Nurse Practitioners Provide More Primary Care in States with Least Restrictive Regulations

Facing a nationwide shortage of primary care physicians, some states in recent years have eased up on regulations that create barriers for nurse practitioners who want to work as primary care providers.

That easing of rules has had the intended effect. According to a new study by researchers at the University of Texas Medical Branch at Galveston, those states with the fewest restrictions on nurse practitioners’ scope of practice had two-and-a-half times more patients receiving primary care from nurse practitioners than did the most restrictive states.

“We wanted to look at what happened in states that allowed nurse practitioners more or less authority,” said Yong-Fang Kuo, lead author of the study. “As you would expect, it makes a big difference. We can now clearly show that states with fewer regulations means more patients get the primary care they need.”

This news is directly relevant to Texans right now, as State Senate Bill 406, which eases regulations on both nurse practitioners and physician assistants, was recently approved by the Texas Legislature and signed by the governor.

Increasing access to primary care is a key focus of national health reform efforts. States with a higher ratio of primary care providers to patients have lower Medicare expenditures and lower mortality rates. The shortage in primary care physicians has happened, in part, because more and more United States medical students are choosing medical specialty fields instead of primary care. In 1998, around 60 percent of U.S. medical students chose careers in primary care. Today, fewer than 25 percent do.

In the meantime, the past two decades have witnessed an increase in nurse practitioner training programs. There are more nurse practitioners in the U.S. now than ever before. States vary greatly, however, in how extensively they regulate nurse practitioners’ scope of practice. In some states, they have essentially the same authority to practice that physicians have. Other states require physician supervision and limit nurse practitioners’ hospital privileges as well as the authority to order tests, make referrals and prescribe medications.

The UTMB study looked at the growth in care provided by nurse practitioners from 1998 to 2010 using state records and national Medicare data. The researchers found that the number of patients seeing nurse practitioners as their primary care provider is on the upswing. In 1998, only 0.2 percent of Medicare patients nationwide used nurse practitioners as their primary care provider, versus 2.9 percent in 2010. In Alaska the percentage was nearly 15 percent.

Over the 12-year time period studied, the highest growth in nurse practitioner primary care was in states that allowed them to practice and prescribe independently: Alabama, Alaska, Idaho, Montana, New Hampshire, New Mexico, North Dakota, Maine, Oregon and Vermont.

The new Texas rules, scheduled to go into effect Nov. 1, would bring nurse practitioners into closer alignment with their counterparts in those states. The bill eliminates the requirement for on-site physician supervision and allows more leeway in the delegation of prescribing authority.

The study appears in the July issue of the journal Health Affairs and was funded by the Agency for Healthcare Research and Quality, the National Institute on Aging, the National Cancer Institute and the National Center for Research Resources, National Institutes of Health.

Co-authors of the study are Figaro Loresto Jr., Linda Rounds and Dr. James Goodwin.