state scope of practice laws and nurse practitioners’ · pdf file ·...
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State Scope of Practice Laws and Nurse Practitioners’ Autonomy
Jeongyoung Park, PhDErin Athey, DNP, FNP-BC, RN
Arlene Pericak, DA, FNP-BC, RNJoyce Pulcini, PhD, FNP-BC, RN, FAAN
Jessica Greene, PhD
AcademyHealthJune 26, 2016
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NPAutonomy
Professional Rules
Regulatory Rules
Organizational Rules
- Access to primary and preventive care- Quality and safety of patient outcomes- Job satisfaction and retention- Turnover and burnout- Etc.
- Low-value care - More tests and visits that increases costs- Etc.
Value of Autonomy
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State SOP
• Each state grants legal authority for NPs to practice• Entry-to-practice qualification• Physician involvement in treatment and diagnosis• Prescription authority• Reimbursement and costs• Etc.
• State SOP has been cited as a primary barrier to NP independent practice
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Remove State SOP Barriers (1)
• Research evidence suggests that NPs provide care of equal quality at lower cost than physicians do
• National organizations (IOM, NGA, FTC) recommended that states remove SOP barriers to increase efficiencies in health care delivery
• Affordable Care Act• Insurance expansion• NPs can be key to practice transformation
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Remove State SOP Barriers (2)
• 1998-2012, 11 states loosened SOP regulations• Despite this trend, SOP remains a highly
contentious topic among different stakeholders and state legislative changes have been slow
• In 2015, less than half the states (21 states and DC) allow full legal authority for NPs
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NPAutonomy
Professional Rules
Regulatory Rules
Organizational Rules
- Access to primary and preventive care- Quality and safety of patient outcomes- Job satisfaction and retention- Turnover and burnout- Etc.
- Low-value care - More tests and visits that increases costs- Etc.
Barriers to Autonomy
← Practice Culture
← Individual Relationship
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Insurance/Payer Policies →
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Study Questions
• To what extent are state SOP laws related to the degree of autonomy that NPs report?
• How much variation in autonomy is there for NPs in states where they have the same legal authority?
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Data and Study Population
• 2012 National Sample Survey of Nurse Practitioners linked to the state NP SOP laws
• 9,021 NPs (70% of all respondents) who provided direct patient care in their primary NP position
• 3,471 primary care NPs (38.7%)• 5,550 specialty care NPs (61.3%)
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2012 State SOP
SOP PracticeAuthority
PrescriptionAuthority
State
Independent O O AK, AZ, CO, DC, HI, ID, IA, ME, MD, MT, NH, NM, ND, OR, VT, WA, WY (16 states and DC)
Restricted Prescription O X AR, IN, KY, MA, MI, NJ, OK, RI, TN, UT, WV (11 states)
Restricted X X AL, CA, CT, DE, FL, GA, IL, KS, LA, MN, MS, MO, NE, NV, NY, NC, OH, PA, SC, SD, TX, VA, WI (23 states)
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Autonomy Measures
Autonomy Coding (%)
Skills are fully utilized Strongly disagreeDisagreeAgreeStrongly agree
(2.2)(13.5)(34.6)(49.7)
Collaborative relationship w/ physician
HierarchicalCollaborative
(16.0)(84.0)
Billing independence Bill under other provider/clinic numberBill under my provider number
(53.8)(46.2)
Managing own panel of patients
NoYes
(54.1)(45.9)
Hospital admitting privileges NoYes
(79.3)(20.7)
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Analyses
• Ordered logistic or logistic regressions to examine the association between SOP and autonomy
• Gender, years since graduating from initial NP program, race/ethnicity, degree, hourly salary, urban/rural location, and work settings
• Primary care NPs vs. specialty care NPs• Robust standard errors clustered at state-level
• Chi-squares to examine variation in each autonomy measure
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“To what extent are state NP SOP laws related to the degree of autonomy that they report?”
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Skills are fully utilized (OR, 95% CI)
**p<0.05;***p<0.0113
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Collaborative relationship w/ physician (OR, 95% CI)
**p<0.05;***p<0.0114
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Billing independence (OR, 95% CI)
**p<0.05;***p<0.0115
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Managing own panel of patients (OR, 95% CI)
**p<0.05;***p<0.0116
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Hospital admitting privileges (OR, 95% CI)
**p<0.05;***p<0.0117
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“How much variation in autonomy is there for NPs in states where they have the same legal authority?”
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Skills are fully utilized***
19***p<0.01
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Collaborative relationship w/ physician***
20***p<0.01
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Billing independence***
21***p<0.01
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Managing own panel of patients***
22***p<0.01
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Hospital admitting privileges
23***p<0.01
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Summary of Key Findings
• Independent prescription authority is critical• SOP matters more to those NPs who provide
primary care• SOP is the primary barrier, but other barriers exist
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Limitations
• No causal linkage• Variation within each SOP category• Validity for measuring autonomy
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Implications
• SOP not a silver bullet• Removing both legal and administrative barriers for
NPs is critical to • Meet increased primary care needs • Deliver continuous, comprehensive, and coordinated
team-based care• Support health care delivery innovation• Make NPs more efficient and effective provider
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Questions?
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SOP and Autonomy (OR, 95%CI)
**p<0.05;***p<0.0128
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Variation in Autonomy
29***p<0.01
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