In an effort to confront healthcare access and cost concerns facing its residents, the State of Tennessee recently initiated a task force to examine an issue that many states are readdressing – the scope of practice for mid-level practitioners. Lawmakers hope the task force will provide a medium outside of a traditional legislative session to reform the rules governing the types of treatment that may be provided by advanced practice registered nurses (APRNs) and under what level of supervision APRNs may practice. APRNs, which include nurse anesthetists and nurse practitioners, traditionally have had a limited scope of practice, with a physician providing oversight. Due to the nature of care provided, APRNs’ scope of practice pushes against the boundary of, and sometimes overlaps, primary care physicians’ practices. This is especially true in rural areas due to a lack of access to care. This prompted Tennessee to take action to settle the battle between the two professions.
Physicians’ main argument against increasing APRNs’ scope of practice is APRNs are not as qualified as physicians and thus do not provide the same level of care. APRNs have responded that they are well-trained on the treatments they offer and that a lack of access to care prompts a higher demand for their services.
It would appear from a purely educational viewpoint, that primary care physicians have a strong argument. Generally, a primary care physician must first earn a degree from a four-year university (BS or BA) and a degree from an accredited medical school (MD), and then complete a residency program which usually lasts three years before licensure. A longer residency is required for more specialized areas (e.g., general surgery). The requirements for an APRN are less strenuous. An APRN, generally, must first obtain a Bachelor of Science in Nursing and, at a minimum, a Master of Science in Nursing from a graduate program (which usually includes clinical training). These programs generally last two years and may even be completed online before practicing.
However, not only do rural populations, like much of Tennessee, increase the demand for APRNs but according to the American Association of Nurse Practitioners, so does the cost effectiveness of APRNs. Even if the demand for APRNs exists, is the care provided safe and appropriate? Are states sacrificing quality of care for quantity and/or cost reduction? These are questions that Tennessee’s task force is primed to answer.
We will have to wait and see what will develop from Tennessee’s task force, but the outcomes may lead other states to follow suit, depending on whether or not an agreement is reached. First, it is important to note that physician supervision of APRNs is directly tied to Medicare reimbursement. Further, the Affordable Care Act has taken a team approach to healthcare and has emphasized the role APRNs should play in primary care. Second, it is important to think about the potential liabilities of the supervising physician. If there is a greater need for APRNs and physicians must then supervise more APRNs, what is the potential increase in liability for physicians? What if physician oversight standards are lowered (e.g., review every 60 days instead of every 30 days)? What management systems must be in place to ensure physician and APRN practices are compliant? These are all issues that may arise as we see more expansion to APRNs’ scope of practice and the level of physician supervision they require.
Thank you to Taylor Wilkins, Belmont University College of Law, for his help in preparing this article.