The Value of Full Practice Authority for Pennsylvania's Nurse Practitioners: Technical Appendix

The American health care market simultaneously faces two precarious trends: rising costs and a growing shortage of primary care providers. An aging population and millions of newly insured under the Affordable Care Act have increased demand growth, but supply growth has stalled as physicians retire and medical school graduates choose specialty careers over primary care. The nation faces a 20,400-physician shortage by 2020. A growing number of key stakeholders have recommended expanding the role of nurse practitioners (NP) to help meet growing primary care gaps, but a number of states limit NPs’ ability to practice to the full extent of their training and experience. Granting NPs full practice authority is one of the most effective steps for states to increase the supply of primary care providers while maintaining high-quality care and driving down healthcare costs. Pennsylvania. Pennsylvania’s legislature is considering joining the states that allow NPs full practice authority. The state’s primary care providers (PCP) are concentrated in its southeast and southwest regions, and nearly 35 percent of Pennsylvanians live in an area or population group with 2 inadequate primary care access. Low-supply areas, especially in the state’s interior, face further pressure as demand grows. Even in Philadelphia, patient wait times for primary care appointments are up to 21 days, from just 9 days in 2009.The state’s primary care landscape suggests more patients — particularly those on Medicaid — are turning to NPs for primary care. Nationwide, NPs serve more diverse and underserved populations, including those in Health Professional Shortage Areas (HPSAs), than other PCPs. NPs are also much more likely to treat the disabled and dual Medicare-Medicaid eligible patients. Access. In early 2014, a Federal Trade Commission report warned that limits like collaboration agreement requirements that unnecessarily limit NP practice authority raise costs, reduce competition, and block consumer benefits. Our analysis suggests that over 1,000 more NPs, roughly a 13 percent increase, would be practicing in Pennsylvania today had the state lifted practice restrictions last decade. An increase of this size for primary care access would help satisfy growing unmet demand. It would also provide more convenient times and locations. For example, NPs often work in retail-based clinics, and other convenient forums, whereas physicians generally do not.Quality. In assessing reform’s effect on quality, studies yield two key takeaways. First, primary care from NPs is of comparable or superior quality to care by physicians. Patient satisfaction also increases. Adults report a 13–15 percent increase in visit quality; children report gains of 17–27 percent. Second, overall health outcomes are better in states that have granted reform. Annual checkups go up and avoidable emergency room visits go down in those states.Costs. Pennsylvania is among the ten states that had the highest levels of per capita health care spending in 2009, the last year of available data. Full practice authority addresses this concern by lowering the cost of primary care without sacrificing quality. Nationally, acute care from NPs is 20 percent less expensive than the same care by physicians. Based on this alone, Pennsylvania would save $6.4 billion after the first ten years of reform. And this estimate is conservative. Reform could produce additional savings on general medical examinations and well-baby visits, which would save healthcare consumers $12.7 billion over ten years. These savings directly translate to lower burdens on consumers, businesses, and public programs. Pennsylvania should follow the lead of 21 other states and the District of Columbia and grant full practice authority to NPs. The existing barriers are unnecessary and weaken a key source of primary care. Removing these barriers is critical to ensuring access to high-quality care, managing health costs, and improving health for all Pennsylvanians.