Advanced Practice Nurses Battle On for Autonomy

As advanced practice nurses gain ground in their battle for autonomy, the Missouri State Medical Association has taken a firm stand against APRN's independent practice authority.

In March, a California appeals court ruled that certified registered nurse anesthetists in that state do not need physician supervision to do their jobs. But it's a tough fight.

Just a month earlier, in a Legislative Report, the MSMA described a "gaggle" of nurse practitioners who who were waiting to make their case in front of the state legislature. The report's author said that these nurses "flooded" the Senate hearing room "like 12-year olds at a Justin Bieber concert."

"I work so hard to try to take the high road," says Lisa Summers, CNM, DrPH, Senior Policy Fellow in the Department of Nursing Practice and Policy at the American Nurses Association. She says she wants to talk about the data when discussing APRNs' autonomy, not revert to turf battles and name-calling.

"Comparing us to 12-year-old girls at a Justin Bieber concert?" she asks rhetorically, a note of incredulity in her voice.

So in this column, I, too, will take the high road. Instead of talking about things like misogyny and disrespect, I will simply talk about two new advances for APRNs' practice autonomy: incentives from the government for hospitals to train APRNs and a new study showing that physician wages aren't affected by APRNs' autonomy.

Under a new Graduate Nurse Education (GNE) Demonstration, CMS will provide hospitals working with nursing schools to train APRNs with payments of up to $200 million over four years to cover the costs their clinical training.

CMS will select up to five eligible hospitals to participate in the demonstration, which is expected to run for four years. Payments to the hospitals will be linked to the number of additional APRNs that the hospitals and their partners are able to train as a result of their participation in the demonstration.

Summers says an important provision is the demonstration's requirement that half of the clinical training must occur in non-hospital settings in the community.

"There's a good example of the government trying to provide an incentive to [say] we can transplant hearts and we can do all kinds of snazzy care; can't we also do some really good primary and preventive care?" she tells HealthLeaders.

Although Summers says the demo is promising, "it's a demo," she says. "It is a drop in the bucket when you compare it to graduate medical education. And while we've had a lot of attention and success in the Affordable Care Act, there are areas where we're still pretty frustrated."

Summers' running list of organizations calling for the expansion of APRN's scope of practice includes the Baker Institute, the National Center for Policy Analysis, the Institute of Medicine, and the Bipartisan Quality Center.

"It's not just the APRN community anymore," says Summers. But despite the crescendo of support for widening APRNs' scope of practice, there is still pushback from a few.

"It is coming from almost exclusively from organized medicine," Summers says, meaning medical groups like the AMA and, of course, the Missouri State Medical Association.

But a new study might help to push back the pushback, at least from a physician wage perspective.

The study, from George Washington University's School of Public Health and Health Services, concluded that physician earnings are largely unchanged in states with fewer barriers for APRNs to practice.

Supported by the Robert Wood Johnson Foundation and published in the journal Nursing Research and Practice, the study used data from the Bureau of Labor Statistics to compare the earnings of family physicians, general physicians, and pediatricians in states with barriers to APRN practice to the earnings of physicians in states with fewer restrictions. Researchers used earnings of surgeons—who are unlikely to be impacted by nurse practice laws—as a control group.

The researchers found no statistically significant variation in average per-hour earnings for any of the physician groups among the states with differing APRN autonomy laws.

"In fact, wages for all three practitioner groups rose at a slightly faster rate between 1999 and 2009 in states with more liberal [scope of practice] laws [than] in states with restrictive laws," the study says.

Of course, physician groups' primary argument is that patient care will suffer without restrictive scope of practice laws. But Summers says there are decades of research showing that patient care doesn't suffer at the hands of APRNs, and that healthcare should focus on a team-based approach to preventive and primary care.

"We've got to move beyond the turf wars and get the care to the people who need it," she says. "There really are plenty of sick people to go around."