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Advanced Practice Nurses

March 12, 2014 | No Comments
Posted by Frank Ciesla

The Federal Trade Commission this month (March 2014) issued its policy analysis in regard to the regulation of Advanced Practice Nurses and competition issues which may arise through the regulation of their practice.  This report can be accessed at http://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced-practice-nurses/140307aprnpolicypaper.pdf.  The report’s table of contents clearly sets forth where the FTC is going.  That table provides:

CONTENTS

EXECUTIVE SUMMARY ………………………………………………..……….1

I. INTEREST AND EXPERIENCE OF THE FTC …………..……………….5

II. BACKGROUND ON APRNS AND SCOPE OF PRACTICE
ISSUES ………………………………………………………….…………..…………7

II.A. Advanced Practice Registered Nurses ………….…..…………….7

II.B. Competition Perspectives on Professional Regulations that
Restrict APRN Scope of Practice ……………………………………………11

I I.B.1. Framework for Evaluating Licensure and Scope of Practice
Regulations ………………………………………………………….……………….12

II.B.2. Analysis of Scope of Practice Limitations Should
Account for the Value of Competition ………………….…………………16

III. APRN SCOPE OF PRACTICE COMPETITION
ADVOCACY COMMENTS AND ADDITIONAL ANALYSIS
BY FTC STAFF ……………………………………………………………………18

I II.A. Potential Competitive Harms from APRN Physician
Supervision Requirements ……………………………………….…….….…20

III.A.1. Restrictive Physician Supervision Requirements
Exacerbate Well-Documented Provider Shortages that
Could Be Mitigated via Expanded APRN Practice ……………………20

III.A.2. Excessive Supervision Requirements May Increase Health
Care Costs and Prices ………………………………………………….……….27

III.A.3. Fixed Supervision Requirements May Constrain
Innovation in Health Care Delivery Models …………………………..31

III.A.4. Mandated Collaboration Agreements Between APRNs and
Physicians Are Not Needed to Achieve the Benefits of
Physician-APRN Coordination of Care …………………………….……34

III.B. APRN Supervision Requirements Should Serve Well-
Founded Patient Protection Concerns ..………………………….…….35

IV. CONCLUSION ………………………………………….…………….…….38

APPENDIX 1: APRN ADVOCACIES ……………………………………..A1

APPENDIX 2: SELECTED BIBLIOGRAPHY .………………………….B1

As can be seen by the table of contents, as well as reviewing the report in detail, it signals the FTC’s intention to support a significant expansion of the scope of practice of Advanced Practice Nurses, as well as to reduce physician oversight of their practice.

Expansion of the scope of practice of Advanced Practice Nurses is a way to meet the shortage of primary care practitioners by expanding both their scope of practice as well as reducing physician oversight.  As set forth in the conclusion:

Our nation faces significant challenges in moderating health care spending and in providing adequate access to health care services, especially for our most vulnerable and underserved populations. Numerous expert health policy organizations have concluded that expanded APRN scope of practice should be a key component of our nation’s strategy to deliver effective health care efficiently and, in particular, to fill gaps in primary care access. Based on our extensive knowledge of health care markets, economic principles, and competition theory, we reach the same conclusion: expanded APRN scope of practice is good for competition and American consumers.

As explained herein and in prior FTC staff APRN advocacy comments, mandatory physician supervision and collaborative practice agreement requirements are likely to impede competition among health care providers and restrict APRNs’ ability to practice independently, leading to decreased access to health care services, higher health care costs, reduced quality of care, and less innovation in health care delivery. For these reasons, we suggest that state legislators view APRN supervision requirements carefully. Empirical research and on-the-ground experience demonstrate that APRNs provide safe and effective care within the scope of their training, certification, and licensure. Moreover, effective and beneficial collaboration among health care providers can, and typically does, occur even without mandatory physician supervision of APRNs.

When faced with proposals to narrow APRN scope of practice via inflexible physician supervision and collaboration requirements, legislators are encouraged to apply a competition-based analytical framework and carefully scrutinize purported health and safety justifications. In many instances, legislators may well discover that there is little or no substantiation for claims of patient harm. If, however, health and safety risks are credible, regulations should be tailored narrowly, to ensure that any restrictions on independent APRN practice are no greater than patient protection requires.

This policy paper will be available on the FTC website, along with related resources and an up-to-date index of FTC staff comments on APRN issues. The FTC hopes to continue to serve as a resource for state legislators who seek our views on these and other competition policy issues, and we welcome a continued dialogue with all interested stakeholders.

One can only conclude that the position of the FTC is unequivocally to support expansion of the scope of practice and to support substantial limitations on the oversight of these limited license practitioners.

As pointed out in other blogs (for instance, http://www.njhealthcareblog.com/2013/12/no-physician-shortage/), on an uncoordinated basis, the scope of practice of limited license practitioners is being expanded throughout the country.  This FTC report clearly establishes the viewpoint of the FTC not just with regard to the area of Advanced Practice Nurses, but in all areas to encourage the states to expand the scope of practice and restrict oversight by physicians of such practices.  As raised in our previous blog (www.njhealthcareblog.com/2013/10/expansion-of-the-scope-of-practice-of-non-physicians-a-harbinger-of-things-to-come), what impact will this have on defining the standards for malpractice? In addition, what will be the impact on establishment of the reimbursement rate for services that are or will be provided under the expanded scope of practice of these limited license practitioners?

In light of the fact that it takes four years of college, 4 years of medical school and 3-4 years of residency for a primary care doctor and only 4 years of college and 2 years of advanced training for an Advanced Practice Nurse, this is a route that will be taken to increase access and reduce cost.  Whether this approach maintains or increases quality is an open issue.

For another discussion regarding expansion of the scope of practice of limited license practitioners (in this case, pharmacists), see the attached Kaiser Health news story (http://www.kaiserhealthnews.org/Stories/2014/February/11/pharmacists-see-clinical-role-expand.aspx) regarding the expanding scope of care now being provided in various states by pharmacists.

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