Expanding the role of advanced nurse practitioners--risks and rewards.

As the 2014 expansion of coverage mandated by the Affordable Care Act (ACA) looms larger, one question with no ready answer is how health care providers, policymakers, and payers will cope with an expected surge in patient demand for services. A shortage of primary care physicians to treat newly insured persons is the most immediate health workforce issue, but when added to the nation’s population growth and more aging patients who require treatment, finding a practitioner may become an even more daunting challenge. In addition, only about one quarter of medicalschool graduates plan careers as primary care physicians,1 and state scope-of-practice laws place limits on the clinical boundaries of advancedpractice registered nurses (APRNs), many of whom are providing primary care services in an array of settings.2 Organized medicine, spearheaded by the American Medical Association (AMA), strongly supports scope-of-practice laws as necessary to ensure patient safety and prevent APRNs from providing primary care without oversight by a physician. Nursing advocates take strong exception to scope-of-practice restrictions, particularly with respect to limits on their authority to prescribe drugs. They emphasize that an Institute of Medicine (IOM) report recommended that nurses should be free to “practice to the full extent of their education and training.” 3,4 Acknowledging that issuance of medical licenses has historically been the purview of states, Congress has not addressed the scope-ofpractice matter,2,5,6 but ongoing activities by the Federal Trade Commission (FTC) related to scope-of-practice laws and their effect on competition in the health care marketplace have drawn the ire of organized medicine. In this article, I report on a recent estimate with regard to a growing shortage of physicians, the status of efforts to implement recommendations of an IOM report that charts a bold future for nursing, and the highly variable limits that state scope-of-practice laws impose on APRNs. I will discuss the intervention of the FTC into scope-of-practice matters, a new report by the National Governors Association that urges states to reexamine their scope-of-practice laws,7 and a 2012 scope-of-practice law 8 enacted in Virginia that the AMA touts as a model for other states to follow. I will also cover a serious but ultimately unsuccessful dialogue organized by the Robert Wood Johnson Foundation that engaged a dozen physician and nursing leaders in search of “common ground” to resolve the issues that divide them. The collapse of this dialogue offered a snapshot of the unsettled states of discussions between national physician and nursing organizations over defining roles in an emerging model of team-based care that relies on interprofessional collaboration as one of its touchstones. The physician workforce has grown more rapidly than the U.S. population over the past 30 years.9 Nevertheless, the Association of American Medical Colleges estimates that by 2015 the nation will face a shortage of 62,100 physicians — 33,100 primary care practitioners and 29,000 other specialists.10 A shortage of nurses evaporated during the recession, since many returned to the workforce, but nurse practitioners are a scarce resource in many areas. Actually, if the numbers of physicians and nurse practitioners were distributed more equally, there may be a sufficient number to care for most people, but because their practices are concentrated in urban and suburban locales, many rural and inner-city areas are left with too few practitioners in places where the need is often the greatest. In studies commissioned by the federal Agency for Healthcare Research and Quality, researchers at the Robert Graham Center estimated that 208,807 doctors, slightly fewer than one third of all fulltime practicing physicians, 52% of nurse practiExpanding the Role of Advanced Nurse Practitioners — Risks and Rewards