NP opportunities hinge on payer policies: study

A study that looked at scope-of-practice laws in six states concluded that the laws don't restrict the breadth of primary-care services that nurse practitioners offer patients, but the laws still affect payer policies which then curtail how and where NPs can practice.

The study, “Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies,” was commissioned by the National Institute for Health Care Reform. Researchers sought to answer whether increasing the scope of practice for NPs would be a good solution to combat primary-care provider shortages. The number of NPs is expected to almost double by 2025.

“Scope-of-practice laws in and of themselves don't appear to limit what primary-care services patients can receive from nurse practitioners, but requirements for documented physician supervision do appear to impact where and how NPs can practice,” Tracy Yee, an HSC researcher and a study coauthor, said in a news release.

Researchers studied laws in Arkansas, Arizona, Indiana, Maryland, Massachusetts and Michigan examining how much physician supervision states require for NPs and how that supervision impacts care. The research included interviews from NPs, practice managers and physicians.

The laws don't, for the most part, spell out what tasks NPs can perform. Instead the laws authorize a range of practices and make it clear if a physician is needed for those practices.

Payer policies had a bigger impact than the laws on how and where NPs could practice. The study pointed out that in Arkansas and Indiana—which require physician supervision for NPs—traditional Medicaid fails to recognize NPs as primary-care providers. That restricts the range of services NPs can offer. While the laws in those states don't say NPs can't be a primary-care provider, the laws also don't explicitly recognize NPs as a primary-care provider either, researchers noted.

“Restrictive (scope of practice) laws, in conjunction with strict payer policies, reportedly limit NPs to working as employees of physician practices, hospitals or other entities rather than in their own independent practices,” according to the study. “Given the interaction of payment and (scope of practice) policies, it's unclear how more opportunities to practice independently would affect NP supply.”

Researchers suggested state legislative reforms, and pointed out legislation in Massachusetts and Michigan where the roles of NPs have been expanded into delivery of primary care services. Changes to Medicare, Medicaid and other public payer reforms could also help. The study pointed to exemptions to scope-of-practice laws for Medicare-certified rural health clinics. NPs at those clinics are recognized as primary-care providers and paid at the same rate as physicians.

One of the NPs interviewed from Arkansas, known as one of the more restrictive states, said the laws made NPs feel like they were “tethered to physicians.”

“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 NP told researchers. “The collaborating physician has to be available and accessible, and I wouldn't want to collaborate with someone 200 miles away.”