APRN Scope-of-Practice Barriers: IOM Policy Analysis

Introduction and Selected IOM Recommendation

One of the main objectives of the Office of Disease Prevention and Health Promotion's Healthy People 2020 campaign is to increase access to care for patients (ODPHP, 2018). However, with more and more primary care physicians leaving primary care for specialized medicine, there is a gap in care coverage. That gap could be filled if advanced practice registered nurses (APRNs) were permitted to practice to the full extent of their education and training—but they are not. The Institute of Medicine (IOM, 2010) recommends that they should, and gives explicit steps on how that recommendation can be achieved.

The IOM's selected recommendation is as follows: "Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions" (IOM, 2010, p. 1).

Background and Current Characteristics

The field of nursing was originally promoted to help fill the gap created by the demand for services and the lack of providers in the latter half of the 20th century, when more and more people began using health care. Throughout the 1950s and 1960s, physicians collaborated with and trained nurses so that the latter would be able to give primary care to patients (O'Brien, 2003). However, there was no adequate channel for credentialing these nurses, and their education and training was never quite put to use in the way it was intended. The IOM (2010) has stressed that now is the time to make that happen.

Some states are beginning to listen to what the IOM (2010) has urged. The Robert Wood Johnson Foundation (2015) reports that "in March, Nebraska granted nurse practitioners (NPs) the ability to provide the full complement of services they are educated and trained to deliver. In May, Maryland enacted its own 'full-practice authority' law. And similar legislation is pending in many other states." However, many other states are still behind the curve, and old laws preventing nurses from achieving the full scope of their practice remain on the books.

The IOM's recommended solutions for eliminating scope-of-practice barriers include expanding and amending the Medicare program to cover services provided by APRNs in the same manner as services provided by physicians, as well as the following additional steps (IOM, 2010):

• Extend the increase in Medicaid reimbursement rates for primary care physicians included in the Affordable Care Act (ACA) to advanced practice registered nurses providing similar primary care services.
• Limit federal funding for nursing education programs to only those programs in states that have adopted the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).
• Require insurers participating in the Federal Employees Health Benefits Program to include coverage of services provided by advanced practice registered nurses that are within their scope of practice under applicable state law.
• Review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive effects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so.

Policy Issue Definition and Political Landscape

As the Institute of Medicine (IOM, 2010) has recommended, advanced practice registered nurses (APRNs) must be able to practice to the fullest extent of their education and training. The IOM (2010) asserts that states must "remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training" (p. 1). This policy issue is important because it addresses a serious problem in today's health care environment: the lack of access to care for many patients.

With more and more primary care physicians leaving primary care for specialized medicine, a gap in care coverage has emerged. That gap could be filled if APRNs were permitted to practice to the full extent of their education and training. This policy affects the broader policy arena because it calls for a change in the laws and legal framework governing the practice of medicine, reimbursements, and coverage.

Some states are beginning to respond to what the IOM (2010) has urged, as noted above with Nebraska and Maryland. However, many other states are still behind the curve, and federal law has not budged regarding allowing APRNs to be reimbursed under Medicare.

At this time, this issue is primarily being addressed at the state government level. Federal-level policy changes would also be required in order to meet the IOM's (2010) recommendations regarding expanding and amending the Medicare program.

Multi-Context Policy Analysis

Social Context

American physicians began working closely with clinically experienced nurses as the need arose in the 20th century. The growing demand for specialized services had caused a number of physicians to leave primary care behind and focus more exclusively on providing specialized care. This exodus produced a gap in primary care across many regions of the country, leaving many patients without the care they required and desired. Throughout the 1950s and 1960s, doctors collaborated with and trained nurses to offer primary care to these patients (O'Brien, 2003). By 1965, the U.S. had established Medicare and Medicaid for patients whose low incomes made health care unaffordable. By subsidizing health care costs, the government increased demand for primary care. As physicians had already been moving into specialized care services, nurses played a major role in filling that gap (Medicare Payment Advisory Commission, 2002).

Ethical Context

From a utilitarian perspective, allowing APRNs to practice to the full extent of their education and training is the only ethical step to take: it would benefit the greatest number of people and thus serve the national community's greatest good. This ethical consideration is rooted in the fact that the APRN is fully qualified to provide this type of care.

Drs. Loretta Ford and Henry Silver developed the first nurse practitioner (NP) program for nursing students. Ford was a nurse and Silver was a physician; working together, they understood what each field could contribute to a new program that would enable nurses to deliver primary care. This program was designed to train nurses at a higher level so that they could fill the gap left by departing physicians.

Legal Context

State laws have placed barriers around the extent to which APRNs may practice independently of physicians. This restricts, in legalistic terms that are outmoded and outdated, the ability of patients to obtain access to care and places undue pressure on the health care industry as a whole.

Historical Context

As O'Brien (2003) states, the curriculum devised by Ford and Silver "focused on health promotion, disease prevention, and the health of children and families." Nurses were specifically trained to operate at a higher level—precisely that level at which their physician mentors had been training them in the 1950s and early 1960s. Nurse educators took the initiative to equip nursing students with the education they needed to give patients the care they desired.

By 1979, there were 15,000 nurse practitioners in the U.S. The number of NPs continued to grow, reaching 24,000 by 1983. Steering committees formed, more associations were established, and millions of federal dollars were allocated to fund nurse practitioner education. By 1989, 90% of all nurse practitioner programs were post-graduate programs (American Association of Nurse Practitioners, 2017).

The lack of a proper credentialing channel was one of several challenges that early APRNs faced. Studies conducted in the 1970s and 1980s demonstrated to skeptics that nurses were fully capable of delivering the kind of primary care that physicians had provided earlier in the century. Indeed, a number of studies indicated that NPs were even more capable of providing quality primary care than physicians. By the 1990s, the primary care physician shortage was less severe than it had been in earlier decades, and some groups within the health care industry sought to move NPs out of the primary care role (O'Brien, 2003). Mundinger (1994) challenged this view, stating: "When measures of diagnostic certainty, management competence, or comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by nurse practitioners is equivalent or superior to that provided by physicians" (p. 214).

Thus, the history of the APRN reflects a story in which a vital need was evident: more patients were seeking care while physicians were departing primary care for specialized practice. Nurses stepped up to meet that need, and with the guidance of Drs. Ford and Silver, the APRN movement was born. Today, however, it remains threatened by legalistic oversight.

Financial and Economic Context

The lack of access to care imposes significant costs on communities. Would-be patients who are in serious need of medical care but lack access often end up homeless or self-medicating with illicit drugs. These outcomes can land them in jails, which are supported by taxpayer funds; housing a single prisoner costs taxpayers approximately $60,000 per year (Szabo, 2014). There is also an economic toll as many individuals who might otherwise be productive members of the workforce are denied the care they require and ultimately leave the workforce due to untreated illness.

Theoretical Underpinnings of the Policy

As the IOM asserts, nurses should be viewed as equal partners with physicians. They have trained alongside them and are qualified to serve patients at the same level of primary care.

References

American Association of Nurse Practitioners. (2017). Historical timeline. Retrieved from https://www.aanp.org/all-about-nps/historical-timeline

IOM. (2010). The future of nursing. Retrieved from http://nacns.org/wp-content/uploads/2016/11/5-IOM-Report.pdf

Medicare Payment Advisory Commission. (2002). Report to Congress: Medicare in rural America. MedPAC.

Mundinger, M. (1994). Advanced-practice nursing—good medicine for physicians? New England Journal of Medicine, 330, 211–214.

O'Brien, J. (2003). How nurse practitioners obtained provider status: Lessons for pharmacists. American Journal of Health-System Pharmacy, 60(22), 2301–2307.

ODPHP. (2018). Access to health services. Retrieved from

Robert Wood Johnson Foundation. (2015). More states removing barriers to nurses' scope of practice. Retrieved from https://www.rwjf.org/en/library/articles-and-news/2015/07/more-states-removing-barriers.html

Szabo, L. (2014). Cost of not caring: Nowhere to go. Retrieved from https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/