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Commentary: Advanced practice nurses still face too many barriers

For residents living in rural or poor urban areas, access to quality healthcare can be hard to come by. Medical deserts, or populated regions more than 60 minutes away from the nearest critical-care hospital, are a growing problem across the country as hospitals in rural and poor urban communities have a difficult time finding quality specialized healthcare providers.

This problem is becoming more pronounced as millions of previously uninsured Americans, many of whom live in rural and other medically underserved areas, are gaining eligibility for healthcare services under the Affordable Care Act. According to HHS, as of June 2015, about 16.4 million Americans already have gained health coverage since the launch of the ACA, with the uninsured rate among low-income Americans dropping by nearly 6.5%.

With the rising number of people accessing our healthcare system, hospital administrators, policymakers and healthcare providers must find ways to improve patient access to safe, quality care, especially in our country's medical deserts, without further burdening the healthcare system.

How can we address this challenge? One solution is to leverage the skills of advanced practice registered nurses, including certified registered nurse anesthetists, nurse practitioners, clinical nurse specialists and certified nurse midwives, by allowing them to practice to the full scope of their education and training without costly physician supervision. APRNs provide safe, high-quality care but at a lower cost, lessening the burden on healthcare systems.

Currently, scope of practice rules for APRNs vary across states and for different types of nurses. For example, according to a review by the American Association of Nurse Anesthetists, laws, rules or regulations of more than half of all states do not require physician supervision of CRNAs. Seventeen of these states have also opted out of a federal requirement that necessitates physician supervision of CRNAs for Medicare reimbursement. In the case of nurse practitioners, 20 states allow full practice authority for NPs, 19 states require a written collaborative agreement with a physician and 12 states are even more restrictive in that physicians must supervise or delegate for NPs to provide patient care. While the current trend of changes in supervision laws shows progress for APRNs, with fewer restrictions and barriers to practice slowly coming down, APRNs still face many restrictions in certain states. Consequently, the duties that APRNs are allowed to perform are often determined not by their education and training, but by the state laws under which they work.

Despite the existing barriers, APRNs are doing what they can to step up and address the needs of our nation's most vulnerable communities. A recent study published in Nursing Economic$ found that CRNAs, who are already the primary providers of anesthesia services in rural America, provide the majority of anesthesia care in U.S. counties with lower-income populations and populations that are more likely to be uninsured or unemployed. The same study found that anesthesiologists, CRNAs' physician counterparts, tend to provide more care in counties with higher-income populations.

The presence of CRNAs ensures that vulnerable patient populations have access to anesthesia required for surgery, labor and delivery, emergency care and chronic pain management. However, with the existing limitations, CRNAs and other APRNs are restricted from further extending their reach and making a greater impact on our neediest communities.

To best meet the needs of the millions of newly insured patients and our most vulnerable populations living in medical deserts, states should remove the remaining barriers and allow all APRNs to practice to the full scope of their education and training without physician supervision.

Juan Quintana is president of the American Association of Nurse Anesthetists.



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