John Hood: North Carolina should quit this club
RALEIGH — When it comes to regulating nurses, North Carolina is in an increasingly exclusive club. Unfortunately, the cost of our club membership far exceeds any benefits.
In most states, nurse practitioners and other advanced-practice nurses have significant authority to treat patients without being subject to the authority of a physician. In Virginia, for example, they enjoy what is called full practice authority thanks to a 2018 reform bill. In other states, nurse autonomy is a bit more limited. Consider the case of Kentucky. While nurses there don’t yet have full practice authority, they can administer certain drugs on their own after four years of collaboration with a doctor.
Only 15 states satisfy neither condition. Their advanced-practice nurses have little autonomy. North Carolina is one of them.
During last year’s debate about Medicaid expansion, the original position of Senate leader Phil Berger and his colleagues was to give nurses more freedom to treat their patients without the costly supervision of physicians. Along with reducing the power of hospital monopolies, scope-of-practice reform was intended to increase the supply of medical care and thus put downward pressure on prices.
Gov. Roy Cooper and the North Carolina House agreed to relax some state constraints on hospital competition. They rebuffed the Senate on scope-of-practice reform. That’s why our state continues to be one of the few than unwisely denies nurses full practice authority.
In this case, the majority has it right. When nurses are fully empowered to provide all the services for which they are trained, costs go down and patients receive either equivalent or better care than they did before. A 2021 study published in the journal Health Economics found no evidence that relaxing scope-of-practice laws had an adverse effect on services delivered. It concluded that allowing nurse practitioners to operate “without physician oversight could reduce health care spending without harming patients.”
For a 2019 study in the Journal of Nursing Regulation, scholars from Columbia University, St. Francis University, and the University of Pittsburgh looked specifically at the effects of the policy on Medicaid recipients. They found that outpatient costs were 17% lower and prescription costs 11% lower in states where nurses enjoy full practice authority.
What about effects on the caregivers themselves? A recent study in Nursing Outlook focuses on New York State’s adoption of full practice authority in 2015. The authors found “significantly better work environments” for nurse practitioners after the policy change.
“There is a growing body of evidence about the impact of nurse practitioner work environment on the quality of care and patient outcomes,” they wrote. “Thus, removing scope-of-practice restrictions on nurse practitioners may also lead to better care and patient outcomes.”
Physician organizations and other opponents of reform argue that without doctor supervision, advanced-practice nurses will make too many mistakes and misdiagnose serious conditions. In theory, this is possible. In practice, it’s not a persuasive objection. While tragic cases certainly occur — regardless of whether a physician owns or takes a financial cut of a nurse’s practice — the medical and financial benefits of reform appear to far outweigh the downsides.
Otherwise, the relevant research would find scope-of-practice reform was followed by marked declines in patient outcomes. They’d find the short-term savings from providing primary care in independent nursing practices were overwhelmed by the long-term costs of treating misdiagnosed patients, including expensive hospital stays and lifelong disabilities.
That’s not what a preponderance of the studies show, however. Scope-of-practice reform confers net benefits. That’s why New York lawmakers adopted the policy in 2015. That’s why Virginia lawmakers adopted it in 2018. That’s why 35 states have less-restrictive nursing regulations than North Carolina does.
When the General Assembly reconvenes this spring, lawmakers ought to rectify last year’s mistake of leaving scope-of-practice reform out of the Medicaid deal. By expanding taxpayer-funded health care, they set the stage for a surge in demand for medical services. Unless they take additional steps to free up supply so it can meet that demand, prices will soar.
John Hood is a John Locke Foundation board member. His latest books, Mountain Folk and Forest Folk, combine epic fantasy with early American history (FolkloreCycle.com).
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