Policy Brief – IOM Recommendation 1 – Remove Scope-of-Practice Barriers

Introduction and Statement of the Problem

The role and contribution of nurses have fundamentally changed from being mere physician assistants to professionals capable of advancing population health outcomes, improving access, and reducing inequities. In 2011, the IOM recognized that despite APRNs having the potential to reduce physician shortage and improve access, especially among disenfranchised populations, specific regulatory and training barriers impeded these possibilities. In acting on the Robert Johnson Foundation initiation on the Future of Nursing, the IOM made several recommendations to Congress, state legislatures, the Centers for Medicare and Medicaid Services (CMS), and other critical stakeholders in the healthcare sector. One of these recommendations was for these players to uproot scope-of-practice hurdles or barriers for APRNs by requiring them to practice fully like physicians. This policy brief examines the IOM’s recommendations of ways to remove scope-of-practice barriers, the background of the problem, current characteristics, the impact of the recommendations from consumer and nurse perspectives, and the current solutions and status in the policy arena.

Recommendation From the IOM Report to Remove Scope-of-Practice Barriers

In its 2011 report, the IOM Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing made several recommendations in 2008 for APRNs to practice to the full extent of their training, education, and knowledge. For example, the committee made four recommendations to Congress regarding empowering APRNs and removing practice barriers. Firstly, the committee requested legislators to expand the Medicare program by introducing coverage of APRN services within the nursing practice’s scope under specific applicable state legislation. Secondly, the committee recommended Congress amend the Medicare program to allow APRNs to certify patients and perform admission assessments for nursing home healthcare services and admission to skilled nursing and hospice facilities. Thirdly, the committee advised Congress to extend the proposed increase in Medicaid payment rates for primary care physicians stipulated in the Affordable Care Act (ACA) to APRNs providing the same primary clinical services. Lastly, the committee requested Congress to limit or restrict federal funding for nursing training/educational programs to programs in states only that have implemented the National Council of State Boards of Nursing Model Practice Act and Model Nursing Administrative Rules.

Additionally, the committee made recommendations to the state lawmakers or legislatures and Centers for Medicare and Medicaid Services (CMS). The first request is for individual states to reform and restructure scope-of-practice laws and policies to conform to the National Council of State Boards of Nursing Model Practice Act and Model Nursing Administrative Rules. The second recommendation was for state legislatures to direct or third-party payers partaking in fee-for-service reimbursement arrangements to give direct payment to APRNs. The latter is practiced within the nursing practice’s scope under state legislation. For the CMS, the committee recommended requested the clarification or amendment of hospital participation requirements in the Medicare program to guarantee that APRNs are eligible for admitting privileges, clinical privileges, and medical staff membership (IOM Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011).

Lastly, the committee made recommendations to the Office of Personnel Management, the Department of Justice’s Antitrust Division, and the Federal Trade Commission. The request to the Office of Personnel Management was to request insurers partaking in the Federal Employees Health Benefits Program to introduce coverage of APRN services falling within their scope – those within state regulation. To the Antitrust Division and the Federal Trade Commission, the committee requested a review of proposed and existing state laws concerning APRNs to determine policies that have anticompetitive impacts without fundamentally contributing to the safety and health of the public. States with unreasonably limiting laws must be advised to reform them to permit APRNs to deliver care to patients to the best of the training and education (IOM Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011).

Background

In writing its 2011 report, the IOM visualized that the future of nursing lies in having more empowered nurses who can practice to their “full” training and education like physicians. “Full practice” mandate is a collection of licensure laws and state practices that accord APRNs the authority to make diagnoses, assess patients, interpret diagnostic results from laboratories, order and prescribe drugs, and initiate and monitor therapies. Traditionally, these roles were reserved for physicians only, while nurses were only supposed to perform nursing roles and serve as physician assistants. Critical decisions involving patients were made by physicians only (Hain & Fleck, 2014).

Although this was the case since the inception of the nursing profession, everything took a new twist in 1965 when Henry Silver and Loretta Ford launched the first certificate program to advance the skills and knowledge of nurses, giving them the necessary expertise and authority to provide primary care to kids in community clinics. The nurse practice training program moved to the certificate level in the 1970s, with nurses now getting masters and bachelor’s degrees for the first time (Hain & Fleck, 2014). In the late 90s and early 2000s, the training of advanced nurses became more advanced, and the debate about giving the “full practice” authority started doing rounds. This debate culminated in the 2011 IOM report that requested Congress and State Legislatures to accord nurses with advanced training and education to practice fully. The whole concept was centered on reducing healthcare disparities associated with access and outcomes, especially in underserved regions and populations.

Current Characteristics

Like when the IOM report was released in 2011, very few changes have occurred within the past decade. State licensure still heavily regulates state licensure and scope of practice of APRNs and limits them from practicing to the full extent of their training and education. Despite the IOM request to harmonize and streamline all state practices and licensure to conform to the National Council of State Boards of Nursing Model Practice Act and Model Nursing Administrative Rules, practice and licensure legislation still varies by state. 

Although most state legislatures have passed legislation by the IOM recommendations, some like Texas are yet to allow APRNs to certify patients and perform admission assessments for nursing home healthcare services and patient admissions to skilled nursing and hospice facilities. Also, very few states have included coverage of APRN services that fall within the scope of practice under applicable state legislation. Only physicians are fully covered. Moreover, Congress is to extend the proposed increase in Medicaid payment rates for primary care physicians stipulated in the Affordable Care Act (ACA) to APRNs providing the same primary clinical services. In a nutshell, APRNs in most states are yet to get the full mandate from Congress and state Nursing Boards to assess patients, order tests, diagnose, interpret lab results, and launch and manage treatments, including making drug prescriptions.

Presently, only 23 states, together with the District of Columbia, have given APRNs full practice authority. These states include Arizona, Colorado, New Mexico, South Dakota, Wyoming, Idaho, Nevada, Oregon, Montana, Iowa, Nebraska, North Dakota, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island, Maryland, and Delaware. Other states like Utah, Kansas, Wisconsin, Illinois, Indiana, Ohio, Pennsylvania, and New York have granted “reduced practice,” meaning that APRNs can partake in at least one NP practice element. Examples of elements that might be restricted or limited include performing certain procedures or prescribing specific medications. California, Texas, Oklahoma, Missouri, Tennessee, Florida, South Carolina, Virginia, North Carolina, and Georgia fall under “restricted practice” (Incredible Health, 2021).

The Impact of the Recommendation from the Perspective of Consumers, Nurses, Other Health Professionals, and Other Stakeholders

Handing APRNs the “full practice authority” or the independence to make critical clinical decisions traditionally for doctors can profoundly impact consumers, nurses, healthcare professionals, hospitals, and other facilities. For consumers (patients), granting the more than 325,000 APRNs the authority to practice independently will more likely improve access to primary care and specialized services. America has been facing the problem of physician shortage for the longest time, an issue linked with poor access and other adverse health outcomes, including reduced quality and safety of care, high mortality rates, patient dissatisfaction, physician burnout and stress, and increased incidences of chronic diseases like diabetes and cancer, among others.

Driven by aging and population growth, the Association of American Medical Colleges (AAMC) in 2021 estimated that the country will face a physician shortage of between 37,800 and 124,000 by 2034. During that period, the country’s population is estimated to rise by nearly 10.6 percent, from the current 328 million to about 363 million, with an approximated rise of 42.4 percent in older people 65 years and above. Therefore, the demand for doctors specializing predominantly in older people is projected to continue growing. Allowing APRNs to practice independently is projected to play a critical role in filling this physician shortage issue, ultimately improving access and other medical outcomes of older adults and other disenfranchised populations like rural residents. Besides increasing consumer access to healthcare care, full practice authority can result in more options in the healthcare market, create a more efficient system, lower costs, and improve job satisfaction among APRNs.

Current Solutions

Currently, states with restricted practice are pushing to amend their state laws to allow APRNs to practice fully by conforming to the National Council of State Boards of Nursing Model Practice Act and Model Nursing Administrative Rules. For example, California has joined the bandwagon of states offering full practice authority. In a bill (AB-890) signed by governor Gavin Newsome and approved in 2020, California will become a full-practice-authority state by January 2023 when the law goes into effect (Brusie, 2020). Lobby groups, nursing associations like ANA (American Nurses Association) and the American Association of Nurse Practitioners (AANP), and other interest groups like IOM are also mounting pressure on states with restricted practice like Texas to reconsider their stand.   

Current Status in the Health Policy Arena

As indicated above, individual states regulate the licensure and medical practice within their territories. Whereas the federal government passed the Affordable Care Act (ACA) in 2010 and several institutions like the IOM have made recommendations of improving healthcare services by granting nurse practitioners full practice authority, the critical decisions rest in the hands of state legislatures; they can reduce, restrict, or allow full practice authority. Currently, about 23 states have granted full practice authority. Others like Massachusetts (Senate Bill 1330 and House Bill 1867) and Pennsylvania (Senate Bill 25) have introduced, debated, and even passed full authority practice bills. Other states like California (Assembly Bill 890), Florida (House Bill 821), Indiana (Senate Bill 394), New Jersey (Senate Bill 1961), North Carolina (Senate Bill 143 and House Bill 185), and Ohio (House Bill 177) have introduced barrier reduction bills in their respective legislatures (Gero, 2019).

Conclusion

In its 2011 report, the IOM made several recommendations to revolutionize the nursing practice, improve patient and healthcare outcomes, and enhance the performance and satisfaction of nurse practitioners. One of the major proposals made by the IOM was to remove the scope-of-practice barriers by granting APRNs full practice authority. In doing so, Congress, state legislatures, CMS, and other vital institutions were required to take a leading role in elevating nurse practitioners. For example, state legislatures were directed to amend their scope-of-practice laws and policies to conform to the National Council of State Boards of Nursing Model Practice Act and Model Nursing Administrative Rules. As of 2022, only 23 states like Arizona and Idaho have restructured their laws, granting full practice authority to practitioners. Others like California and Texas have initiated bills to remove barriers within the next two or three years. The proposed changes are expected to improve access to healthcare services and address the physician shortage problem.

References

Association of American Medical Colleges. (2021). AAMC report reinforces mounting physician shortage. Retrieved April 15, 2022, from https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-physician-shortage

Brusie, C. (2020, Oct 20). California grants nurse practitioners full practice authority by 2023. Nurse.org. Retrieved April 14, 2022, from https://nurse.org/articles/california-nurse-practitioners-full-practice/

Gero, J. (2019, Mar 18). The state of full practice authority in the 2019 legislative session. National Nurse-led Care Consortium. Retrieved April 16, 2022, from https://nurseledcare.phmc.org/news-nurse/item/524-the-state-of-full-practice-authority-in-the-2019-legislative-session.html

Hain, D., & Fleck, L. M. (2014). Barriers to NP practice that impact healthcare design. The Online Journal of Issues in Nursing, 19(2). https://doi.org/10.3912/OJIN.Vol19No02Man02

Incredible Health. (2021, Nov 5). Nurse practitioner scope of practice by state for 2022. https://www.incrediblehealth.com/blog/nurse-practitioner-scope-of-practice-by-state

IOM Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. National Academies Press (US).