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The Economic Burden and Practice Restrictions Associated With Collaborative Practice Agreements: A National Survey of Advanced Practice Registered Nurses

      The U.S. healthcare system is facing workforce shortages in rural and primary care settings. Despite growing demand for providers and comparable quality metrics, advanced practice registered nurses (APRNs) still face significant barriers to independent practice due to reduced scope of practice regulations. In this study, APRNs working in rural areas and APRN-managed private clinics were one and a half to six times more likely to be assessed Collaborative Practice Agreement (CPA) fees, often exceeding $6,000 and up to $50,000 annually. Similarly, APRNs subject to minimum distance requirements, fees to establish a CPA, and supervisor turnover reported a 30% to 59% uptick in restricted care. Such unnecessary regulation risks diverting health services away from and increasing costs in traditionally underserved areas, contributing to inequities in care. It is incumbent on state legislatures to address these disparities and make their constituents’ access to high-quality care a top priority.

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      References

        • Adams E.K.
        • Markowitz S.
        Improving Efficiency in the Health-Care System: Removing Anticompetitive Barriers for Advanced Practice Registered Nurses and Physician Assistants, Policy Proposal 2018-08.
        The Hamilton Project, 2018
        • American Academy of Family Physicians
        Guidelines on the supervision of certified nurse midwives, nurse practitioners and physician assistants.
        2018 (Retrieved from)
        • American Academy of Family Physicians
        Primary care for the 21st century: Ensuring a quality, physician-led team for every patient.
        2012 (American Academy of Family Physicians)
        • American Medical Association
        AMA responds to IOM report on future of nursing [Press release].
        (Retrieved from)
        • American Medical Group Association
        Compensation and productivity survey.
        2016 (Retrieved from)
        • APRN Consensus Work Group, National Council of State Boards of Nursing APRN Advisory Committee
        Consensus model for APRN regulation: Licensure, accreditation, certification & education.
        2008, July 7 (Retrieved from)
        • Barnes H.
        • Richards M.R.
        • McHugh M.D.
        • Martsolf G.
        Rural and nonrural primary care physician practices increasingly rely on nurse practitioners.
        Health Affairs. 2018; 37: 908-914
        • Brom H.M.
        • Salsberry P.J.
        • Graham M.C.
        Leveraging health care reform to accelerate nurse practitioner full practice authority.
        Journal of the American Association of Nurse Practitioners. 2018; 30: 120-130
        • Buerhaus P.I.
        • DesRoches C.M.
        • Dittus R.
        • Donelan K.
        Practice characteristics of primary care nurse practitioners and physicians.
        Nursing Outlook. 2015; 63: 144-153
        • Chapman S.A.
        • Phoenix B.J.
        • Hahn T.E.
        • Strod D.C.
        Utilization and economic contribution of psychiatric mental health nurse practitioners in public behavioral health services.
        American Journal of Preventive Medicine. 2018; 54: S243-S249
        • Collins L.M.
        • Lanza S.T.
        Latent class and latent transition analysis: With applications in the social, behavioral, and health sciences.
        718. John Wiley & Sons, Hoboken, NJ2013
        • Conover C.
        • Richards R.
        Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina.
        Nursing Outlook. 2015; 63: 585-592
        • Declercq E.R.
        • Paine L.L.
        • Simmes D.R.
        • DeJoseph J.F.
        State regulation, payment policies, and nurse-midwife services.
        Health Affairs. 1998; 17: 190-200
        • Deshefy-Longhi T.
        • Swartz M.K.
        • Grey M.
        Characterizing nurse practitioner practice by sampling patient encounters: An APRNet study.
        Journal of the American Academy of Nurse Practitioners. 2008; 20: 281-287
        • DesRoches C.M.
        • Gaudet J.
        • Perloff J.
        • Donelan K.
        • Iezzoni L.I.
        • Buerhaus P.
        Using Medicare data to assess nurse practitioner–provided care.
        Nursing Outlook. 2013; 61: 400-407
        • Dill M.J.
        • Pankow S.
        • Erikson C.
        • Shipman S.
        Survey shows consumers open to a greater role for physician assistants and nurse practitioners.
        Health Affairs. 2013; 32: 1135-1142
        • Donelan K.
        • DesRoches C.M.
        • Dittus R.S.
        • Buerhaus P.
        Perspectives of physicians and nurse practitioners on primary care practice.
        New England Journal of Medicine. 2013; 368: 1898-1906
        • Fairman J.A.
        • Rowe J.W.
        • Hassmiller S.
        • Shalala D.E.
        Broadening the scope of nursing practice.
        New England Journal of Medicine. 2011; 364: 193-196
        • Federal Trade Commission
        Policy perspectives: Competition and the regulation of advanced practice nurses.
        2014 (Retrieved from)
        • Federation of State Medical Boards
        Assessing scope of practice in health care delivery: Critical questions in assuring public access and safety.
        2005 (Retrieved from)
        • Fung Y.L.
        • Chan Z.
        • Chien W.T.
        Role performance of psychiatric nurses in advanced practice: A systematic review of the literature.
        Journal of Psychiatric and Mental Health Nursing. 2014; 21: 698-714
        • Green L.V.
        • Savin S.
        • Lu Y.
        Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication.
        Health Affairs. 2013; 32: 11-19
        • Hooker R.S.
        • Muchow A.N.
        Modifying state laws for nurse practitioners and physician assistants can reduce cost of medical services.
        Nursing Economics. 2015; 33: 88
        • Hosmer Jr., D.W.
        • Lemeshow S.
        • Sturdivant R.X.
        Applied logistic regression.
        3rd ed. 398. John Wiley & Sons, Hoboken, NJ2013
        • Huang E.S.
        • Finegold K.
        Seven million Americans live in areas where demand for primary care may exceed supply by more than 10 percent.
        Health Affairs. 2013; 32: 614-621
        • Institute of Medicine (US), Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing
        The future of nursing: Leading change, advancing health.
        National Academies Press, Washington, DC2011
        • Kazer M.W.
        • O’Sullivan C.K.
        • Leonard M.
        Examining changes to statewide NP practice in Connecticut.
        The Nurse Practitioner. 2018; 43: 37-41
        • Ku L.
        • Jones K.
        • Shin P.
        • Bruen B.
        • Hayes K.
        The states’ next challenge—securing primary care for expanded Medicaid populations.
        New England Journal of Medicine. 2011; 364: 493-495
        • Kuo Y.F.
        • Loresto Jr., F.L.
        • Rounds L.R.
        • Goodwin J.S.
        States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners.
        Health Affairs. 2013; 32: 1236-1243
        • Laurant M.G.
        • Hermens R.P.
        • Braspenning J.C.
        • Akkermans R.P.
        • Sibbald B.
        • Grol R.P.
        An overview of patients’ preference for, and satisfaction with, care provided by general practitioners and nurse practitioners.
        Journal of Clinical Nursing. 2008; 17: 2690-2698
        • Loresto Jr., F.L.
        • Jupiter D.
        • Kuo Y.F.
        Examining differences in characteristics between patients receiving primary care from nurse practitioners or physicians using Medicare Current Beneficiary Survey data and Medicare claims data.
        Journal of the American Association of Nurse Practitioners. 2017; 29: 340-347
        • Mundinger M.O.
        • Kane R.L.
        • Lenz E.R.
        • Totten A.M.
        • Tsai W.Y.
        • Cleary P.D.
        • Shelanski M.L.
        Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.
        JAMA. 2000; 283: 59-68
        • National Council of State Boards of Nursing
        Consensus Model Implementation Status.
        2018 (Retrieved from)
        • Neff D.F.
        • Yoon S.H.
        • Steiner R.L.
        • Bejleri I.
        • Bumbach M.D.
        • Everhart D.
        • Harman J.S.
        The impact of nurse practitioner regulations on population access to care.
        Nursing Outlook. 2018; 66: 379-385
        • Perry J.J.
        The rise and impact of nurse practitioners and physician assistants on their own and cross-occupation incomes.
        Contemporary Economic Policy. 2009; 27: 491-511
        • Petterson S.M.
        • Liaw W.R.
        • Phillips Jr., R.L.
        • Rabin D.L.
        • Meyers D.S.
        • Bazemore A.W.
        Projecting US primary care physician workforce needs: 2010-2025.
        Annals of Family Medicine. 2012; 10: 503-509
        • Pittman P.
        • Williams B.
        Physician wages in states with expanded APRN scope of practice.
        Nursing Research and Practice. 2012; 2012: 671974
        • Polsky D.
        • Candon M.
        • Saloner B.
        • Wissoker D.
        • Hempstead K.
        • Kenney G.M.
        • Rhodes K.
        Changes in primary care access between 2012 and 2016 for new patients with Medicaid and private coverage.
        JAMA Internal Medicine. 2017; 177: 588-590
        • Reagan P.B.
        • Salsberry P.J.
        The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners.
        Nursing Outlook. 2013; 61: 392-399
        • Rigolosi R.
        • Salmond S.
        The journey to independent nurse practitioner practice.
        Journal of the American Association of Nurse Practitioners. 2014; 26: 649-657
        • Roblin D.W.
        • Becker E.R.
        • Adams E.K.
        • Howard D.H.
        • Roberts M.H.
        Patient satisfaction with primary care: Does type of practitioner matter?.
        Medical Care. 2004; 42: 579-590
        • Rudner N.
        • Kung Y.M.
        An assessment of physician supervision of nurse practitioners.
        Journal of Nursing Regulation. 2017; 7: 22-29
        • Smiley R.A.
        • Lauer P.
        • Bienemy C.
        • Berg J.G.
        • Shireman E.
        • Reneau K.A.
        • Alexander M.
        The 2017 National Nursing Workforce Survey.
        Journal of Nursing Regulation. 2018; 9: S1-S88
        • Timmons E.J.
        The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care.
        Health Policy. 2017; 121: 189-196
        • Xue Y.
        • Ye Z.
        • Brewer C.
        • Spetz J.
        Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review.
        Nursing Outlook. 2016; 64: 71-85

      Biography

      Brendan Martin, PhD, is a Senior Research Scientist for Nursing Regulation at the National Council of State Boards of Nursing.

      Biography

      Maryann Alexander, PhD, RN, FAAN, is the Chief Officer for Nursing Regulation at the National Council of State Boards of Nursing.

      Linked Article

      • Conflict of Interest Compliance Article 3
        Journal of Nursing Regulation Vol. 12Issue 2
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          As is standard in scholarly publishing, NCSBN’s Journal of Nursing Regulation (JNR) requires its authors to disclose any potential conflicts of interest (COI). Although COI information has always been collected by our staff in order to support editors’ review of the paper, it was not our standard practice to publish COI statements in each article. In this issue, JNR is retrospectively publishing the COI statements, which were collected with the below papers at submission, in order to make potential COI’s transparent to readers, as well as editors.
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