Why Efforts to Expand NP Authority Have Met Resistance

• Over the past several years, the idea to expand NP authority has made its way through the legislature but continues to meet resistance.
• Advocates say giving NPs the authority to practice without a supervising physician or collaborating with a physician would help lower costs and help provide care in rural areas.
• But those in opposition believe taking a physician out of the care team would lead to worse health outcomes and drive up costs.

Practitioners, healthcare leaders, and legislators have been screaming from the mountaintop about the healthcare industry’s workforce shortage. But one suggestion that some believe could help alleviate the burden hasn’t been able to get out of the gate— allowing nurse practitioners to provide care without a supervising physician. 

What’s the Latest on Efforts to Expand NP Authority?

Just this month, three measures (H.B. 821, H.B. 1490, and H.B. 1652) in the Mississippi legislature that would have given advanced practice registered nurses (APRN) and certified registered nurse anesthetists (CRNA) the ability to practice without a supervising physician — with the caveat that they had completed a specific amount of supervised clinical or practice hours — all died in committee. 

The Mississippi State Medical Association (MSMA) and the American Medical Association opposed the trifecta of bills. Dr. James L. Madara, AMA’s CEO and executive vice president, wrote to the Mississippi House Public Health and Human Services Committee that the bills “significantly weaken the existing collaborative practice requirements” and all but remove physicians from the healthcare team. 

“Multiple studies have shown that doing so will worsen health outcomes for Mississippi patients and lead to higher costs — all without improving access to care in rural areas,” he wrote. 

Authors of the 2022 study, “Targeting Value-based Care with Physician-led Care Teams,” reviewed nearly a decade’s worth of data at a Mississippi clinic that included more than 300 physicians, 150 advanced practice providers (APP), more than 208,000 patient survey response and cost data on thousands of Medicare beneficiaries. 

“By allowing APPs to function with independent panels under physician supervision, we failed to meet our goals in the primary care setting of providing patients with an equivalent value-based experience,” the authors wrote, noting higher quality care with physicians and higher costs ($43 per patient per month) for those whose primary provider was an APP. 

MSMA also organized grassroots and media campaigns in opposition to the measures.

In April, Wisconsin’s APRN Modernization Act failed also failed, despite advocacy efforts dating back more than a decade, according to the Milwaukee Journal Sentinel. The measure would have allowed the state nursing board to license qualified nurses as APRNs, giving them the authority to practice without a supervising physician and prescribe medication. 

Wisconsin Gov. Tony Evers vetoed the measure because he objected to standards that did not “provide adequate experience requirements, titling protections, and safeguards for patients who may be treated for chronic pain management.”

Past Efforts to Expand NP Authority

At the national level, attempts were made in two previous legislative sessions to expand practice authority for APRNs. 

The bipartisan Improving Care and Access to Nurses (ICAN) Act of 2023, first introduced in 2022, was a second attempt to remove “numerous administrative and practice barriers” for APRNs to care for patients. It would have allowed providers other than physicians to administer care under Medicare and Medicaid, such as: 

• Allowing NPs or physicians assistants to fulfill documentation requirements for Medicare coverage of special shoes for diabetic individuals; 
• Expediting the ability of physician assistants, nurse practitioners, and clinical nurse specialists to supervise Medicare cardiac, intensive cardiac, and pulmonary rehabilitation programs; and  
• Allowing NPs to certify the need for inpatient hospital services under Medicare and Medicaid. 

American Nurses Association (ANA) President Jennifer Mensik Kennedy, PhD, MBA, RN, NEA-BC, FAAN, said in a statement at the time that the measure would improve care for millions of people. 

“By updating the Medicare and Medicaid programs and enabling APRNs to practice to the top of their education and clinical training, like they did at the height of the COVID-19 pandemic, the patients and communities being served by these nurses will get improved access to care, from the provider of their choice,” Kennedy stated. “This is especially true for those living in underserved communities who are often faced with a shortage of providers. The ICAN Act removes superfluous regulations that serve as barriers to expanding care in areas where APRNs are often the primary provider.”

The American Association of Nurse Practitioners also issued a statement in 2023 in favor of the measure. AANP President Stephen Ferrara, DNP, said at the time that the legislation would help the healthcare system better reflect the modern workforce. 

However, the American College of Emergency Physicians and more than 100 other organizations opposed the measure, stating that data shows “scope expansions” haven’t increased access to care in underserved or rural areas.

“While all health care professionals play a critical role in providing care to patients and non-physician practitioners are important members of the care team, their skill sets are not interchangeable with those of fully educated and trained physicians,” they wrote in a joint letter to Congress.

California physicians also were among those opposed to a similar move in 2019, with the state medical association citing a lack of “adequate care.” 

What’s the Big Deal, Anyway?

Two key arguments against expanding the role of APRNs center on the amount of training and cost effectiveness. 

Physicians, according to AMA, complete between 12,000 and 16,000 hours of clinical training compared to 500 to 750 hours for NPs.

“Rather than support an unproven path forward, legislators should consider proven solutions to increase access to care and reduce health care costs, including supporting physician-led team-based care,” Dr. Madara wrote. “That would involve expanding coverage and payment for high-quality telehealth and state funding for graduate medical education to increase the physician workforce.”

More than half of U.S. states and territories have NP-related full-practice authority licensure laws, according to AANP, including: Alaska, Arizona, Colorado, Connecticut, Delaware, District of Columbia, Guam, Hawaii, Idaho, Iowa, Kansas, Maine, Maryland, Massachusetts, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Northern Mariana Islands, Oregon, Rhode Island, South Dakota, Utah, Vermont, Washington, and Wyoming.

AANP argues that full-practice authority improves access to and streamlines care, along with decreasing costs and protecting patient choice. It also presents its own findings that show NPs acting with full authority reduce care costs. 

The Bottom Line

Despite advocacy efforts over the past several years, initiatives to increase practice authority for APRNs have had little success at the national level. But more than half of U.S. states and territories already have such measures in place. Resistance in states that have not yet expanded practice capabilities stems from concern about quality and cost of care, as well as the differences in training between physicians and APRNs. 

Read More