Dec. 15 2010

If the Affordable Care Act goes into full effect, it will add 32 million Americans to the list of those covered by insurance when there already is a shortage of primary care providers. At the same time there is broad consensus among the experts that healthcare costs must come down in the next phase of reform.


John Rowe, MD

The authors of a Perspective, “Broadening the Scope of Nursing Practice” published today in the New England Journal of Medicine, make a compelling argument that one key to covering all Americans while controlling costs, is to expand the role of nurse practitioners or advance practice nurses (APRNs) so that they are permitted to practice to the full extent of their knowledge and competence. This is also the position of a new report from the Institute of Medicine (IOM) on the future of nursing. Currently, many states restrict the role APRNs can play.

The paper was co-authored by Columbia University’s Mailman School of Public Health Professor of Health and Policy Management John (Jack) W. Rowe, MD, former president of Mount Sinai Medical Center. Dr Rowe, the only MD signing the piece, is a strong proponent of expanding the scope of nurses to practice primary care medicine, though such an expansion is opposed by the American Medical Association, the American Academy of Pediatricians, and the American Academy of Family Practice.

In the Perspective, he and fellow authors including former Secretary of Health and Human Services Donna Shalala, point to evidence from hundreds of studies indicating that primary care services -- such as wellness and prevention services, diagnosis and management of many acute illnesses, and management of chronic diseases -- can be provided by APRNs at least as safely and effectively as those provided by physicians. Both the IOM and the Macy Foundation have arrived at this conclusion and are calling for expansion of nurses’ scope of practice in primary care.

“The only barriers limiting APRNs’ capacity to practice to the full extent of their ability are state-based regulatory ones,” says Dr. Rowe, who also was former CEO of Aetna, Inc.  However, the country is already seeing the beginnings of a shift as 14 states plus the District of Columbia have already liberalized and standardized the care nurse practitioners can provide.

There are several other reasons to relax state regulations. “Implementing new delivery models and expanded scope of practice and team-based approaches such as medical homes and other care organizations -- even U.S. retail clinics -- which would provide care and reduce costs -- requires establishing interdisciplinary teams in which nurses provide a range of services,” notes Dr. Rowe and his fellow authors. “These approaches which are associated with broadening nurses’ scope of practice have already demonstrated an improvement in quality and patient satisfaction.”

Cost savings are another reason to expand the role of APRNs. Research in Massachusetts already shows that using nurse practitioners or physician assistants to their full capacity could save the state $4.2 billion to $8.4 billion over 10 years.

In closing, Dr. Rowe and coauthors Julie A. Fairman, PhD, RN of the University of Pennsylvania School of Nursing; Susan Hassmiller, PhD, RN, of the Robert Wood Johnson Foundation; and former Secretary Donna E. Shalala, PhD, make a final, compelling case for broader scope-of-practice boundaries.  Since APRNs’ education is supported by federal and state funding, the U.S healthcare system is underutilizing a valuable government investment.  Between three and 12 nurse practitioners can be educated for the price of producing one physician.