APRN Prescriptive Authority: New Hampshire vs. Massachusetts

Introduction: Geographic Context and Prescriptive Authority

Massachusetts is the 44th largest state in the United States with 7,838 square miles of land (Netstate.com, 2014). By comparison, New Hampshire (NH) is the 45th largest state with 8,969 square miles of land. These statistics reveal that NH is the larger of the two states in terms of land mass, yet in 2014 had less than one-fifth the population of neighboring Massachusetts (U.S. Census Bureau, 2014). Accordingly, NH residents are more likely to live in a rural setting and receive healthcare services from advanced practice registered nurses (APRNs) (Buerhaus, DesRoches, Dittus, & Donelan, 2014). Physicians, on the other hand, are more likely to practice in suburban areas.

Given the logistical constraints associated with providing primary, acute, and long-term care in rural settings, it may come as no surprise that APRNs practicing in NH have plenary authority to prescribe medications (New Hampshire Board of Nursing, 2013a). In other words, board-certified APRNs practicing in NH have the same prescriptive authority as licensed physicians. This stands in stark contrast to a number of other states that require physician oversight of prescriptive authority, in addition to limiting the classes of drugs that can be prescribed by APRNs (Gadbois, Miller, Tyler, & Intrator, 2014). All that is needed to prescribe FDA-approved drugs in NH is a valid individual or group registration number from the U.S. Drug Enforcement Agency (DEA) (New Hampshire Board of Nursing, 2013b).

New Hampshire's Regulatory Framework for APRNs

New Hampshire's approach to APRN prescriptive authority is streamlined and permissive. Board-certified APRNs in the state obtain plenary prescriptive authority, meaning they can prescribe any FDA-approved medication without requiring physician approval or oversight. The regulatory requirements are minimal: an APRN must hold current board certification and maintain a valid individual or group DEA registration number. This framework reflects New Hampshire's acknowledgment that many APRNs practice in rural areas where physician supervision may be geographically impractical or impossible to arrange.

The simplicity of New Hampshire's system stands in sharp contrast to states with more restrictive models. Rather than limiting prescriptive authority by drug class or requiring ongoing supervision agreements, New Hampshire has chosen to increase educational entry requirements. APRNs practicing in the state must hold a Master of Science in Nursing (MSN) or advanced practice nursing degree, a requirement implemented in 2004 (Gadbois, Miller, Tyler, & Intrator, 2014). The logic underlying this approach is that rigorous graduate training, combined with board certification, adequately prepares APRNs to practice independently with full prescriptive authority.

Supervising Physician Requirements and Prescriptive Agreements

Massachusetts imposes strict requirements on physicians who supervise APRNs with prescriptive authority. The supervising physician must hold an unrestricted full license in Massachusetts, have completed training in an accredited school in the United States or Canada, be board-certified, and be practicing in a specialty area similar to that of the supervised APRN (Board of Registration in Nursing, 2014). For physicians supervising PCNSs, training must have been completed in psychiatry at an accredited institution of higher learning. If the supervising physician has hospital admitting privileges for the specialty area, board certification is not required for CNPs and CRNAs. The supervising physician must also maintain valid controlled-substance registrations through both the Massachusetts Department of Public Health and the DEA.

The written agreement between the Massachusetts APRN and supervising physician must define the nature and scope of the APRN's prescriptive authority and be renewed every two years (Board of Registration in Nursing, 2014). The agreement should describe how supervision can be delegated to another physician, along with any limitations in the duration and scope of the delegation. The agreement must state the circumstances that trigger physician consultation or referral, define the mechanism and duration for monitoring prescribing practices, and require review of Schedule II drug administration within 96 hours. Even though medical marijuana is still categorized as a Schedule I drug by the DEA (Silverman, 2015), CNPs are authorized by the state of Massachusetts to prescribe this drug under appropriate physician supervision (Board of Registration in Nursing, 2014).

The prescriptive agreement between the APRN and supervising physician is a public document and must be provided to anyone requesting a copy (Mass.gov, 2015b). If the APRN needs prescriptive authority in multiple settings but a supervising physician is not available who practices in all settings, then a supervising agreement must be created with a physician for each additional setting. Other restrictions include physician oversight of APRN patient diagnosis and treatment in Massachusetts (Gadbois, Miller, Tyler, & Intrator, 2014).

Educational Requirements and Drug Scheduling Considerations

APRNs requesting prescriptive authority in Massachusetts are only required to have a general Master of Science degree, while in NH, APRNs must have a Master of Science in Nursing (or advanced practice nursing degree) to enter the workforce (Gadbois, Miller, Tyler, & Intrator, 2014). The increased training requirement for APRNs in NH is somewhat recent and was implemented in 2004. Both states require practicing APRNs to keep their national credentials in good standing and allow APRNs to prescribe Schedule II through V drugs after obtaining the necessary approval from the state and DEA. This contrasts with several other states that prohibit administration of Schedule II drugs by APRNs.

Schedule II drugs encompass narcotic painkillers, which have been blamed for a dramatic increase in opioid-related overdoses and deaths (U.S. Centers for Disease Control and Prevention, 2015). The regulatory approaches of New Hampshire and Massachusetts to Schedule II drug prescribing reflect broader policy trade-offs between facilitating healthcare access and controlling medication misuse risk.

Conclusion: Policy Trade-offs and State Rationales

Massachusetts is by far the more restrictive state of the two when it comes to regulating the prescriptive authority of APRNs. The relatively strict regulatory environment in Massachusetts may seem extreme when compared to NH, but NH requires a Master of Science in Nursing before an APRN can practice in the state. Rather than impose a complex system of prescriptive authority regulation on APRNs, NH has instead chosen to increase the training requirement and then confer the same prescriptive authority to APRNs that is enjoyed by licensed physicians. This makes sense given that many NH APRNs practice in rural settings, where it may be difficult or impossible to establish oversight agreements with nearby physicians. New Hampshire's regulatory environment therefore allows APRNs to practice without restrictions, which in turn increases access to healthcare services in rural settings.

Massachusetts, on the other hand, has created a complex system of regulatory oversight that tailors prescriptive authority and its restrictions to distinct APRN specialties. This has the advantage of limiting the number of APRNs who can legally prescribe Schedule II–V drugs to only those specialties where the scope of practice requires this authority. For example, CNSs typically practice in a hospital setting where patients have ready access to licensed physicians. Conferring prescriptive authority to CNSs would therefore be redundant. The same would be true for CNPs, CRNAs, and PCNSs practicing in a hospital setting, but not if these APRNs practiced in small clinics or as sole practitioners. The requirement for a supervising agreement with a physician would tend to limit the ability of these APRNs to practice in rural settings, but Massachusetts is much more populated than NH, so this may not be a major concern for state regulators. CNMs are more likely to practice as sole practitioners in rural settings, so making plenary prescriptive authority available to this specialty makes sense.

The regulatory system governing APRN prescriptive authority in Massachusetts is therefore less concerned about increasing access to healthcare services in rural settings and more concerned about limiting the number of medical professionals prescribing Schedule II–V drugs.