As the United States’ fastest growing primary care workforce -nearly 260,000 strong - nurse practitioners (NPs) are well-poised to be the nation’s frontline defense both during the acute phase of the coronavirus pandemic, and after. NPs have advanced clinical training beyond their registered nurse (RN) degree to evaluate patients, order and interpret diagnostic tests, diagnose, initiate and manage treatment (including pharmacologic and non-pharmacologic treatment), coordinate care, and provide counseling to patients and families. NPs provide critical services for the chronic diseases that continue to plague our most vulnerable communities in the midst of a pandemic and make certain populations more vulnerable to more acute forms of the coronavirus.
But NPs in all states cannot provide the same level of independent chronic disease management. NPs are subject to different scope-of-practice (SOP) restrictions based on the state in which they work, dictating the extent to which they can practice or prescribe independent of a supervisory contract with a physician collaborator. In response to the strain that the massive influx of COVID-19 cases has imposed on health care systems across the country, the federal government and states have implemented policies to surge health workforce capacity, a number of which directly impact NPs and come closer to equalizing their level of independence. As clinicians and researchers, we must examine the impact of these policy changes on cost, quality, and access for our most vulnerable communities.
Policy Change Overview
At the federal level, the Centers for Medicare and Medicaid Services has relaxed SOP for NPs to expand access to care and to help meet the demand for patient care services during the pandemic. The policy is still subject to limitations of state law. At the state level, as of April 24, 22 additional states have temporarily relaxed NP SOP legislation, adding to the 22 states, two territories, District of Columbia, Veterans Health Administration, and Indian Health Service that already had independent SOP for NPs. These temporary relaxed SOP agreements have a number of variations. At the epicenter of the United States’ coronavirus pandemic, New York Governor Andrew Cuomo suspended the requirement for a written practice or collaborative agreement with a physician.
NPs Provide Access to Primary Care and Treatment
In recent years, there has been an influx of evidence that demonstrates the benefit of expanded NP SOP. NPs help fill gaps in access to care with 89 percent certified to practice in primary care and a majority practicing in traditionally underserved areas.* However, SOP regulations hinder the advantages offered by NPs. Variations in the SOP regulations across states have an indirect impact on patient care, as the degree of physician supervision affects practice opportunities and payer policies. People living in states with independent NP SOP regulations have less than a 30-minute drive to their primary care practice. Beyond access, NPs provide essential care to some of the nation’s most vulnerable populations including disadvantaged Medicare beneficiaries, Medicaid recipients, patients with opioid use disorders, and patients with mental health conditions. NPs fill gaps in treatment for patients with opioid use disorders. With a waiver, NPs can prescribe buprenorphine, a treatment for opioid use disorder. In areas for independent NP regulations, scholars find twice as many waivered NPs per 100,000. Overall, scope of practice regulations hinder access to primary care and treatment as a result many vulnerable populations suffer.
Despite growing evidence of the benefits of expanded NP SOP, arguments exist that NPs are costly, provide subpar quality of care, and jeopardize patient safety. However, current literature has increasingly countered these perspectives. A recent systematic review found that NPs are more cost effective in regards to laboratory testing, diagnostic exams, and overall patient visit expenditures when compared to their physician colleagues. In addition, one large-scale study found that Medicare beneficiaries attributed to NP care had lower hospital admission rates, readmissions, inappropriate emergency department use, and low-value imaging compared to physician assistants. A second study found that NPs had a lower cost of care across inpatient and office-based settings as compared to physicians. The cost effectiveness of NP-led care appears unprecedented.
Primary care services, however, do not have to be strictly NP or physician-led. While some argue that all physicians want to and should lead patient care, a recent qualitative study provides evidence otherwise. Provider co-management of patients has increasingly emerged in practice and is defined as shared patient care responsibilities to meet the demand for care. Physicians in this study not only preferred to co-manage with NPs, but shared perspectives that co-management improves adherence to quality-based guidelines, increased continuity of care, and reduced clinician burnout. A second study with physicians and NPs found that poor NP-administration relations and outdated policy were the greatest inhibitors to independent NP SOP. Given that a series of studies have found that primary care delivered by NPs is of equal or higher quality compared to MDs on a variety of outcomes (e.g., mortality), policymakers and administrators should re-evaluate NP SOP policy to leverage all opportunities for optimal delivery of patient care.
Recommendations for Future Research
Future research should investigate the impact of COVID-related SOP policy on additional patient and system outcomes. In response to rapidly evolving changes to NP SOP, we implore health services researchers to elucidate the impact of these policy changes on the continuum of cost, quality, access, and clinician wellbeing. It is also crucial to acknowledge that not all organizations may have implemented change despite state and federal-based policy. Future research should include comparative effectiveness studies across geographic regions including the downstream consequences of care delivery changes during the immediate response to COVID-19.
The opinions expressed in this blog post are the authors’ own and do not necessarily reflect the view of AcademyHealth.
* Editor's Note: This sentence was updated on May 6, 2020 to more accurately reflect that the percentage refers to certification.