Ask the Professors: What are the Barriers to Full NP Practice Authority in Michigan?
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“When patients have improved access to a consistent primary healthcare provider, such as a nurse practitioner, they have better healthcare outcomes and are more satisfied with the care received. This is especially important in many rural areas in Michigan, including the Upper Peninsula.”
Dr. Deena Kelly Costa, Assistant Professor at the University of Michigan School of Nursing (UMSN)
The retirement of the Baby Boomers is leading to a nationwide primary care crisis, where there won’t be enough primary care physicians to meet the demands of the population. But in some states, like Michigan, the crisis might already be here. Michigan has 261 Health Professional Shortage Areas (HPSAs) that do not have enough primary care providers for the local population. The majority of those HPSAs are considered either rural or partly rural and are associated with higher chronic disease burden and higher cost of care. Their combined population comes to just under three million people, making up approximately a third of the entire state. Nurse practitioners (NPs) could be the answer.
“Michigan NPs are perfectly poised to help address the gap in primary care services,” says Deena Kelly Costa, PhD, RN, FAAN, assistant professor at the University of Michigan School of Nursing (UMSN).
As highly educated clinicians whose training goes beyond that of traditional registered nurses (RNs), nurse practitioners are proficient in a number of critical services that states like Michigan sorely need.
“The majority (89.7 percent) of NPs are educated and trained in one of the primary care NP specialties, i.e. pediatrics, family (across the lifespan), and adult-gerontology,” says Elizabeth K. Kuzma, DNP, FNP-BC, clinical assistant professor and family nurse practitioner program lead at UMSN. “This is twice as high as the percent of physicians trained in primary care.”
Research has repeatedly shown that NPs provide high-quality, cost-effective care that’s equal to or better than that of physicians. And the quality and safety of NP education has been proven time and again. If empowered to practice the care that they’ve been trained to provide, NPs can act as a force multiplier in Michigan’s fight against the primary care crunch.
“Nurse practitioners provide healthcare in clinics and other primary care or outpatient settings all over the state,” Dr. Costa says. “Further, NPs constitute approximately one-quarter of all healthcare providers in rural settings. As the state of Michigan is diverse, with a number of large cities, suburban communities, and many smaller rural communities, NPs play a significant role in caring for Michiganders across the state.”
Meet the Experts: The University of Michigan’s Dr. Deena Kelly Costa & Dr. Elizabeth K. Kuzma
Dr. Deena Kelly Costa is an assistant professor at the University of Michigan School of Nursing (UMSN), where she teaches primarily in the master’s in health systems, nursing leadership, and effectiveness science program. She received both her MS and her PhD from the University of Pennsylvania.
A trained health services researcher with clinical expertise in adult critical care nursing, Dr. Costa’s work care has been published in leading journals such as JAMA, Chest, and Critical Care Medicine. Her prior research, published in Chest, documented the benefits of having NPs in the critical care setting. Given her expertise and research experience, Dr. Costa advised Governor Gretchen Whitmer’s office to advise on staffing and scope of practice regulations that were ultimately incorporated into Executive Order 2020-30 during the spring surge of the Covid-19 pandemic.
Dr. Elizabeth Kuzma is a clinical assistant professor at the University of Michigan’s School of Nursing (UMSN) in the health behavior and biological sciences department, where she is also the family nurse practitioner program lead. She earned her MSN from Michigan State University and her DNP from Wayne State University.
Dr. Kuzma sees public policy advocacy at all levels as the broadest form of patient advocacy for health promotion and disease prevention. She is the immediate past American Association for Nurse Practitioners (AANP) State Representative for Michigan, and currently serves on the AANP National Research Committee, the Michigan Council of Nurse Practitioners (MICNP) Finance Committee, and is the Chair of the UMSN’s Faculty Practice Advisory Committee. She was awarded the AANP State Award for Excellence in 2012.
Barriers for Michigan’s NPs: Lacking an APRN-Specific Scope of Practice
Unfortunately, Michigan doesn’t allow NPs the latitude that their education and training should afford them: according to the American Association of Nurse Practitioners (AANP), Michigan is a restricted practice state and the least flexible of all its neighbors in regards to NP practice authority.
Unlike a majority of other states, Michigan NPs have no clearly defined scope of practice (SOP) for their individualized profession. Typically, an SOP outlines what services a particular healthcare profession is competent and able to provide under the terms of their professional licensure. But in Michigan, NPs operate under the SOP of registered nurses (RNs), which undersells their experience, education, and training. It also restricts Michigan’s patient population from accessing what could be an affordable, convenient, and competent medical resource.
“The way that Michigan’s nurse practitioners are described in the Public Health Code is limited, and creates unnecessary barriers for patients who want to access healthcare from nurse practitioners,” Dr. Kuzma says. “Not having a clearly defined scope of practice and being legally tied to another healthcare profession in order to practice limits the ability of NPs to reach all patients in need of care.”
Barriers for Michigan’s NPs: Burdensome Supervision Requirements
Current regulations require Michigan NPs to work underneath a supervising physician, whose approval they need to perform certain procedures, access certain diagnostic tests, or write scheduled prescriptions. This creates numerous barriers to providing care, and effectively eliminates a significant portion of the force-multiplying benefit that NPs could have in Michigan, particularly in the rural areas.
And if a supervising physician retires, or even simply decides to no longer serve in the same capacity, an NP will have to stop providing care until a replacement can be found, thus leaving that NP’s patients without a primary care provider in the interim.
“Personally, I have worked with a collaborating physician who had their own privately-owned medical practice separate from where I practiced,” Dr. Kuzma says. “When I ordered laboratory or diagnostic studies for my patients, the orders were placed under the physician’s name. Often, the results would be sent to his private practice and not the practice where I worked. Our practice had to call his private practice and request the results of these laboratory or diagnostic studies be faxed over to our practice. This always created delays in receiving patients’ results and following up on abnormal results requiring further intervention or referral to specialty care. Sometimes the delay was greater than a week.”
A weeklong delay is often much more than a mere inconvenience to the patient and provider. Effective healthcare access is dependent upon being able to be seen promptly by a primary care provider, and upon being able to receive both preventative and responsive treatments in a timely manner. Regulatory burdens, such as supervisory requirements and an undefined scope of practice, don’t ensure better care for Michigan’s residents.
The Benefits of Full Practice Authority for NPs & Patients
The solution is full practice authority (FPA). Under FPA, NPs have full authority to evaluate patients, diagnose illnesses, prescribe medications, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure provisions of a state nursing board. The Federal Trade Commission, the National Academy of Medicine, the American Association of Retired Persons (AARP), and others have all called for a reduction in the barriers NPs face in providing primary care. Currently, nearly half of all states and territories in the US have adopted legislation that moves towards full practice authority for NPs.
“Full practice authority for Michigan NPs would mean that Michiganders have greater access to healthcare services and to nurse practitioners,” Dr. Kuzma says.
States with FPA laws improve access to care, utilization of care, and provider supply. A 2016 RAND study suggests the same is possible in Michigan, should steps towards full practice authority be taken. Reducing the barriers NPs face in delivering care can also reduce the cost of care, and protect a patient’s choice as to what provider they see. Unburdened by stifling collaborative agreements, Michigan’s NPs could more easily relocate to rural and underserved populations and begin addressing the needs of a sizable and vulnerable chunk of the state’s population.
“When patients have improved access to a consistent primary healthcare provider, such as a nurse practitioner, they have better healthcare outcomes and are more satisfied with the care received,” Dr. Costa says. “This is especially important in many rural areas in Michigan, including the Upper Peninsula. Data from a recent study suggests the presence of nurse practitioners in rural areas is steadily increasing, and that in 2016, nearly one in four rural providers was a nurse practitioner.
Interestingly, states with full practice authority had the highest prevalence of rural NPs. Leveraging the NP workforce, especially in more rural settings, through full practice authority could have profoundly beneficial implications for Michiganders and their health.”
The road to full practice authority in any state is shaped with numerous legislative victories, large and small. In Michigan, that road is longer than it is in most of the country. In 2017, the state finally began allowing NPs to prescribe non-scheduled drugs, to order physical or speech therapy, and to perform independent house calls. Further progress at the legislative level has been sluggish, but Michigan’s NPs are committed to public health and wellness. They will continue to advocate for changes at the state and federal level that improve the health of the public.
“Many Michigan NPs are working hard to advocate for the profession,” Dr. Costa says. “As a profession and through professional organizations, NPs continue to advocate for evidence-based legal and regulatory environments that grant NPs to practice to the full extent of their education and training autonomously.”
Steps Toward Expanded Practice Authority in Michigan
Grassroots efforts by the Michigan Council of Nurse Practitioners (MICNP) and other NPs are making headway in educating the public and raising awareness about what the profession can provide. Support at the national level comes through the American Association of Nurse Practitioners (AANP). Sometimes advocacy means reaching across the aisle to groups like the American Medical Association (AMA), and other times it means preventing misinformation from being spread, but the focus is always on how to best serve patients and their families.
“All healthcare providers, including NPs, should work together to ensure all patients are able to access high-quality healthcare by updating laws and regulations that impede the delivery of safe and effective healthcare,” Dr. Kuzma says.
In March of 2020, Governor Gretchen Whitmer issued an executive order that suspended scope of practice laws temporarily, in an effort to combat the effects of the Covid-19 pandemic. This move mimicked one made by several other states. When facing a medical crisis, the country often turns to NPs for support. Michigan would be wise to empower its NPs to practice to the full extent of their training before the next crisis hits, rather than after.
“As Covid-19 surges have overwhelmed hospitals in Michigan and physicians, nurses and other clinicians have been pulled into the acute care setting to care for the exploding Covid-19 patient population, NPs in the community are ready, willing, educated and able to provide preventive and primary healthcare services to all Michiganders,” Dr. Costa says.
“If afforded the ability to practice to the full scope based on their education, training, and national certification, NPs could do this without any barriers or restrictions, allowing them to fully engage in healthcare and help fill the gaps in primary care needs in the state.”
Matt Zbrog is a writer and researcher from Southern California, and he believes nurse practitioners (NP) are an indispensable component of America’s current and future healthcare workforce. Since 2018, he’s written extensively about the work and advocacy of NPs, with a particular focus on the rapid growth of specialization programs, residencies, fellowships, and professional organizations. As part of an ongoing series on state practice authority, he’s worked with NP leaders, educators, and advocates from across the country to elevate policy discussions that empower NPs. His articles have featured interviews with the leadership of the American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and many other professional nursing associations.