by Jordan Roberts
Director of Government Affairs, John Locke Foundation
Legislation has been introduced this session with an eye toward lowering costs and expanding access to health care for North Carolinians. One such bill, the Healthcare Expansion Act of 2019, seeks to repeal North Carolina’s outdated Certificate of Need laws and make it easier for North Carolinians to see psychologists via telemedicine.
Another bill designed to address high costs and access for North Carolinians is the SAVE Act. (SAVE stands for Safe, Accessible, Value-directed and Excellent care.) The bill would eliminate state-imposed barriers for advanced practice registered nurses (APRNs).
The bill would address outdated regulations on APRNs, which include nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists. Each of these registered nurse designations must complete a minimum level of education and additional certification requirements to be certified. However, government-imposed restrictions on APRNs reduce access to care in the state and raise health care costs.
The SAVE Act would accomplish two goals. The first deals with the authority of the Board of Nursing to regulate these professions. Under current law, both the NC Medical Board and the NC Board of Nursing regulate nurse practitioners and certified nurse midwives. The proposed bill would give the Board of Nursing sole authority over the practice of these two professions. The NC Board of Nursing already supervises clinical nurse specialists and certified registered nurse anesthetists exclusively. Additionally, this bill seeks to codify the services that both clinical nurse specialists and certified registered nurse anesthetists already perform and grant each with an APRN title. Certified registered nurse anesthetists and clinical nurse specialists scope of practice will remain the same meaning they won’t be performing any new services because of the change in the law.
The second goal is to remove the requirement that nurse practitioners and certified nurse midwives have a collaborative practice agreement to treat patients. North Carolina is one of 12 states that restrict the practice authority of nurse practitioners and certified nurse midwives unless they obtain a collaborative practice agreement with a supervising physician.
A collaborative practice agreement is an agreement between an APRN and their supervising physician that outlines “patient management, prescribing authorities, and how the [nurse] and physician will communicate with each other.” The problem with APRNs and the collaborative practice agreement they must obtain is that the supervising physician does not have to do much supervising. Nurse practitioners and certified nurse midwives do not have to be in the same geographic region as their supervising physician and are only required to meet twice a year. Agreements between physicians and nurses can be expensive, adding another layer of costs to health care delivery.
Additionally, nurses who must obtain collaborative practice agreements are restricted by the activity of their supervising physician. If at any point a supervising physician informs a nurse that they plan to retire or move out of state, the nurse will have to stop practicing until they find another supervising physician. Access to care would increase by removing the collaborative practice agreement in North Carolina because nurses who are highly trained to treat patients in a primary care setting would not be restricted by the movement or availability of a supervising physician.
Benefits of Increasing the Freedom of APRNs
An extensive study conducted by Chris Conover of Duke University examined the local and statewide economic benefits that would result from granting APRNs full practice authority. The study estimated that potential annual health cost savings would range from $433 million to $4.3 billion. In addition to cost savings, the study projected that granting full practice authority would increase jobs in the state, increase the amount of tax revenue collected by the state, and address a large portion of the regional physician shortages North Carolina faces.
Access to health care for rural populations is a critical issue. Not only are physicians scarce in rural areas they can also be maldistributed across regions. According to the NC Department of Health and Human Services, 82 of North Carolina counties are designated as a health professional shortage area for primary care. As Dr. Conover found in his study, more flexibility for APRNs could mitigate some of the shortages in rural areas on North Carolina.
Opponents of the bill claim that removing the collaborative practice agreement comes at the risk that patients may encounter safety risks. However, a substantial body of research shows that in most cases, APRNs provide comparable, if not higher quality, care compared to traditional physicians and can be more cost-effective.
For instance, one study looked at 11 randomized control trials to assess the quality and cost-effectiveness of nurse practitioners in primary care and specialized ambulatory care settings. The report concluded, “Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving.”
The American College of Nurse-Midwives compiled a massive review of the research on midwifery. The findings from numerous studies suggest that certified nurse midwives lower the infant mortality rate compared to physicians, reduce health care costs, increase access in underserved areas, and enhance patient satisfaction.
The bill does not change the scope of practice for clinical nurse specialists or certified registered nurse anesthetists; it merely defines their practice in state law. Some are concerned about granting certified registered nurse anesthetists an APRN license. However, the research shows that certified registered nurse anesthetists provide equal levels of quality care compared to traditional anesthesiologists. A study from 2010 examined the quality of care among nurse anesthetists for 14 states that had opted out of their supervisory requirement under Medicare to receive reimbursement for certified registered nurse anesthetists services. The researchers found that there was no evidence of increased deaths or patient complications. Other studies have found that certified registered nurse anesthetists are the most cost-effective providers of administering anesthesia.
Increasing the practice authority of APRNs by eliminating unnecessary government barriers such as the collaborative practice agreement would bring tremendous benefits to the state. It would cost taxpayers nothing and would increase the freedom of high-quality health professionals to practice as they wish. I believe it is time for North Carolina lawmakers to grant APRNs full practice authority.