By Carin Gorrell
There’s a growing healthcare crisis in America, and while it’s not getting the same airtime as that other (universal) healthcare dilemma, it’s equally disturbing: There aren’t enough physicians to go around, and it’s only going to get worse. The U.S. has a shortage of more than 20,000 physicians, and that number could jump as high as 121,900 by 2030, due largely to our growing and aging population, according to a report from the Association of American Medical Colleges. Over the next decade, our population will climb another 24.9 million to an estimated 359.4 million, according to U.S. Census Bureau projections. At the same time, half of Americans will surpass age 65 and start moving into retirement—and one-third of currently practicing physicians will join them.
Some parts of the country are already feeling the hit of a healthcare void, particularly in rural areas, where only 11% of physicians choose to practice. Take Kansas, where 101 of 105 counties had a primary care health professional shortage in 2017. Or Florida, where 62% of low-income children don’t have a physician.
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As experts scramble to find ways to get more physicians in the field, one solution is gaining traction across the country. What if we lift unnecessary restrictions on advanced practice registered nurses (APRNs), and empower them to practice to the full extent of their training without a physician’s oversight? Four state legislatures—Florida, Kansas, Kentucky, and Mississippi—recently introduced bills that, if passed, would grant APRNs full practice authority (FPA). (To learn how to support APRNs in your state, click here.)
The concept of full practice authority for APRNs isn’t new. In fact, APRNs already have FPA in 24 states and the District of Columbia. As more states follow suit, proponents are pushing for FPA across the country and pointing to its success in removing barriers to quality healthcare. In FPA states, APRNs can order tests, diagnose conditions, prescribe medications, refer patients to specialists, and perform numerous other duties without paying a collaborating physician for oversight. In states without FPA, APRNs must have a contract with a physician who charges them for the contract, can determine what categories of patients they care for and which services they provide, and sign off on services.
The distinction between physicians and APRNs
Though APRNs don’t attend medical schools like physicians, their training is rigorous. They’re educated as registered nurses first, then advance their education—including a minimum of a master’s degree in nursing and often a doctoral (about 18% have one), and then obtain hundreds or even thousands of hours of hands-on specialized practice.
“We can make a diagnosis and treat conditions— but our training is more holistic and focused on health promotion and disease prevention,” says Edward Briggs, MS, DNP, APRN, a family nurse practitioner in Florida. “We work toward making sure patients know how to take care of themselves, and that they have their immunizations and examinations on time, so we can keep them healthy.”
In other words, APRNs are perfectly positioned to deliver safe and quality healthcare services, including in primary care–an area of medical care that’s getting hit especially hard by the physician shortage. The number of newly minted physicians pursuing primary care positions has been declining for years, but 2019 saw the lowest on record, according to the National Resident Matching Program. Much of that decline has to do with income potential, says Briggs. “There’s just much more revenue in specialty skills like orthopedics and cardiology.”
The problems with limiting APRN authority to practice
Primary care physicians are particularly absent in rural areas of the country, providing an opportunity for APRNs to help fill the access to care gap. But in states where they don’t have full practice authority, APRNs are restricted by what’s called a Collaborative Practice Agreement, a contract they must sign with a physician in order to provide care. These contracts vary from state to state, and they can be limiting in ways that significantly block patients’ access to care.
In some states, the physician determines the scope of the collaborating APRN’s practice, which means facets of the provider’s training and skills may simply go to waste. “If I’m contracted with an internal medicine doctor who doesn’t see children, and somebody brings a baby into my clinic, though I’m trained to see that baby, I can’t,” says Carolyn Coleman, DNP, the nurse practitioner program coordinator at the University of Southern Mississippi. For the parents of that baby, that could (and often does) translate to an hours-long drive to the nearest pediatrician for concerns like a textbook ear infection, when an APRN in town could have diagnosed the condition and prescribed antibiotics.
These collaborative agreements can be geographically limiting for APRNs, too, who often have to work in the same vicinity or even medical clinic as their collaborating physician. This exacerbates the vast practitioner deserts in the rural in-betweens. In Mississippi, for instance, APRNs are required to work within a 75-mile radius of their collaborating physician, precluding nurses like Coleman from establishing a clinic in a remote area with no nearby physician.
Also, as states experience the physician shortage, it’s often difficult for APRNs to find physicians to collaborate with. “You can’t work without that contract, and there are not enough physicians around here to contract with us,” says Coleman of the catch-22. She also points out that the contracts are expensive—ranging from a few thousand dollars a month to as much as $12,000 a month, paid for by the nurse or their facility—and typically require little to no oversight on the physician’s part. “It’s basically permission to work,” says Coleman. “There are a lot of advanced practice nurse practitioners willing to go into small rural areas if they were just allowed to.”
But what about the patients?
Those concerned that patient care is compromised for patients seeing an APRN rather than a physician can breathe easy. Numerous studies suggest that patients who are treated by APRNs have comparable outcomes to those treated by physicians in the same areas of practice.
One review, for example, found no differences in patient outcomes with regard to emergency department or urgent care visits, rehospitalization rates, and mortality rates. Another study of the elderly in rural areas found no significant difference in patient outcomes on five different measures, including 30-day hospital readmission rates.
In one area, APRNs even perform slightly better than MDs: patient satisfaction, particularly as it pertains to the interaction with their provider. “That may be because we typically spend more time with patients, so we’re able to relate more readily,” says Briggs. “We can deal with patients on a more human level because we don’t have that power dynamic of ‘I’m the doctor and you’re the patient.’”
States that have granted APRN full practice authority are actually providing better access to care for their residents. For instance, in Nevada, the number of practicing APRNs grew by 33.4% after FPA was passed in 2013, with the three most rural counties seeing some of the highest growth. And a recent national analysis of rural counties and primary care health professional shortage areas found that the number of nurse practitioners per 100,000 population increased the most in states with FPA regulation.
Ultimately, while physicians may be increasingly hard to come by and patient care needs grow, APRNs are poised to fill the gap. In fact, the employment of all four APRN roles (certified nurse anesthetists, certified nurse midwives, clinical nurse specialists, and certified nurse practitioners) is expected to grow another 26% between 2018 and 2028. That’s great news for patients—but only if they can see these advanced providers and take advantage of the full scope of their education and training. To support the FPA bill in your state, click here.
