicator of a decline in the quality in the service rendered by NPs.
Objection 4: Nothing Prevents Nurse Practitioners from Providing Primary Care Under Existing Law
The final argument posed was that given the relative independence of NPs in Mississippi, nothing stops them from helping to stand in the gap. In many ways, this argument cuts against the objections that call into question the quality of care dispensed by NPs, and without economic analysis, might appear like a fair point. Subject to pretty minimal, retrospective oversight from a supervising physician, NPs are already providing primary care, often in settings that would appear entirely independent to an outside observer.
But consider that the twenty-two states that have recognized full practice authority have seen a substantial growth of 29 percent in the number of nurse practitioners in their states, with Arizona experiencing a 73 percent bump in nurse practitioners serving rural areas. If you think about it, it makes sense. Paying $20,000 plus of your revenue for supervision reduces potential income and is not only an economic disincentive but a barrier to starting an independent practice. The supervision model also carries capital risks. A successful clinic, for instance, could have a supervising physician withdraw from a collaborative agreement, leaving their business in jeopardy. In that situation, prospective supervising physicians would have all the leverage.
So, the ultimate question becomes does the collaborative agreement requirement add enough value to outweigh the value of having more nurse practitioners in Mississippi available to provide primary care?
There is little evidence to suggest it does, particularly in light of the experience in full practice authority states and Mississippi’s desperate need to address its access crisis.