Keys to Unlocking Better Patient Outcomes
Op Ed By Carole R. Myers, PhD, RN
Former Lieutenant Governor Ron Ramsey and Speaker of the House Beth Harwell commissioned a Scope of Practice Task Force to change the conversation and the players in the ongoing debate about the need for and value of physician supervision of Advanced Practice Registered Nurses (APRNs) in the state. The 12,612 APRNs in Tennessee include 9,717 Nurse Practitioners (77.0 percent of the total), 2,564 Certified Registered Nurse Anesthetists (20.3 percent), 193 Certified Nurse Midwives (1.5 percent), and 138 Clinical Nurse Specialists (1.1 percent).
Currently APRNs who prescribe in Tennessee must have a physician supervisor review and sign 20 percent of the APRNs' patient charts (100 percent of charts when controlled substances are prescribed), prescribe from an approved formulary of drugs, and have a physician on-site visit every 30 days. This high level of physician supervision is why Tennessee is considered one of the 12 most restrictive states in the country regarding APRN practice.
Approximately one-half of the states (22) allow the full practice authority whereby the APRN is allowed to practice without physician supervision or collaboration. There are 17 other states that are less restrictive than Tennessee but have not granted full practice authority. Since 2010, eight states have granted full practice authority, and eight more have made incremental progress towards full practice authority. Recently the Veterans' Administration granted full practice authority to Nurse Practitioners, Certified Nurse Midwives, and Clinical Nurse Specialists; a comment period is currently open regarding Certified Registered Nurse Anesthetists. Full practice authority is supported by the National Governor's Association, Institute of Medicine, Rand Corporation, Federal Trade Commission, Josiah Macy Foundation and other prominent organizations.
In Tennessee, access to care and health outcomes are acute issues. Supervision impedes patients' access to care. APRNs are the only primary care, women's health, obstetric and anesthesia providers in many areas. Only 25 percent of Tennessee counties have an adequate supply of primary care physicians; three of Tennessee's 85 counties (3 percent) have no primary care physicians. Half of Tennessee counties have no hospital obstetric services. CRNAs are the only anesthesia provider in 41 (43 percent) of the 95 counties. In rural and other underserved areas, physician collaborators are frequently in short supply.
Contractual costs and complying with statutory requirements add unnecessary healthcare costs. When physician supervision of APRNs is eliminated, physicians spend approximately 8 percent more time on patient care with no increase in hours spent on all medical activities.
In the America's Health Rankings report released in December 2016, Tennessee ranks 44th out of the 50 states and the District of Columbia, a poor grade. This is a drop of one place from the prior report. A key to facilitating improvement in access and improved outcomes is allowing Tennessee APRNs to practice to the top of their license without unnecessary physician supervision, commensurate with their nationally accredited education and board certification.
The impetus to full practice authority is necessitated by several factors. These factors include a shortage of available primary care, women's health, obstetrical, and anesthesia providers; and emphasis on primary, preventative, and community-based care; and untenable healthcare cost and relatively poor outcomes, which together constitute poor value. In addition, patients are demanding better access and more choice regarding providers. Research studies for 50 years have consistently shown equal or better levels of satisfaction with APRN-delivered care when compared to physician care, comparable patient outcomes, and enhanced access in rural and other underserved areas (examples of the research studies from a robust body of evidence include a 2010 review of 26 studies by Laurant, et al. and a randomized trial and follow-up study with 1,316 and 416 adult patients respectively by Mundinger in 2000 and Lenz, et al. in 2004).
The Tennessee Medical Association has indicated its willingness to modify supervision requirements. This is a welcome change ... but more is needed. Modifying supervision does not address the inadequate access in many parts of the state and with certain populations and the state's poor health outcomes.
The time has come for Tennessee to implement evidence-based strategies to improve patient outcomes. Nurse members of the task force proposed a tiered licensure model with physician supervision of two years for all new APRNs and eventual elimination of legislated or regulated supervision. This allows patients to benefit from improved access, choice, and well-being. The tiered approach facilitates ongoing evaluation and adjustment and an orderly transition.
The key to unlocking better health outcomes rests with physicians, APRNs, and other members of the healthcare team agreeing to set aside self-interests, putting the patient at the center of all they do. Maintaining the status quo is holding Tennessee back. We need to put Tennesseans first and move our state forward.
Carole R. Myers, PhD, RN served as co-chair of the Healing Arts Scope of Practice Task Force. She is an associate professor in the College of Nursing with a joint appointment in the Department of Public Health at the University of Tennessee where she coordinates inter-disciplinary health policy courses and a graduate certificate in health policy. Myers' research centers on policymaking and health services with an emphasis on public health programs, access to services, and disparities.