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Research & Commentary: Expanded Role for Nurses Could Help Address Ohio’s Primary Care Shortage

September 17, 2018

In this Research & Commentary, Matthew Glans examines a new bill in Ohio that would allow well-trained advanced practice registered nurses (APRNs) to provide expanded care without unnecessary regulatory barriers.

Like many states, Ohio is facing a health care shortage, leaving many patients without basic primary care services. In fact, to maintain current rates of primary care utilization, Ohio will need “an additional 681 primary care physicians by 2030, or an 8% increase in physicians compared to the state’s current (as of 2010) 7,783 PCP workforce,” the Robert Graham Center estimated.

Even worse, the United States could experience a shortage of 120,000 physicians by 2030, which would have a dramatic impact, according to the Association of American Medical Colleges (AAMC). The AAMC ranked Ohio 21st among states in the number of active patient care primary care physicians per capita, according to The Plain Dealer.

Avoiding a health care shortage is complicated by the fact that becoming a licensed health care provider is an expensive and slow process. Supporters of strict state licensing standards argue they assure quality, but critics argue the arduous and often expensive licensing process harms the health care market by hindering entry for new physicians and thereby impeding the competition that lowers costs and improves consumer access to health care services.

A proposal being considered in the Ohio General Assembly would help address this shortage by allowing well-trained advanced practice registered nurses (APRNs) to provide expanded care without unnecessary regulatory barriers. Introduced by Rep. Theresa Gavarone (R- Bowling Green), the new proposal would allow APRNs to work independently of physicians. APRNs are well-trained and licensed professionals, who have earned a master’s degree, post-master’s certificate, or practice-focused doctor of nursing practice degree in their designated roles.

APRNs are trained to provide a range of medical services including disease diagnosis, treatment, and prescription medication orders. However, APRNs are not allowed to practice these services in Ohio unless they enter into a Prescriptive Authority Agreement (PAA) with a doctor. Although PAAs do not require doctors to directly supervise APRNs, they can cost hundreds of thousands of dollars. Supporters argue PAAs ensure safety, as physicians have more expertise in treating patients.

Jesse McClain, president of the Ohio Association of Advanced Practice Nurses said PAAs are merely fees and that little interaction exists under the current system.  McClain stated the agreements were “little more than a fee APRNs pay to a physician in order to practice. Far from collaboration, this contract requires APRNs to provide a subset of their charts to physicians for review, while no actual collaboration regarding patient care occurs between the contracted physicians and APRNs.”

Allowing APRNs and nurse practitioners to administer health care services would greatly improve health care access and reduce costs. Currently, more than 20 states and the Veterans Administration allow APRNs to practice independently of doctors. Although critics claim expanding the scope of practice for APRNs will reduce overall quality of care, a 2012 article in Health Affairs reviewing 26 studies on the topic noted the “health status, treatment practices, and prescribing behavior [of APRNs] were consistent … [with those of] physicians.” Furthermore, a 2015 study in the International Journal for Quality in Health Care found “few differences in primary care provided by APNs and physicians; for some measures APN care was superior.”

Eliminating the costly supervision requirements for APRNs is a good step toward increasing the number of APRNs in Ohio, which will reduce the primary care physician shortage and increase the availability of health care to patients across the Buckeye State.

The following articles examine the doctor shortage, scope of practice, and medical licensing from varied perspectives.
 

Quality of Primary Care by Advanced Practice Nurses: A Systematic Review
https://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality%20of%20Primary%20Care%20Advanced%20Practice%20Nurses.pdf
In this study, published in the International Journal for Quality in Health Care, the authors conduct a systematic review of randomized controlled trials of the safety and effectiveness of primary care provided by advanced practice nurses and evaluate the potential of their deployment to help alleviate primary care shortages.

Healthcare Openness and Access Project: Mapping the Frontier for the Next Generation of American Health Care
https://www.heartland.org/publications-resources/publications/healthcare-openness-and-access-project-mapping-the-frontier-for-the-next-generation-of-american-health-care
The Healthcare Openness and Access Project (HOAP) is a collection of state-by-state comparative data on the flexibility and discretion U.S. patients and providers have in managing health care. HOAP combines these data to produce 38 indicators of openness and accessibility. The project provides state-by-state rankings over a number of variables, including occupational licensing.

End State Licensing of Physicians
https://www.cato.org/publications/commentary/end-state-licensing-physicians
Shirley Svorny of the Cato Institute argues in this article for the ending of state licensing for physicians. Svorny says the state licensing system is both costly and unneeded. “The benefits of state licensing are overstated. Licensing authorities verify education and training, but little else. State licenses do not indicate an individual physician’s specialty-specific skills. Specialty certification is the purview of medical specialty boards, which are private,” wrote Svorny.

Medical Licensing: An Obstacle to Affordable, Quality Care
http://heartland.org/policy-documents/medical-licensing-obstacle-affordable-quality-care
Shirley Svorny of the Cato Institute argues licensure not only fails to protect consumers from incompetent physicians, it also makes health care more expensive and less accessible by raising barriers to entry. Only institutional oversight and a complex network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today.

Reform for a Healthy Future: Expanding Scope of Practice for Nurse Practitioners in Texas
https://www.texaspolicy.com/library/doclib/2014-05-PP19-ScopeofPractice-CHCP-JohnDavidson.pdf
In this Policy Perspective, John Davidson of the Texas Public Policy Foundation argues Texas’ medical practice laws are highly restrictive compared to many other states and incentivize NPs to practice elsewhere, thereby exacerbating a growing provider shortage in the state.

The Medical Monopoly: Protecting Consumers or Limiting Competition?
http://heartland.org/policy-documents/medical-monopoly-protecting-consumers-or-limiting-competition
Sue A. Blevins of the Cato Institute examines the effect of government health care policies on the health care market. Blevins finds licensure laws appear to limit the supply of health care providers and restrict competition to physicians from non-physician practitioners. The primary result is an increase in physician fees and income, driving up health care costs.

Medical Licensing in the States: Some Room for Agreement – and Reform
http://www.cato.org/blog/medical-licensing-states-some-room-agreement-reform
Charles Hughes of the Cato Institute discusses the growing doctor shortage, how it is likely to increase with the implementation of Obamacare, and the steps some states are taking to address the issue.

A Cure for what Ails Us
http://heartland.org/policy-documents/cure-what-ails-us
Justin Owen, Trey Moore, and Christina Weber of the Beacon Center of Tennessee analyze the current predicament facing Tennessee policymakers in the wake of the Affordable Care Act. The report also offers state-led solutions that would move the nation’s health care system in the proper direction, treating the diseases that weaken the system themselves, rather than merely treating symptoms.

Six Reforms to Occupational Licensing Laws to Increase Jobs and Lower Costs
http://heartland.org/sites/default/files/occupational_licensing.pdf
Byron Schlomach of the Goldwater Institute argues reforming licensing could open career opportunities and reduce costs without sacrificing consumer safety. The paper recommends six reforms.
 

Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute. For further information on this subject, visit The Heartland Institute’s website, and PolicyBot, Heartland’s free online research database.

If you have any questions about this issue or The Heartland Institute’s website, contact Lindsey Stroud, a state government relations manager at The Heartland Institute, at lstroud@heartland.org or 312/377-4000.

Author
Matthew Glans joined the staff of The Heartland Institute in November 2007 as legislative specialist for insurance and finance. In 2012, Glans was named senior policy analyst.
mglans@heartland.org @HeartlandGR