Quality and Safety of Nurse Practitioner Care: The Case for Full Practice Authority in Pennsylvania

Introduction

Pennsylvania is one of the most restrictive states in the nation for nurse practitioners (NP) despite having a shortage of primary care throughout the state, especially in rural areas and low-income urban neighborhoods (Association of American Medical College, 2012; Brown, Polsky, Barbu, Seymour, & Grande, 2016). Pennsylvania requires nationally-certified and fully-licensed NPs to maintain formal, written collaborative agreements with at least two physicians. Independent research estimates that removing NP practice restrictions could save the Commonwealth $6.4 billion and improve access to care over the next 10 years without any harm to patients (Jeap & Bailey, 2015). Improving access to primary care in Pennsylvania now depends upon the Pennsylvania House of Representatives adopting SB 717, companion legislation to HB 765, that removes the outdated and unnecessary requirement that each NP has written collaborative agreements with at least two physicians.In July 2016, the Pennsylvania State Senate voted 41 to 9 in support of SB 717 to eliminate these required collaborative agreements. Major stakeholders in Pennsylvania favor the adoption of SB 717 and granting NPs full practice authority, including: consumers; the Hospital and Healthsystems Association of Pennsylvania (HAP); AARP; the Pennsylvania Higher Education Nursing Schools Association (PHENSA) and its 43 nursing school members whose NP graduates leave Pennsylvania because of practice restrictions; the Pennsylvania State Nurses Association (PSNA); and the Pennsylvania Coalition of Nurse Practitioners (PCNP) representing more than 172,000 nurses in Pennsylvania. Additionally, full practice authority for NPs to practice to the full extent of their education and training is supported by the National Academy of Medicine (Institute of Medicine, 2010), the Federal Trade Commission (Gilman & Koslov, 2014) and the National Governors’ Association (National Governors Association, 2012).

SB 717 does not alter the legal scope of practice for NPs. Under current law, NPs:

• Diagnose and treat common conditions such as sore throats and earaches
• Write prescriptions for medications such as antibiotics
• Provide immunizations like the flu shot
• Help patients manage their chronic conditions such as high blood pressure and diabetes

SB 717 removes an unnecessary regulation that provides no benefits to patients. Indeed, the collaborating physician is not required to be present or review NP clinical records. Written collaborative agreements are even required for NPs who practice in hospitals surrounded by physicians.

This policy brief focuses on the single issue that concerns some elected officials: Is it safe for NPs to provide care without written physician collaborative agreements? The answer is clearly yes. This article reviews the independent, objective evidence supporting that conclusion.

The Public’s Interest

The rationale to remove the requirement for written NP-physician collaborative agreements is not to save money, although it will, but to improve access to needed primary care. In 2015, the total number of graduates from U.S. medical schools electing primary care residencies was only 1,965 for the whole country, clearly not enough to offset physician retirements much less keep up with population needs. In contrast, 14,400 NPs graduated from primary care programs in the same year, and this number is increasing annually (Pohl, Barksdale, & Werner, 2015).

Currently, 22 states and the District of Columbia do not require collaborative agreements for NP practice. The residents of these states have suffered no adverse outcomes, and access to primary care has increased. Required collaborative agreements limit the growth of the number of NPs available to provide care (Reagan & Salsberry, 2013) and they deter NPs from locating in areas of greatest need where there are few physicians. In states that do not require collaborative agreements, NPs are significantly more likely to work in primary care (Barnes, Maier, Altares Sarik, Germack, Aiken, & McHugh, 2016), and more patients in those states receive primary care from NPs (Kuo, Loresto, Rounds, & Goodwin, 2013).

There is no evidence that quality of care is diminished or patient safety is at risk with the elimination of collaborative agreements (Fairman, Rowe, Hassmiller, & Shalala. 2011). Consistent with these findings, modernizing Pennsylvania’s laws will increase access to primary care for all residents; help rural residents get timely care; shorten appointment delays for Medicaid patients; and enhance consumer choice of healthcare providers. Adoption by the Pennsylvania House of Representatives of SB 717 is in the public’s interest.

References