Nurse Practitioners: Prescriptive Authority Update

Alexandra R. Cambra, PharmD
Wednesday June 20, 2018

Since 2000, nurse practitioners have enhanced the availability and quality of primary care for Americans, especially aging baby boomers. However, if the primary-care health care delivery system remains fundamentally unchanged through 2020, experts project a shortage of 20,400 primary care physicians. The Health Resources and Services Administration indicates that the supply of primary care nurse practitioners (NPs) will increase by 30%, from 55,400 in 2010 to 72,100 in 2020. With proper integration of NPs and physicians’ assistants into our health care system, the physician shortage will shrink to about 6000.1 Full prescriptive authority lets NPs integrate properly into the health care system.

LONG ROAD
Nurses’ roles began evolving during the Vietnam War in the 1960s, when concerns about the delivery of primary health care initially arose. The role continued to progress through many different certifications before NPs, such as certified nurse-midwives, certified registered nurse anesthetists, and clinical nurse specialists, became commonplace. These elevated roles existed mainly in acute inpatient settings and specialty units.2

For NPs to practice most advantageously, they must have prescriptive authority, promulgated in state scope of practice laws as 2 distinct types: authority legislated by regulations or nursing statutes, and delegable authority.

The types of prescriptive authority permitted in nursing legislation are further broken down into 2 categories: dependent authority, under which physicians must cosign the order, and independent authority, under which NPs can prescribe alone.2

Results of a study, conducted in North Carolina, showed that NPs with full prescriptive authority provide cost-effective care with high-quality outcomes.3 Delegable authority mandates an initial patient-physician relationship. It is further broken down into 3 categories: physician determination of patient-specific medications, prescription renewal by the nurse, and standing order/protocols.

WHY AREN’T WE ALL THERE YET?
Barriers to full prescriptive authority come from federal and state legislature, and organization’ business structures. For example, under Medicare’s Physician Fee Schedule, NP services are paid at 85% of the physicians’ rate, which financially gives primary care practices an incentive to bill under the physician’s name. Additionally, federal regulations require physician cosigners on home care service orders. At the state level, 29 states still restrict NP practice and/or prescriptive authority by requiring collaborative relationships or physician supervision. Organizationally, in the primary care setting, physicians can employ medical assistants (MAs) to help support their practices, but NPs cannot. Results from a 2014 study showed that patient cost was cut by 9% to 12% if NPs could hire MAs as supportive personnel in primary care.4

WHO HAS ALREADY FIGURED IT OUT?
In 2016, the Department of Veteran Affairs (VA) issued a rule giving full practice and prescriptive authority to NPs. Even in states requiring physician supervision, NPs at the VA can practice with full practice rights within the scope of their VA employment.4

NPs employed in pediatric intensive care units (PICUs) are also front-runners. In a 2017 national survey of 112 PICU medical directors of various organizations, 49% reported that NPs have full practice authority, and 73% reported that NPs have prescriptive authority in line with state laws.5

CURRENT STANDING
Joy Elwell, director of the doctor of nurse practice program at the University of Connecticut in Storrs,said it best: “In all 50 states and 5 districts, NPs have some level of prescriptive authority.”

These levels are restricted by the state’s individual scope of practice, as noted above. Today, 23 states and the District of Columbia allow full practice authority, independent of physicians’ collaborative/supervision agreements. The most recent state to give NP full practice authority was Oklahoma, in March 2017.

Elwell also said, “As of 2017, NPs in Florida and Georgia can prescribe [some] controlled substances.” The other 27 states require either supervisory or collaborative practice.

“In general, the Northeast [Connecticut, Maine, New York, and Vermont], Northwest [Nevada, Oregon, Utah, and Washington], and Southwest [Arizona, New Mexico, and Wyoming] have excellent scope of practice laws,” Elwell said. “They give NPs practice and prescriptive authority equal to physicians. In the Southeast, the laws are less favorable. NPs can diagnosis, treat, and prescribe, but they must do so under supervisory/ collaborative practice with physicians.”

One of the most restrictive states is Alabama, Elwell said.

Alabama’s scope of practice law states that the supervising physician in a collaborative practice must be on-site 10% of the time. Parts of Alabama are extremely rural, and the collaborating physician may need to travel long distances. If the physician fails to arrive at the clinic, the state will close the practice, and suspend the NP’s license. Many times, the area has no other primary care practice, so patient care suffers. California, Massachusetts, New Jersey, Ohio, Pennsylvania, and Texas, among others, which have restrictive scopes of practice, have bills in their state legislatures to grant full prescriptive authority (Figure).

FIGHTING THE GOOD FIGHT
Patients, payers, and pharmacists tend to accept NPs without pushback.

“The American Medical Association [AMA] exerts pushback on a national level,” Elwell said. “Politically, the AMA says that physicians should resist legislation that promotes NP scope of practice.”

However, most local physicians disagree because they want to help provide health care to the 300 million-plus Americans.

The American Association of Nurse Practitioners is lobbying for change at the national level and supporting state-specific efforts. Each state also has its own NP association pushing to advance practice.

CONCLUSION
NPs have made great strides toward full practice, and prescriptive authority over the past 2 decades. Advocates, such as Elwell, think that over the next 10 years, more than 30 states will change their scope of practice laws to allow NPs to have full practice authority. As our population ages, and more people have access to health care, Americans will need NPs backed by advanced education and law to provide much-needed health care.

For updates on the different states’ scope of practice, visit scopeofpracticepolicy.org/practitioners/nurse-practitioners.



Alexandra R. Cambra, PharmD, is a graduate of the University of Connecticut in Storrs and works for CVS.



References
  1. Health Resources & Services Administration. Projecting the supply and demand for primary care practitioners through 2020. bhw.hrsa.gov/health-workforce-analysis/primary-care-2020. Updated October 2016. Accessed April 10, 2018.
  2. Edmunds MW, Cawley J. Historical review of prescriptive authority: the role of nurses (NPs, CNMs, CRNAs, and CNSs) and physician assistants. Basicmedical Key. basicmedicalkey.com/historical-review-of-prescriptive-authority-the-role-of-nurses-nps-cnms-crnas-and-cnss-and-physician-assistants/. Published July 22, 2016. Accessed April 10, 2018.
  3. Conover C, Richards R. Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina. Nurs Outlook. 2015;63(5):585-92. doi:10.1016/j.outlook.2015.05.009.
  4. Poghosyan L. Federal, state, and organizational barriers affecting nurse practitioner workforce and practice. Nursing Economics. 2018;36(1):43-45.
  5. Gigli KH, Buerhaus PI, Minnick AF, Dietrich MS. Regulation of pediatric intensive care unit nurse practitioner practice: A national survey. Journal of the American Association of Nurse Practitioners. 2018;30(1):17-26.


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