Recent Info on Full Practice Authority for APRNs

[traumaRUs, MSN, APRN]

I recently received the AACN Critical Care Newsletter and was looking thru it casually. One of the articles that caught my eye was from the Hamilton Project and the subject was full practice authority (FPA). This is always a hot topic with my fellow APRNs. Although I live in a state where FPA is practiced, there are still limitations to my practice authority:

• Can order home health but can't sign the admitting orders. Same with PT/OT/ST.
• I can pronounce a patient deceased but can't sign a death certificate.
• Only recently was able to sign off on handicapped placards for the Department of Motor Vehicles.

Just little things to be sure but they impede my ability to care for my patients.

From the American Association of Nurse Practitioners here is a map showing the status of all US states regarding full practice authority.

We all know that the cost of healthcare in the US continues to rise; for some care; to astronomical levels. For instance, its estimated that hemodialysis provided for 3-4 hours per week three times per week costs $89,000 per year.

There are many thoughts as to how to reduce our healthcare costs. However, one that is gaining favor rapidly is expanding the role of APRNs to allow them to practice to the full extent of their licensure. For those of us in the trenches; providing healthcare to our patients on a daily basis and faced with restrictions on our scope of practice, we are actually increasing healthcare costs as well as decreasing productivity.

One example that I'm personally involved in is ordering home care for my patients. When a patient is hospitalized for any period of time, especially a patient who is already chronically ill, they tend to lose some degree of functionality. Many, perhaps most, want to return home if at all possible. Home care is essential to achieving this goal. So, I order the home care; nursing, therapy or other care and the home care agency sends out someone to do the evaluation. Then, they come up with a plan of care. However, they now need orders to start the care. Calling me on my cell phone and having me quickly fax them an order is simple, easy and time-saving. But...that's not what happens. Nope, I have to then call the physician, explain the care needed and then hope he has time to sign the orders that I have written and faxed to him. Sometimes these are physicians that haven't even seen the patient. At the very least we are delaying care by one day. However, if the physician is busy or has further questions, it can involve more prolonged communication and delay in care.

We are all concerned with our employment opportunities and this is another area where growth potential for NPs is high and expected to continue to increase. This graph shows an increase in employment opportunities for APRNs from 2016 to 2026 from the Bureau of Labor Statistics.

You only have to glance thru the APRN and NP forums for the subject of full practice authority. There are many many threads on this. "Opponents contend that quality of care may suffer under the direction of a nonphysician practitioner, citing the shorter length of training and clinical experience required. Their arguments that restrictions are necessary to protect public health." Here is an extensive summary of multiple studies done regarding full practice authority. This is the first table with multiple studies regarding the efficacy of full practice authority for NPs that I've seen recently. It bears reading for all APRNs. Even if you live in a state where you already have full practice authority, this is an important issue for all of us.

Thoughts??

References:

American Association of Nurse Practitioners

Bureau of Labor Statistics

The Hamilton Project

[Spadeforce]

I too often see APRNs wanting equal pay to the docs but the same ones saying FPA = saved healthcare dollars.

We all know increased administrative burden and cronyism is what is jacking up healthcare costs. Not the docs raking in the money.

But if APPs want full practice (will prob never happen for PAs) then they gotta hold the same liability. Cant wait to see how this pans out with the decrease in NP standards lol.

Even in states with full SOP many hospitals place the limitations sooo it prob won't make much difference really.

[Susie2310]

We know that many APRN's would love to have full practice authority. However, their education and training is a very small fraction of a physician's.

The above poster referenced the standards of NP training; using the search function will bring up many discussions about this topic.

There are numerous discussions on this forum about nurse practitioner education/training versus physician education/training, the limitations of nurse practitioner education/training, and the quality of care provided by nurse practitioners versus physicians, which should be easy to find using the search function.

I live in a state where NP's do not practice independently, and I am very glad that I do so. In my state NP's are supervised by physicians and practice under standardized procedures; I believe this is absolutely necessary in order to provide safe patient care. The thought of no physician oversight at all, as described by the OP, is not something I could possibly support.

There are multiple reasons for ever rising healthcare costs. Lack of competition, i.e. healthcare monopolies of large healthcare organizations in some states and reduced numbers of insurers participating in healthcare exchanges in a number of states are significant causes of inflated health care costs, which particularly affect those who purchase health insurance on the individual market. These problems can be fixed if there is the political will. Also, some states have chosen not to expand Medicaid and participate in the healthcare exchanges. Another contributor to increased healthcare costs is fraudulent billing practices. We need to address the causes of inflated healthcare costs and take steps to eradicate them if we are to reduce healthcare costs. Failing to correctly identify the causes of inflated and ever rising healthcare costs, and making the solution out to be full practice authority for APRN's, is a false solution, and in my opinion is disingenuous.

[traumaRUs, MSN, APRN]

We know that many APRN's would love to have full practice authority. However, their education and training is a very small fraction of a physician's.

The above poster referenced the standards of NP training; using the search function will bring up many discussions about this topic.

There are numerous discussions on this forum about nurse practitioner education/training versus physician education/training, the limitations of nurse practitioner education/training, and the quality of care provided by nurse practitioners versus physicians, which should be easy to find using the search function.

I live in a state where NP's do not practice independently, and I am very glad that I do so. In my state NP's are supervised by physicians and practice under standardized procedures; I believe this is absolutely necessary in order to provide safe patient care. The thought of no physician oversight at all, as described by the OP, is not something I could possibly support.

There are multiple reasons for ever rising healthcare costs. Lack of competition, i.e. healthcare monopolies of large healthcare organizations in some states and reduced numbers of insurers participating in healthcare exchanges in a number of states are significant causes of inflated health care costs, which particularly affect those who purchase health insurance on the individual market. These problems can be fixed if there is the political will. Also, some states have chosen not to expand Medicaid and participate in the healthcare exchanges. Another contributor to increased healthcare costs is fraudulent billing practices. We need to address the causes of inflated healthcare costs and take steps to eradicate them if we are to reduce healthcare costs. Failing to correctly identify the causes of inflated and ever rising healthcare costs, and making the solution out to be full practice authority for APRN's, is a false solution, and in my opinion is disingenuous.

Just curious - are you an APRN? And if yes, where do you practice? Hospital, office, clinic?

The issues I personally cited: not being able to inititate home care orders greatly impact my patients. A physician and I would be equaily able to do this. It does not take additional education beyond that of an APRN to initiate home care.

My article is not to push for APRNs to be able to do open heart surgery! Its just to get rid of the barriers needed to do our job and care for our patients.

[traumaRUs, MSN, APRN]

I too often see APRNs wanting equal pay to the docs but the same ones saying FPA = saved healthcare dollars.

We all know increased administrative burden and cronyism is what is jacking up healthcare costs. Not the docs raking in the money.

But if APPs want full practice (will prob never happen for PAs) then they gotta hold the same liability. Cant wait to see how this pans out with the decrease in NP standards lol.

Even in states with full SOP many hospitals place the limitations sooo it prob won't make much difference really.

This article is about full practice athority - being able to practice to our licensure. As to liability - well let me tell you about that....I am held to the same standard as the MDs when doing the same task or making the assessment with the same pt.

[Susie2310]

Just curious - are you an APRN? And if yes, where do you practice? Hospital, office, clinic?

Respectfully, I am an RN and I have an opinion on this subject as it affects patient care. Also, APRN's are nurses too.

[traumaRUs, MSN, APRN]

Respectfully, I am an RN and I have an opinion on this subject as it affects patient care. Also, APRN's are nurses too.

No problem with that and of course APRNs are nurses. My points are:

1. It doesn't take an MD license to sign home care orders

2. MD is not needed to sign for DMV handicapped placards.

And fortunately while I live in a state with FPA, our ability to practice is limited by the hospitals where we are credentialed and by our practices. I am extremely fortunate to work in a large practice where autonomy and FPA is valued.

[Neuro Guy NP, DNP, PhD, APRN]

No one needs a piece of paper to tell him or her when to collaborate with someone. That's just ridiculous. Physicians don't need a piece of paper that requires them to consult with someone, yet they call a consultant when needed. It's the same concept - remove unnecessary barriers to practice that limit care.

Also, don't forget that plenty of physicians make horrible mistakes all the time, just look at all the malpractice attorneys and lawsuits there are. So a little document AKA a collaborative agreement - whether required by law or not isn't going to stop us from doing the same, so it's a very flawed argument.

FYI the state I now practice in is FPA.

[Oldmahubbard]

I am in a state where NP practice was modernized a few years back. No more collaborative requirement for those with a relatively small amount of experience.

Having lived for many years under the old rule, I can tell you that a very quick look at a small fraction of NP records every 3 months, as previously required, would not protect the public from an incompetent person.

So the old requirements were BS. And NPs are expected to know what is outside their scope, just like every other medical professional, and to refer.

That being said, we are now graduating people from such low quality programs that I truly fear for the profession.

[Spadeforce]

Not disagreeing with the signing of documents being allowed for NPs but I still don't see how they save money if they want equal pay.

I do have to say, while the group that makes these proposals seems legit, they are misinformed on the healthcare professions.

IE- they want full practice authority for PAs. This cannot work currently because PAs are taught as generalists and have actual scope of practice agreements written out between them and physicians stating exactly what they can and cannot do on an individual basis. So if PAs have full authority, in which specialty is that going to be in, all of them??? Since they are trained as generalists this would mean allowing them to do everything. 2 years of training and they can be your CTS, neurosurgeon, etc, etc.? I just do not see hospitals/insurers actually agreeing to this so even if its allowed at the state level it won't float.

Its a little more well defined with NPs since they are more role specific, but with the current quality of training I cannot really back FPA, but the current model we have is silly so it needs done away with. Here come the malpractice suits lol.

[LibraSunCNM, BSN, MSN, CNM]

Not disagreeing with the signing of documents being allowed for NPs but I still don't see how they save money if they want equal pay.QUOTE]

But who here is talking about NPs getting equal pay as physicians? I'm confused.

As a CNM, I'm definitely seeing the projections for growth within the profession pan out in real life, programs are graduating about 3 times as many students as they were 5 years ago, and the number of programs is growing. Since CNM programs are well regulated, and our healthcare system desperately needs midwives to step in to change maternity care in this country, I'm thrilled about it. However, I do voice the same sentiments as others here about sub-par NP diploma mills. Overall, though, I totally support full practice authority for APNs. People who object to it as removing some sort of safety barrier clearly don't know the ins and outs of the actual process involved. So many of these "barriers" are just red tape, like a doctor who you barely ever see signing off on a few charts every once in a while. It's totally arbitrary, and as others have said, doesn't actually prevent unsafe practitioners from falling through the cracks. Lobbying for stricter accrediting standards for NP programs would probably protect the public better, IMO.

I too often see APRNs wanting equal pay to the docs but the same ones saying FPA = saved healthcare dollars.

We all know increased administrative burden and cronyism is what is jacking up healthcare costs. Not the docs raking in the money.

But if APPs want full practice (will prob never happen for PAs) then they gotta hold the same liability. Cant wait to see how this pans out with the decrease in NP standards lol.

Even in states with full SOP many hospitals place the limitations sooo it prob won't make much difference really.

Even with equal pay expanding access to primary care care result in lower overall healthcare costs. This about a simple example of what costs more: 1. treating a patient with IFG with metformin and preventing complications or 2. treating a overt diabetic with insulin and diabetic nephropathy? The simple act of increasing access to care can lower overall costs, regardless of whether its a physician or an NPP.

All providers (physician or NPP) are held to the same legal tort liability; they are held to the same quality measures too by third party payers.