by Teresa Camp-Rogers, MD, MS
The concept of “access to care” is perfectly suited for politics. It is difficult to prove but a delight to debate. After all, anyone can simply suggest that a proposed policy, measure, or program “can” or “may” increase access to care.
The phrase is catchy. It captures our desire to do good for others. But out at the front lines of medicine, in rural and underserved areas, it is critical to ask for concrete evidence of the impact of any proposal.
Nowhere is this truer than with the concept of Full Practice Authority (FPA) for nurse practitioners (NPs). Advocates for expanded NP practice insist that FPA, as a policy, increases access to care. This proposed policy started as a possibility, turned into a theoretical outcome, and ultimately became a ‘given,’ or expected benefit.
But it is not clear how laws expanding FPA lead to increased NPs in rural areas. Access to care is not a metric. It is an ideal. We can try to measure it and find the truth on whether it has been achieved.
When determining the scientific answer to a question it is critical to be as specific as possible. When we consider how NPs affect access to care in our healthcare system, an effective measure is to simply look at the concentration of NPs practicing in rural areas. We can look to see if it has changed over time. We can look to see what interventions have or have not occurred during that time.
The AANP claims that “states with FPA are more likely to have NPs working in rural and underserved areas and NP practices than states with more restrictive licensure models.”1 Examining the data supporting this claim is essential.
Is FPA associated with increased numbers of NPs practicing in rural areas?
One study from Nursing Outlook in June 2020, attempts to answer this specific question.2 The authors examined the change in total number of NPs working in underserved areas in states before and after FPA was passed. A positive relationship was found between FPA and increased numbers of NPs. Unfortunately, the authors appear to have used the incorrect test. This is important because the test they used has been associated with severe bias and misleading results.
The statistical method used for analysis in this study was intended to detect differences in groups over time2 and has been used to evaluate the impact of health policy. The risk of misleading statistics is highest when the assumptions are not met for the test3 and the methods should discuss each statistical assumption necessary to use the test. It does not.
Perhaps most importantly, the authors did not consider the impact of the rapid production of NPs on their test results. Over the course of seven years, from 2010 to 2017, the number of NPs more than doubled from 90,000 to 190,0004. The rapid produciton of NPs through 100% acceptance rates, 100% online schools, and abbreviated education has changed where NPs choose practice by simply saturating the market.
Another approach is to examine the first-hand experience of non-FPA states.
Have non-FPA states experienced an increase in the number of NPs in rural areas?
States without FPA have experienced dramatic increases in the number of NPs in both rural and urban areas. The total number of NPs in Mississippi has nearly doubled from 2167 to 4258 over the course of 7 years and without adopting FPA.5 The Bureau of Labor Statistics (BLS) provides unbiased data that challenges the NP claim that FPA leads to increased numbers of NPs working rural areas.6 Looking at data from the BLS, the entire state of Mississippi is above average for concentration of NPs (Figure 1). It appears that other states experienced the same.
Figure 1. Bureau of Labor Statistics Data on Nurse Practitioners, May 20215
Notable observations from the BLS data on NPs includes:
- Five of 5 nonmetropolitan areas with the highest concentration of nurse practitioners are in non-FPA states (Tennessee, Kentucky, Mississippi).
- Four of 5 nonmetropolitan areas with the highest employment in nurse practitioners are in non-FPA states (Tennessee and Mississippi).
- Nine of the top 10 metropolitan areas with the highest concentration of jobs in nurse practitioners are in non-FPA states.
- Four of the top 5 states for concentration of NPs are non-FPA states.
Lack of FPA does not prevent NPs from thriving in both metropolitan and non-metropolitan areas. FPA does not cause anyone to practice in rural areas. Mississippi, Tennessee, West Virginia, and Missouri represent four of the five states for highest number of NPs employed per 1000 jobs. It was all done in the context of a physician-led team, without FPA.
- Full Practice Authority. https://www.aanp.org/advocacy/advocacy-resource/policy-briefs/issues-full-practice-brief Accessed August 28, 2022.
- DePriest K, D’Aoust R, Samuel L, Commodore-Mensah Y, Hanson G, Slade EP. Nurse practitioners’ workforce outcomes under implementation of full practice authority. Nurs Outlook. 2020 Jul-Aug;68(4):459-467. doi: 10.1016/j.outlook.2020.05.008. Epub 2020 Jun 24. PMID: 32593462; PMCID: PMC7581487.
- Columbia University. Difference in Difference Estimation. https://www.publichealth.columbia.edu/research/population-health-methods/difference-difference-estimation. Accessed August 28, 2022.
- Auerbach DI, Buerhaus PI, Staiger DO. Implications Of The Rapid Growth Of The Nurse Practitioner Workforce In The US. Health Aff (Millwood). 2020 Feb;39(2):273-279. doi: 10.1377/hlthaff.2019.00686. PMID: 32011941.
- AMA Resource Library. Primary Care Physicians to Nurse Practitioners. 2020. Accessed May 12, 2021.
- US Bureau of Labor Statistics. Occupational Employment and Wages, May 2021. https://www.bls.gov/oes/current/oes291171.htm#st. Accessed August 28, 2022.
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