Expansion of APRN Autonomy Challenged by Physician Groups

By Christine Mitchell

Christine Mitchell is a junior at the University of Pennsylvania studying nursing.

With the passage of State Senate bill 717 (SB 717), Pennsylvania has become the most recent state to expand the autonomy and practice rights of nurse practitioners. The bill, which passed on a 41 to 9 vote, amends the Professional Nursing Law, which was passed in 1951. [1] Under the new law, certified registered nurse anesthetists, certified nurse-midwives and nurse practitioners (APRNs) can practice independently of physicians and issue oral orders. These practices will be regulated by the State Board of Nursing, as opposed to being regulated by individual facilities. Significantly, these practitioners will be permitted to prescribe Methadone, which is used to treat narcotic drug addictions. [2]

Advanced practice nurses are providers that have completed a bachelors of science in nursing (BSN) as well as a master's (MSN) or doctorate degree (DNP) in nursing. Throughout both the undergraduate and graduate training, students are placed in hospitals to gain direct patient care experience. Masters and doctoral students are paired with either a nurse practitioner or physician to receive advanced training in diagnosis and treatment planning. The majority of students entering master's programs have practiced as nurses, providing a foundation of knowledge about patient care.

Expanding nurse practitioner autonomy has been hailed by many as a way to provide quality care in areas of medicine that tend to lack providers, particularly in primary care and rural areas. Many medical students choose to enter higher paying, more prestigious specialties, leaving primary care offices with fewer doctors. The lack of providers, combined with increased patient loads due to expanded health insurance access, poses significant challenges to primary care clinics, including patient wait times that can stretch for months.

The push for nurse practitioners to receive full practice rights has been a contentious one, with physician groups such as the American Medical Association actively lobbying against the change. Following a proposal by the Veterans Health Administration (VA) to allow advanced practice nurses to practice independently (in a similar fashion to Pennsylvania), the AMA issued a statement outlining their disappointment in the "unprecedented proposal". [3] This proposal, however, is far from unprecedented. Their statement directly contradicts a study published in their own journal, which found that "outcomes were comparable" to those of a physician when patients were treated by nurse practitioners with a full scope of practice. [4]

It makes sense that physicians are concerned about the expansion of advanced practice nursing; it is possible, even likely, that supplementing their professional staff with APRNs will prove to be an attractive option for many hospitals and clinics. Nurse practitioners generally are paid less than physicians but their time can be billed at a rate similar to the Medicaid and Medicare physician rate. While there may be a concern that increased APRN care may cause downward pressure on physician salaries, a study from George Washington University found no difference in wages between states with restrictive scope of practice laws, and those without. [5] Many physicians argue that their concern stems from a desire to provide the best possible care for patients, however there is little evidence to support that claim (in fact, many studies support the efficacy of APRNs).

While states such as Pennsylvania are moving forward with expanding advanced practice nursing autonomy, it is clear that a divide still exists between MDs and APRNS. The momentum appears to be with expanded use of advanced practice nursing, however it is unlikely that the AMA will relent any time soon. Until a national consensus is reached, it will be important to watch and study the effects of the individual state decisions, as well as the experience of the VA.

[1] Vance, Patricia. "Modernization of the Professional Nursing Law." January 23, 2015. Accessed August 3, 2016.
[2] Ibid.
[3] American Medical Association. "AMA Statement on VA Proposed Rule on Advanced Practice Nurses." May 25, 2016. Accessed August 3, 2016.
[4] Mundinger, Mary; Kane, Robert. "Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial." Journal of the American Medical Association 283(2000): 59-68.
[5] Pittman, Patricia; Williams, Benjamin. "Physician Wages in States with Expanded APRN Scope of Practice.' Nursing Research and Practice 2012(2012).

Photo Credit: Flickr User Ralf

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