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The Nurse Practitioner Solution

EXECUTIVE SUMMARY

Nurse practitioners (NPs) are advanced nurses trained and certified at the master’s and post master’s level to deliver high quality
health care to patients of all ages. However, numerous laws and regulations limit the scope of services NPs provide by requiring
they work under the supervision of physicians. These restrictions have reduced the availability of primary and specialty health
care, worsened patient outcomes, and increased costs.

Fortunately, some states around the country have steadily eliminated barriers on NPs and expanded the practice authority of
these professionals to serve the health care needs of communities. In addition, the Veterans Health Administration has taken
important steps to allow NPs to independently deliver patient care without physician supervision.

These reforms have dramatically expanded access to health care services around the country, including rural and underserved
communities. States that enact full practice authority have increased the availability of check-ups, decreased hospital use, and
reduced emergency room visits.

Providing NPs full practice authority has also helped states reduce health care costs. States that implement these reforms spend 17
percent less per-capita on outpatient care, 11 percent less on prescription drugs, and 15 percent less on pediatric preventive care
than states that restrict access to NPs.

These reforms show expanding the practice authority of NPs can effectively increase health care access and lower medical costs for
patients and communities in need. As states experience increasing primary care shortages, NPs can play a crucial role in ensuring
families can attain high quality medical care.

NURSE PRACTITIONERS

NPs are advanced nurses that are trained and certified to provide a full range of important healthcare service including
taking comprehensive histories, providing physical examinations, diagnosing, treating, and managing diseases and
illnesses, ordering, performing, supervising, and interpreting laboratory and imaging studies, aid in health promotion,
disease prevention, health education, and counseling and prescribing medications and durable medical equipment.
In order to practice, NPs must complete a masters or a doctoral degree, receive national certification, under periodic peer
review, and pass clinical outcome evaluations.

Public and private colleges and universities began introducing NP programs in 1965 after Congress created Medicare and
Medicaid. Both programs dramatically increased demand for physician services and created an urgent need for additional
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health care providers to meet patients’ needs. Today there are over 400 NP programs that teach a variety of different
specialties including family medicine, pediatrics, acute care, and women’s health.

NP programs cost significantly less than primary care programs which allow nurses to offer lower prices for medical care.
On average, a master’s of science in nursing cost between $8,671 and $11,077 per year and takes two to four years to
complete.1 By contrast, a degree in medicine on average costs between $36,755 and $59,076 and can take up to eight
years to complete.2

As a result, NPs on average charge patients significantly less for a variety of health care services compared to primary care
physicians. In 2015, economists at Brandeis University found NPs charge patients 29 percent less for health evaluations
and 11 percent less for in-patient care than physicians.3 This leads to lower out-of-pocket spending for Medicare
beneficiaries and greater savings for taxpayers.

Studies consistently show NPs deliver care as safely and effectively as physicians. In 2012, the National Governors
Association released a systematic review of peer-reviewed academic studies that concluded patients treated by advanced
nurses enjoyed the same health outcomes as those served by physicians.4

More recently, experts have further demonstrated some patients even receive better care from NPs than physicians. In
2018, researchers published a study in the Journal of the American Public Health Association that compared health
outcomes for disabled Medicare beneficiaries treated by NPs versus those treated by physicians.5 The authors found
patients treated by NPs needed fewer hospitals admissions and emergency rooms visits compared to individuals who
received care from primary care physicians. These results further demonstrate NPs have the education and experience to
serve the health care need of patients.

STATES IMPOSE NP BARRIERS

Yet despite overwhelming evidence NPs deliver high-quality care, many lawmakers fear NPs lack the training and
experience to safely treat patients and impose a range of restrictions on their practice authority. Currently, 28 states
curtail the ability of nurse practitioners to deliver patient care in a variety of ways. For example, many states require NPs
to work under the supervision of physicians through contracts known as “Collaborative Practice Agreements” or “Nurse
protocol agreements.” Under these contracts, physicians determine which services NPs are allowed to offer and restrict
the ones they believe NPs lack the training to deliver.

States also limit how far NPs can practice from their supervising physicians, effectively preventing nurses from providing
patient care in rural and underserved areas. For example, Florida requires NPs practice 25 miles or less from their
supervising physician’s office or 75 miles within a county that is contiguous to the physician office’s county.6 In Missouri,
NPs are prohibited from practicing more than 75 miles from their supervising physician.7

Other states also impose clinical practice requirements that mandate NPs practice under physician supervision for a
minimum period of time before they can independently practice. For instance, Virginia mandates NPs work under the
full-time supervision of a doctor for at least five years.8 In Illinois, nurses must complete 4,000 hours of supervisory
hours and 250 additional hours of continuing education.9 And in Minnesota, NPs must work 2,080 hours under the
supervision of a physician before they can independently practice.10 The website nursepractitionerschools.com contains a
comprehensive list of state statutes and regulations that determine the practice authority of NPs.11
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NURSE RESTRICTIONS HARM HEALTH CARE ACCESS

These restrictions have significantly contributed to the growing primary care shortage communities face around the
country. Collaborative Practice Agreements routinely prevent NPs from offering health care services until they are fully
trained and certified to deliver care. In addition, limiting the distance NPs can practice from their supervising physician
prevents them from treating patients in rural communities that are far from physician offices. As a result, over 80 percent
of all Americans who face a primary care shortage—roughly 63 million individuals—live in states that restrict access to
NPs.12

These primary care shortages impose long-lasting and even fatal harm on America’s most vulnerable patients. Individuals
who lack a reliable source of primary care experience delays in diagnosis, pay higher health care costs, and die earlier than
patients who can regularly access basic medical care.13

Sadly, state primary care shortages are only projected to get worse. Over the next 13 years, growing numbers of
physicians will be entering retirement while more Americans will be retiring and demanding more health care.14,15
According to the Association of American Medical Colleges, the United States will have 122,000 fewer physicians than
will be required to meet patients’ needs by 2032.16

STATES END BARRIERS ON NURSING

Fortunately, growing numbers of states around the country recognize the enormous harm barriers on NP imposed on
patient and have steadily eliminate these restrictions. Since 1980, 22 states and the District of Columbia have eliminated
mandates that requires NPs work under the direct supervision of a physician as well as other limitations on their
practice authority.17

Once states remove these barriers, NPs flock to underserved areas and provide patients relief. In 2018, researchers at the
University of Rochester found that the number of NPs serving primary care shortage areas increased 30 percent within
states that provide nurses full practice authority.18 After Arizona enacted these reforms, the number of NPs serving rural
communities increased 73 percent.19

These reforms have dramatically improved health care access and health outcomes for patients. In 2016, a study by
economists from the U.S. Census Bureau and the University of Hawaii found adults were 11 percent more likely to
receive a routine physical examination in states that expanded the practice authority of NPs. In addition, they found that
states that pursued these reforms reduced the rate of emergency room visits for patients by 21 percent.20

VETERANS HEALTH ADMINISTRATION EMPOWERS NURSES

The Veterans Health Administration (VA) has also taken important steps to expand access to NPs. In December 2016,
the agency finalized new rules that allow VA facilities to give advanced practice registered nurses (APRN), including NPs,
full practice authority to deliver care to veterans without the supervision of a physician.21 Then Under-Secretary David
Shulkin promised these changes would increase “our capacity to provide timely, efficient, effective and safe primary care,
aids VA in making the most efficient use of APRN staff capabilities, and provides a degree of much needed experience to
alleviate the current access challenges that are affecting VA.”22

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Before these reforms, NPs within the VA were subjected to the patchwork of state-level scope of practice laws that
routinely restricted their ability to effectively treat patients. In 2016, a report by the Congressionally established
Commission on Care concluded this patchwork of laws “fail[s] to optimize use of advanced practice registered nurses
(APRNs).” In order to improve access to patient care, the Commission recommended the VA “develop policy to allow
full practice authority for APRNs.”23

Fortunately, the agency applied the Commission’s recommendations and gave NPs in every VA facility full practice
authority to independently treat patients. Although the VA is still collecting data and measuring the effects of these
reforms, some facilities are already seeing wait times improve. For example, after the VA facility in Amarillo, TX moved
to allow NPs to independently provide care, the average wait time to see a provide decreased from 16 days in March 2017
to three days in September 2018.24 These results show promising signs that giving NPs full practice authority can enhance
patient access to quality health care.

LESSONS FOR STATES

These successful reforms demonstrate NPs can help state policymakers address their communities’ health care challenges.
According to the Kaiser Family Foundation, over 132,000 NPs currently reside in 28 states that limit their practice
authority.25 Removing their practice barriers would significantly expand health care access and alleviate physician
shortages in these states. Analysis by HHS estimates states could reduce their physician shortage by two-thirds simply by
loosening laws that prevent NPs from independently treating patients.26

These reforms will also significantly reduce the cost of health care services for patients. In 2014, analysis from the
National Bureau of Economic Research found patients spend 15 percent less for pediatric checkups in states that expand
the practice capabilities of NPs compared to more restrictive states.27 More recently, a 2019 study in the Journal of
Nursing Regulations showed families spend 17 percent less on outpatient care and 11 percent less on prescription drugs
in full practice authority states.28

Experts predict these low prices would generate enormous savings for state health care systems. Researchers from the
University of Central Florida estimates expanding the practice authority of nurses would reduce annual health care
spending in Florida by over $9 billion.29 In North Carolina, removing barriers on NPs would reduce annual medical costs
by $4.3 billion.30 And in Pennsylvania, empowering NPs with full practice authority would reduce health care spending
by $12.7 billion over ten years.31 These savings will ensure far more families can afford the health care they need.

As lawmakers consider their various options to expand patients access to NPs, they should pursue the following reforms:

Collaborative Practice Agreements: States should repeal state mandates that require NPs establish a collaborative practice
agreement, a standard care agreement, or a protocol with a physician.

Clinical Practice Requirement: States should eliminate mandates that require NPs practice under the supervision of a
physician for a minimum amount of time before they can independently practice medicine.

Scope of Practice Restrictions: States should eliminate laws that limit the range of tests, procedures and medications NPs
can provide patients.

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Licensing Reciprocity: States should recognize out-of-state NPs licenses and authorize out-of-state nurses to practice
without needing an additional in-state license.

CONCLUSION

For decades, NPs have delivered high quality primary and specialty care to patients of all ages in a variety of settings and
communities. In particular, NPs have demonstrated they can effectively address the health care needs of individuals and
families in rural communities that often lack reliable access to physicians.

Sadly, a variety of state laws prevent NPs from effectively serving the health care needs of tens of millions of Americans.
Many states require nurses establish collaborative practice agreements with physicians that severely limit the range of tests
and procedures they can provide patients. In addition, states also require NPs work under the supervision of physicians
for years before they can independently provide care. All of these restrictions have reduced health care access and
increased the cost of medical care.

Fortunately, growing numbers of policymakers in state legislatures and the VA have taken important steps to remove these
harmful barriers on NPs. These reforms have expanded the availability of routine health care, improved patient health,
and lowered health care costs. States should learn from these successes and empower these qualified providers to serve our
nation’s growing health care needs.

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CITATIONS

1. Lydia Riley, Tyler Litsch, and Michelle Cook. “Preparing the next generation 22. U.S Department of Veterans Affairs. Decmeber 14, 2016). VA Grants Full
of health care providers: A description and comparison of nurse practitioner Practice Authority to Advanced Practice Registered Nurses. Retrieved from
and medical student tuition in 2015” Journal of the American Association of https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847
Nurse Practitioners. December 8, 2015. https://onlinelibrary.wiley.com/doi/ 23. Final Report of the Commission on Care. Commission On Care. June
pdf/10.1002/2327-6924.12332 30, 2016. https://s3.amazonaws.com/sitesusa/wp-content/uploads/
2. 2012-2019 Tuition and Student Fees Report. Association of American Medical sites/912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.
Colleges. https://www.aamc.org/data/tuitionandstudentfees/ pdf
3. Jennifer Perloff, Catherine DesRoches, and Peter Buerhaus. “Comparing 24. Holly Jeffreys. “Empowering Advanced Practice RNs Can Save Texas
the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Lives.” Panel Discussion, Texas Public Policy Foundation, Austin,
Care Nurse Practitioners and Physicians.” Health Services Research. https:// Texas, November 8, 2018. https://www.texaspolicy.com/events/
onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.12425 empowering-advanced-practice-rns-can-save-texas-lives
4. The Role of Nurse Practitioners in Meeting Increasing Demand 25. Total Number of Nurse Practitioners. Kaiser Family Foundation. https://www.
for Primary Care. National Governors Association. December kff.org/other/state-indicator/total-number-of-nurse-practitioners/?currentTime
2012. https://www.heartland.org/_template-assets/documents/ frame=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%
publications/1212nursepractitionerspaper.pdf 22asc%22%7D
5. Peter Buerhaus, Jennifer Perloff, Sean Clarke, Monica O’Reilly-Jacob, Galina 26. Projecting the Supply and Demand for Primary Care Practitioners Through
Zolotusky, and Catherine DesRoches. “Quality of Primary Care Provided 2020. Health Resources Service Administration. November 2013.https://bhw.
to Medicare Beneficiaries by Nurse Practitioners and Physicians.” American hrsa.gov/health-workforce-analysis/primary-care-2020
Public Health Association. https://journals.lww.com/lww-medicalcare/ 27. Micah Weinberg and Patrick Kallerman. “Full Practice Authority for Nurse
Fulltext/2018/06000/Quality_of_Primary_Care_Provided_to_Medicare.5.aspx Practitioners Increases Access and Controls Cost.” Bay Area Council Economic
6. Fla. Stat. Ann. § 458.348 Institute. April 2014. https://canpweb.org/canp/assets/File/Bay%20Area%20
7. Mo. Code of State Reg. §20-2200-4.200 Council%20Report%204-30-14/BAC%20NP%20Full%20Report%20
4-30-14.pdf
8. Va. Code Ann. § 54.1-2957
28. Lusine Poghosyan, Edward Timmons, Cilgy Abraham, and Grant Martsolf.
9. 225 ILCS 65 “The Economic Impact of the Expansion of Nurse Practitioner Scope of
10. Minn. Stat. Ann. § 148.211 Practice for Medicaid.” Journal Of Nursing Regulations. April 2019. https://
www.journalofnursingregulation.com/article/S2155-8256(19)30078-X/fulltext
11. “How Does Nurse Practitioner Authority Vary By State?” Nurse
Practitioner Schools. https://www.nursepractitionerschools.com/faq/ 29. Lynn Unruh, Ashley Rutherford, and Lori Schirle. “What Role do
how-does-np-practice-authority-vary-by-state/ Advance Registered Nurse Practitioners have in Meeting Florida’s Health
Needs and Contributing to its Economy?” Florida Action Coalition.
12. Primary Care Health Professional Shortage Areas (HPSAs). Kaiser Family November 14, 2016. https://www.flcenterfornursing.org/DesktopModules/
Foundation. https://www.kff.org/other/state-indicator/primary-care-health- Bring2mind/DMX/API/Entries/Download?Command=Core_
professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22 Download&EntryId=1245&PortalId=0&TabId=503
colId%22:%22Location%22,%22sort%22:%22asc%22%7D
30. Christopher Conover and Robert Richards. “Economic Benefits of Less
13. Access to Health Services. Office of Disease Prevention And Health Restrictive Regulation of Advanced Practice Registered Nurses in North
Promotion. https://www.healthypeople.gov/2020/topics-objectives/topic/ Carolina: An Analysis of Local and Statewide Effects on Business Activity.”
Access-to-Health-Services February 2015. Duke University, Center for Health Policy and Inequalities
14. 2017 State Physician Workforce Data Report. Association of American Medical Research. http://ushealthpolicygateway.com/wp-content/uploads/2018/01/
Colleges. November 2017. https://store.aamc.org/downloadable/download/ Report-Final-Version.pdf
sample/sample_id/30/ 31. Kyle Jaep and John Baile. “The Value of Full Practice Authority for
15. Multiple Chronic Conditions Chartbook. Agency for Healthcare Research Pennsylvania’s Nurse Practitioners.” Duke University School of Law. September
and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/ 3, 2015. https://law.duke.edu/news/pdf/nurse_practitioners_report-PA-
prevention-chronic-care/decision/mcc/mccchartbook.pdf TechnicalAppendix.pdf
16. The Complexities of Physician Supply and Demand: Projections from 2017
to 2032. Association of American Medical Colleges. April 2019. https://www.
aamc.org/system/files/c/2/31-2019_update_-_the_complexities_of_physician_
supply_and_demand_-_projections_from_2017-2032.pdf
17. “State Practice Environment.” American Association of Nurse Practitioners.
https://www.aanp.org/advocacy/state/state-practice-environment
18. Ying Xue, Viji Kannan, Elizabeth Greener, Joyce Smith, Judith Brasch,
Brent A. Johnson, and Joanne Spetz. Full Scope-of-Practice Regulation Is
Associated With Higher Supply of Nurse Practitioners in Rural and Primary
Care Health Professional Shortage Counties. Journal of Nursing Regulations.
January 2018. https://www.journalofnursingregulation.com/action/
showFullTextImages?pii=S2155-8256%2817%2930176-X
19. Howard Eng, Joe Tabor, and Alison Hughes. Arizona Rural Health Workforce
Trend Analysis. Arizona Rural Health Office. April 2011. http://azahec.uahs.
arizona.edu/sites/default/files/u9/azworkforcetrendanalysis02-06.pdf
20. Jeffrey Traczynski and Victoria Udalova. “Nurse Practitioner Independence,
Health Care Utilization, and Health Outcomes.” May 4, 2014. http://www2.
hawaii.edu/~jtraczyn/paperdraft_050414_ASHE.pdf
21. 81 FR 90198