Challenges Nurse Practitioner Encounter

Challenges Nurse Practitioner Encounter

Challenges The Advanced Nurse Practitioner Encounter In Their Scope Of Practice

Challenges Nurse Practitioner Encounter

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There is no question that access to primary care is critical for population health. Currently, more than one in 10 U.S. residents resides in a county with fewer than one primary care physician per 2,000 people, and the demand for primary care will increase as the population grows and ages, chronic conditions increase, and insurance coverage expands (UnitedHealth Group, 2018).

Lack of access to primary care contributes to an increase in avoidable suffering and wasted dollars, as people are forced to seek expensive emergency care or hospitalization after their often preventable health condition is too advanced to ignore (Rosano et al., 2013Shi, 2012).

Challenges Nurse Practitioner Encounter:The primary care workforce is also changing.

Between 2010 and 2016, the physician workforce grew by 1.1% whereas the nurse practitioner (NP) workforce grew by 9.4%; these trends are projected to continue through 2030, with the availability of advanced practice providers predicted to outstrip the availability of physicians in primary care (Auerbach, Staiger, & Buerhaus, 2018).

Between 2008 and 2016, the fraction of providers who were NPs in primary care practices grew by over 40%, whereas the fraction of providers who were physicians in these settings dropped by 12% (Barnes, Richards, McHugh, & Martsolf, 2018).

Given this shift, it is increasingly important to understand how state-level NP scope of practice (SOP) policies influence access to primary care. Systematic reviews have found that states with full SOP policy have more and faster growth of NPs, greater likelihood of NPs caring for underserved populations, and improved utilization of services (Patel, Petermann, & Mark, 2018Xue, Ye, Brewer, & Spetz, 2016).

Challenges Nurse Practitioner Encounter:Less restrictive SOP

is also associated with lower odds of having to drive over 30 min to a primary care provider (Neff et al., 2018), and greater supply of NPs in rural and primary care health professional shortage counties (Xue et al., 2018).

One rigorously conducted study of states’ changing from restrictive to full SOP found increased consumer utilization of checkups, increased availability of appointments when wanted, more adults rating their health care as excellent, decreased emergency room visits for ambulatory care sensitive conditions, and decreased administrative burden for physicians (Traczynski & Udalova, 2018).

Because restrictive SOP policies can serve as an anticompetitive barrier for primary care providers, removal of such policies may result in increased access to care. States with full SOP may have a more efficiently functioning primary care labor market that allows employers the opportunity to better optimize the most cost-effective and productive mix of providers, resulting in gains in increased output of primary care at lower costs of production (Adams & Markowitz, 2018).

The rationale for restrictive NP SOP

policies frequently invokes the differential training of NPs and physicians, and the assertion that NPs practicing independently cannot provide the same quality of care as physicians (Isaacs & Jellinek, 2012). However, restrictive SOP has not been found to improve quality of care (Perloff, Clarke, DesRoches, O’Reilly-Jacob, & Buerhaus, 2017).

Furthermore, a systematic review of randomized controlled trials of the quality of NP-provided care found that NP delivered care resulted in similar or better outcomes compared with physician-delivered care (Swan, Ferguson, Chang, Larson, & Smaldone, 2015). Others found that Medicare beneficiaries primarily cared for by NPs had fewer hospital admissions, readmissions, inappropriate emergency department use, and use of low-value imaging compared with beneficiaries attributed to physicians (Buerhaus et al., 2018).

Evidence suggests that NP-delivered care is safe and effective, and that implementing full state-level NP SOP policy may increase access to care. So why have more states not implemented full NP SOP policy? The answer may be more political than evidence based. McMichael (2017) found that a state’s decision surrounding implementation of full SOP was more related to political spending by physician groups within the state than to population access needs.

Restrictive SOP policies

have also been hypothesized to protect the interest of a guild profession, such as medicine, rather than the public (Kleiner, 2015). For example, one study found that less restrictive NP SOP policies resulted in lower prices of well-child visits, but also resulted in decreases in physician wages (Kleiner, Marier, Park, & Wing, 2016). Another possibility is that state legislators do not have enough evidence to inform legislative priorities.

Regardless, we need to understand how NP SOP policies shape primary care, especially as the NP workforce rapidly expands. It is essential to build data infrastructures that reliably capture the NP workforce and NP delivered care.

Many national data sets do not accurately identify NP-delivered care; for example, The Medical Expenditures and Panel Survey combines registered nurses with NPs and insurance claims data often underestimate NP-delivered care because of “incident to” billing (Barnes & Novosel, 2018).

In addition, there is a need for conceptually and methodologically sophisticated research that moves away from cross-sectional comparisons of states with full versus restrictive SOP policies and toward quasiexperimental designs.

By leveraging state-level or health system–level changes as natural experiments, we can better disentangle the causal effects of implementing full SOP policy.

Furthermore, there is a need for increased engagement in interdisciplinary policy work so that varying disciplines can build bridges to the common goal of population health with a broader, more inclusive lens. Finally, it remains crucial to conduct, disseminate, and use objective but meaningful research to inform actionable policy change, especially when policy research often dwells in the “shadow of politics” (Peterson, 2018).

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Ms. Patel’s work was partially supported by a National Service Research Award Pre-Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 HS000032, and by The Alex and Rita Hillman Foundation through the Hillman Scholars Program in Nursing Innovation at the University of North Carolina at Chapel Hill

Adams, E. K., Markowitz, S. (2018). Improving efficiency in the health-care system: Removing anticompetitive barriers for advanced practice registered nurses and physician assistants. Policy Proposal, 8, 913.
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Mark, B. A., & Patel, E. (2019). Nurse Practitioner Scope of Practice: What Do We Know and Where Do We Go?. doi:

 From above identify three challenges the Advanced Nurse Practitioner encounter in their Scope of practice (SOP). 

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Challenges Nurse Practitioner Encounter

Challenges Nurse Practitioner Encounter