Position statement: Full practice authority for advanced practice registered nurses is necessary to transform primary care
2017; Elsevier BV; Volume: 65; Issue: 6 Linguagem: Inglês
10.1016/j.outlook.2017.10.002
ISSN1528-3968
AutoresJordon D. Bosse, Katherine Simmonds, Charlene M. Hanson, Joyce Pulcini, Lynne M. Dunphy, Patricia M. Vanhook, Lusine Poghosyan,
Tópico(s)Global Health Workforce Issues
ResumoLack of full practice authority (FPA) for advanced practice registered nurses (APRNs) is a barrier to the provision of efficient, cost-effective, high-quality, and comprehensive health care services for some of our most vulnerable citizens (Agency for Healthcare Research and Quality, 2014Agency for Healthcare Research and QualityPrimary care workforce facts and stats no. 3. Agency for Healthcare Research and Quality, Rockville, MD, 2014http://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.htmlGoogle Scholar, Buerhaus et al., 2015Buerhaus P.I. DesRoches C.M. Dittus R. Donelan K. Practice characteristics of primary care nurse practitioners and physicians.Nursing Outlook. 2015; 63: 144-153Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, Pohl et al., 2010aPohl J.M. Hanson C. Newland J.A. Cronenwett L. Unleashing nurse practitioners' potential to deliver primary care and lead teams.Health Affairs (Millwood). 2010; 29: 900-905Crossref PubMed Scopus (40) Google Scholar, Seibert et al., 2004Seibert E.M. Alexander J. Lupien A.E. Rural nurse anesthesia practice: A pilot study.AANA Journal. 2004; 72: 181-190PubMed Google Scholar). APRNs have the education, knowledge, skills, and experience necessary to provide basic and comprehensive primary care services; they are a ready workforce, ideally positioned to improve access to care, contribute to health disparities reduction efforts, and lower the cost of providing such care (National Center for Workforce Analysis 2013National Center for Workforce Analysis. (2013). Projecting the supply and demand for primary care practitioners through 2020. Rockville, MD: Health Resources and Services Administration Bureau of Health Professions. Retrieved from http://bhpr.hrsa.gov/healthworkforce/index.htmlGoogle Scholar, Perloff et al., 2016Perloff J. DesRoches C.M. Buerhaus P. Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians.Health Services Research. 2016; 51: 1407-1423Crossref PubMed Scopus (83) Google Scholar). However, barriers at the state and national levels continue to prevent these highly qualified health care providers from practicing to the full extent to which their education and training have prepared them. It is the position of the American Academy of Nursing (academy) that FPA of APRNs is essential to achieving health equity. Despite the increase in the number of individuals who obtained health insurance under the Patient Protection and Affordable Care Act (ACA), 17% of U.S. women and 28% of U.S. men did not have access to primary care services in 2013 to 2015 (The Henry J. Kaiser Family Foundation, 2016aThe Henry J. Kaiser Family FoundationPercent of women who report having no personal doctor/health care provider, by race/ethnicity. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 2016http://www.kff.org/disparities-policy/state-indicator/no-personal-doctor/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7DGoogle Scholar, The Henry J. Kaiser Family Foundation, 2016bThe Henry J. Kaiser Family FoundationPercent of men who report having no personal doctor/health care provider, by race/ethnicity. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 2016http://kaiserf.am/2yNLQsTGoogle Scholar). Rates of primary care access varied by race and ethnicity, with people from racial and ethnic minority backgrounds having least access; twice as many Hispanic men (47%) than white men (23%) reported not having a doctor (The Henry J. Kaiser Family Foundation, 2016aThe Henry J. Kaiser Family FoundationPercent of women who report having no personal doctor/health care provider, by race/ethnicity. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 2016http://www.kff.org/disparities-policy/state-indicator/no-personal-doctor/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7DGoogle Scholar, The Henry J. Kaiser Family Foundation, 2016bThe Henry J. Kaiser Family FoundationPercent of men who report having no personal doctor/health care provider, by race/ethnicity. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 2016http://kaiserf.am/2yNLQsTGoogle Scholar). Other marginalized populations, including older adults, people who are poor or who live in rural areas, and people who are gay, lesbian, bisexual, transgender (including nonbinary or genderqueer), among others also have reduced access to comprehensive health services including primary care (Gates, 2014Gates G.J. In U.S., LGBT more likely than non-LGBT to be uninsured; LGBT adults more likely to lack a personal doctor and enough money for healthcare. Gallup Poll News Service, Los Angeles, CA2014http://bit.ly/2zFkunVGoogle Scholar, Mather et al., 2015Mather M, Jacobsen LA, Pollard KM. (2015). Population bulletin. 70. Retrieved from http://www.prb.org/pdf16/aging-us-population-bulletin.pdfGoogle Scholar, Ritchie, 2014Ritchie A. (2014). Access to primary care remains a challenge for 62 million Americans. Medical Economics, Practice Management. Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/affordable-care-act/access-primary-care-remains-challenge-62-million-Google Scholar, Ward et al., 2015Ward B.W. Schiller J.S. Freeman G. Clarke T.C. Early release of selected estimates based on data from the January-June 2015. National Health Interview Survey, Hyattsville, MD2015Google Scholar, Weaver et al., 2014Weaver R.G. Manns B.J. Tonelli M. Sanmartin C. Campbell D.J.T. Ronksley P.E. Hemmelgarn B.R. Access to primary care and other health care use among western Canadians with chronic conditions: a population-based survey.CMAJ Open. 2014; 2: E27-E34Crossref PubMed Google Scholar). People who do not have primary care providers have less access to the health care system as a whole, are less likely to obtain preventative health care services, and have worse health (Starfield et al., 2005Starfield B. Shi L. Mackinko J. Contribution of primary care to health systems and health.The Milbank Quarterly. 2005; 83: 457-502Crossref PubMed Scopus (2962) Google Scholar), contributing to increased health care costs and increased mortality (Hossain et al., 2013Hossain W.A. Ehtesham M.W. Salzman G.A. Jenson R. Calkins C.F. Healthcare access and disparities in chronic medical conditions in urban populations.Southern Medical Journal. 2013; 106: 246-254Crossref PubMed Scopus (21) Google Scholar, Office of Disease Prevention and Health Promotion, 2010Office of Disease Prevention and Health PromotionAccess to health services.2010https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services#7Google Scholar, Weaver et al., 2014Weaver R.G. Manns B.J. Tonelli M. Sanmartin C. Campbell D.J.T. Ronksley P.E. Hemmelgarn B.R. Access to primary care and other health care use among western Canadians with chronic conditions: a population-based survey.CMAJ Open. 2014; 2: E27-E34Crossref PubMed Google Scholar). The proposed repeal and potential replacement of the ACA (along with state Medicaid expansions, tax credits, and some coverage provisions) is concerning as it will dramatically increase the number of individuals who do not have access to basic health services, including primary care (Congressional Budget Office, 2017Congressional Budget Office. (2017). H.R. 1628, American Health Care Act of 2017. Washington, D.C. Congressional Budget Office. Retrieved from https://www.cbo.gov/publication/52752Google Scholar). Essential health benefits, such as emergency services, maternity and newborn care, preventive and wellness services, and chronic disease management, also face an uncertain future; if this coverage is eliminated, existing health disparities are likely to worsen (Congressional Budget Office, 2017Congressional Budget Office. (2017). H.R. 1628, American Health Care Act of 2017. Washington, D.C. Congressional Budget Office. Retrieved from https://www.cbo.gov/publication/52752Google Scholar). Access to high-quality, affordable, and comprehensive primary care health care services is critical to the health of our nation, and APRNs can help meet this need (Josiah Macy, 2010Josiah Macy Jr. FoundationWho will provide primary care and how will they be trained. Josiah Macy Jr. Foundation, Durham, NC2010Google Scholar, Lenz et al., 2004Lenz E.R. Mundinger M.O. Kane R.L. Hopkins S.C. Lin L.S. Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up.Medical Care Research and Review. 2004; 61: 332-351Crossref PubMed Scopus (189) Google Scholar). There are four distinct APRN roles: nurse practitioner (NP), certified nurse midwife (CNM), clinical nurse specialist (CNS), and certified registered nurse anesthetist (CRNA). Each role has a specific scope of practice that is based on their unique educational preparation and training and allows them to contribute to primary care in distinct and important ways (Federation of State Medical Boards, 2017Federation of State Medical Boards. Assessing scope of practice in health care delivery: Critical questions in assuring public access and safety. Retrieved from https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/2005_grpol_scope_of_practice.pdfGoogle Scholar, Safriet, 2002Safriet B. Closing the gap between can and may in health care providers' scopes of practice: A primer for policymakers.Yale Journal of Regulation. 2002; 19: 301-334Google Scholar). APRNs bring a holistic as well as patient-centered and family-centered approaches to the prevention and management of complex health and behavioral issues addressed in various care settings across the life span. They work collaboratively with physicians and other members of the health workforce to optimize patient care and health. For example, NPs provide a range of comprehensive care services to address individuals' physical and mental health needs across the life span, and CNMs provide primary sexual and reproductive health services across the life span as well as postpartum care, childbirth, and care of newborns (Phillippi and Barger, 2015Phillippi J.C. Barger M.K. Midwives as primary care providers for women.Journal of Midwifery & Women's Health. 2015; 60: 250-257Crossref PubMed Scopus (8) Google Scholar, Pohl et al., 2010bPohl J.M. Hanson C.M. Newland J.A. Nurse practitioners as primary care providers: History, context, and opportunities.in: Who will provide primary care and how will they be trained? Josiah Macy Jr. Foundation, Durham, NC2010: 167-213Google Scholar). CNSs and CRNAs increase access to affordable care services for populations in rural areas (Seibert et al., 2004Seibert E.M. Alexander J. Lupien A.E. Rural nurse anesthesia practice: A pilot study.AANA Journal. 2004; 72: 181-190PubMed Google Scholar). APRNs provide needed services to some of the most vulnerable populations in our society, including individuals from racial and ethnic minorities, Medicaid and Medicare recipients, residents of rural and frontier areas, and the uninsured and underinsured (Agency for Healthcare Research and Quality, 2014Agency for Healthcare Research and QualityPrimary care workforce facts and stats no. 3. Agency for Healthcare Research and Quality, Rockville, MD, 2014http://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.htmlGoogle Scholar, Buerhaus et al., 2015Buerhaus P.I. DesRoches C.M. Dittus R. Donelan K. Practice characteristics of primary care nurse practitioners and physicians.Nursing Outlook. 2015; 63: 144-153Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, Seibert et al., 2004Seibert E.M. Alexander J. Lupien A.E. Rural nurse anesthesia practice: A pilot study.AANA Journal. 2004; 72: 181-190PubMed Google Scholar). The ability of APRNs to practice to the full extent of their education and training is inextricably linked to state-level scope of practice 1Scope of practice refers to "the activities that an individual health care practitioner is permitted to perform within a specific profession. Those activities should be based on appropriate education, training, and experience" (Federation of State Medical Boards, 2017Federation of State Medical Boards. Assessing scope of practice in health care delivery: Critical questions in assuring public access and safety. Retrieved from https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/2005_grpol_scope_of_practice.pdfGoogle Scholar; p. 8). laws and regulations (National Coalition of State Boards of Nursing, 2008National Coalition of State Boards of Nursing. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Chicago, IL: APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. Chicago, IL: Retrieved from https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdfGoogle Scholar). At the state level, scope of practice for nurses is established either by legislative statute or by regulation, the Board of Nursing (BON), or other executive agencies (Buppert, 2014Buppert C. Nurse practitioners business and legal guide.5th ed. Jones & Bartlett Publishers, Burlington, MA2014Google Scholar). Scope of practice in many states is limited by Board of Medicine (BOM) and/or Board of Pharmacy (BOP) oversight, removing the authority of nursing to govern APRN practice and licensure, and the ability for APRNs to practice to the full extent of their training as part of organized interprofessional health care teams (Hanson, 2014Hanson C. Understanding regulatory, legal, and credentialing requirements|nurse key.in: Hamric A. Hanson C. Tracy M. O'Grady E. Advanced practice nursing: An integrative approach. 5th ed. Elsevier, St. Louis, MO2014: 557-558Google Scholar, Pohl et al., 2010aPohl J.M. Hanson C. Newland J.A. Cronenwett L. Unleashing nurse practitioners' potential to deliver primary care and lead teams.Health Affairs (Millwood). 2010; 29: 900-905Crossref PubMed Scopus (40) Google Scholar). Requirements such as mandated collaborative practice agreements (CPAs) and physician-supervised transition-to-practice periods 2CPAs require that APRNs deliver care with physician oversight. APRNs often must pay for this mandated oversight and receive little actual oversight. Sometimes, these agreements are temporary, as in the case of transition-to-practice periods, which exist in 10 states. In these states, transition to practice requires that APRNs have physician oversight for a varying number of hours or years after which they can apply to work independently (Phillips, 2015Phillips S.J. 27th Annual APRN legislative update.The Nurse Practitioner. 2015; 40: 16-42Crossref PubMed Scopus (16) Google Scholar). increase the cost of providing care, lead to gaps in care, and deter APRNs from working in these restrictive states, without any demonstrated improvement in safety or quality (Fauteux et al., 2017Fauteux N, Brand R, Fink J, Frelick M, Werrlien D. (2017). The case for removing barriers to APRN practice—Robert Wood Johnson Foundation. Princeton, NJ: The Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/en/library/research/2017/03/the-case-for-removing-barriers-to-aprn-practice.htmlGoogle Scholar, Kleiner et al., 2014Kleiner M. Marier A. Park K.W. Wing C. Relaxing occupational licensing requirements: Analyzing wages and prices for a medical service.The Journal of Law and Economics. 2014; 59: 261-291Crossref Scopus (52) Google Scholar, Safriet, B.J. 2011Safriet, B. J. (2011). Federal options for maximizing the value of Advanced Practice Nurses in providing. In The future of nursing: Leading changes, advancing health (pp. 443–475). Washington, D. C.: The National Academies Press.Google Scholar). State-level challenges to APRN FPA have been exacerbated by ambiguities at the federal level. For example, failure to define APRNs as primary care providers under the ACA left this matter up to individual states, which contributed to barriers to FPA such as inconsistent policies regarding reimbursement for services delivered by APRNs, including lower payment 3Nurse practitioners are reimbursed at rates of 65% to 85% lower than physicians for providing the same services of the same quality (Kurtzman et al., 2017Kurtzman E.T. Barnow B.S. Johnson J.E. Simmens S.J. Infeld D.L. Mullan F. Does the regulatory environment affect nurse practitioners' patterns of practice or quality of care in health centers?.Health Services Research. 2017; 52: 437-458Crossref PubMed Scopus (33) Google Scholar, Safriet, B.J. 2011Safriet, B. J. (2011). Federal options for maximizing the value of Advanced Practice Nurses in providing. In The future of nursing: Leading changes, advancing health (pp. 443–475). Washington, D. C.: The National Academies Press.Google Scholar). rates (Brooks Carthon et al., 2015Brooks Carthon J.M. Barnes H. Altares Sarik D. Federal polices influence access to primary care and nurse practitioner workforce.The Journal for Nurse Practitioners. 2015; 11: 526-530Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, Kurtzman et al., 2017Kurtzman E.T. Barnow B.S. Johnson J.E. Simmens S.J. Infeld D.L. Mullan F. Does the regulatory environment affect nurse practitioners' patterns of practice or quality of care in health centers?.Health Services Research. 2017; 52: 437-458Crossref PubMed Scopus (33) Google Scholar, Safriet, 2002Safriet B. Closing the gap between can and may in health care providers' scopes of practice: A primer for policymakers.Yale Journal of Regulation. 2002; 19: 301-334Google Scholar, Safriet, B.J. 2011Safriet, B. J. (2011). Federal options for maximizing the value of Advanced Practice Nurses in providing. In The future of nursing: Leading changes, advancing health (pp. 443–475). Washington, D. C.: The National Academies Press.Google Scholar). Centers for Medicaid and Medicare prohibit APRNs from common tasks such as conducting admission evaluations and monthly assessments of patients admitted to skilled nursing facilities (American Association of Nurse and Practitioners, 2012American Association of Nurse Practitioners. (2012). Fact sheet: Long term care. Retrieved from https://www.aanp.org/legislation-regulation/federal-legislation/68-articles/351-fact-sheet-long-term-careGoogle Scholar). In some cases, APRNs who have been authorized to perform within the full scope of their practice are later denied reimbursement for their services (Government Accountability Office, 2014Government Accountability OfficeNurse anesthetists billed for few chronic pain procedures: Implementation of CMS payment policy inconsistent. Government Accountability Office, Washington, DC2014Google Scholar), which limits patients' access to care. FPA for all APRNs in every state is further impeded by lack of consumer awareness of the type and amount of training APRNs receive and the services that they can provide, opposition from professional medical associations, and legislators who are tired from previous legislative attempts to widen APRN scope of practice (Safriet, B.J. 2011Safriet, B. J. (2011). Federal options for maximizing the value of Advanced Practice Nurses in providing. In The future of nursing: Leading changes, advancing health (pp. 443–475). Washington, D. C.: The National Academies Press.Google Scholar). In states where NPs have FPA, benefits to patients, the health care system, and payers have been identified, including:•Significantly fewer emergency room visits for nonemergency health care (Traczyndski and Udalova, 2013Traczyndski, J., & Udalova, V. (2013). Nurse practitioner independence, health care utilization, and health outcomes. Paper presented at the Fourth Annual Midwest Health Economics Conference, Madison, WI.Google Scholar), lower hospitalization rates (Oliver et al., 2014Oliver G.M. Pennington L. Revelle S. Rantz M. Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients.Nursing Outlook. 2014; 62: 440-447Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar), and expanded health care utilization, particularly among the most vulnerable (Traczyndski and Udalova, 2013Traczyndski, J., & Udalova, V. (2013). Nurse practitioner independence, health care utilization, and health outcomes. Paper presented at the Fourth Annual Midwest Health Economics Conference, Madison, WI.Google Scholar, Xue et al., 2016Xue Y. Ye Z. Brewer C. Spetz J. Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review.Nursing Outlook. 2016; 64: 71-85Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar).•Care provided at lower cost than physicians, including preventative care (Perloff et al., 2016Perloff J. DesRoches C.M. Buerhaus P. Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians.Health Services Research. 2016; 51: 1407-1423Crossref PubMed Scopus (83) Google Scholar, Traczyndski and Udalova, 2013Traczyndski, J., & Udalova, V. (2013). Nurse practitioner independence, health care utilization, and health outcomes. Paper presented at the Fourth Annual Midwest Health Economics Conference, Madison, WI.Google Scholar).•Fewer prescriptions for drugs commonly linked to overdose deaths (Schirle and McCabe, 2016Schirle L. McCabe B.E. State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states.Nursing Outlook. 2016; 64: 86-93Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar).•Reports of increased teamwork between NPs and physicians in primary care organizations (Poghosyan et al., 2014Poghosyan L. Boyd D. Knutson A.R. Nurse practitioner role, independent practice, and teamwork in primary care.The Journal for Nurse Practitioners. 2014; 10: 472-479Abstract Full Text Full Text PDF Scopus (28) Google Scholar). 2008: NCSBN releases the Campaign for Consensus (National Coalition of State Boards of Nursing, 2008National Coalition of State Boards of Nursing. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Chicago, IL: APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. Chicago, IL: Retrieved from https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdfGoogle Scholar), an initiative to encourage states to implement a consensus model for the standardization of regulatory requirements, such as licensure, accreditation, certification, and education of all four roles of APRNs. 2010: The Future of Nursing report is released in which The National Academy of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) in collaboration with the Robert Wood Johnson Foundation (RWJF) called for "nurses to practice to the full extent of their education and training … [and] …should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States" (Institute of Medicine, 2011Institute of MedicineThe future of nursing: Leading change, advancing health. National Academies Press, Washington, DC2011Google Scholar; p. 4). The ACA is passed, and in anticipation of the need to bolster primary care services, key provisions sought to increase access to clinical placements among graduate nursing students, the number of NPs who provide care in medically underserved areas, and access to primary care by the nation's poor and underserved individuals (Brooks Carthon et al., 2015Brooks Carthon J.M. Barnes H. Altares Sarik D. Federal polices influence access to primary care and nurse practitioner workforce.The Journal for Nurse Practitioners. 2015; 11: 526-530Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar). 2010: The Center to Champion Nursing in America (CCNA) 4A collaboration between RWJF, the AARP, and AARP foundation. provided its support for The Future of Nursing and supported the development of state-level action coalitions to work on building infrastructure to implement the report's recommendations (Brown, 2012Brown MH. (2012). The center to champion nursing in America: A progress report. Retrieved from http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2012/rwjf72607Google Scholar). By 2012, 48 states had active state-level coalitions (Brown, 2012Brown MH. (2012). The center to champion nursing in America: A progress report. Retrieved from http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2012/rwjf72607Google Scholar). 2016: The Veteran's Administration (VA) finalizes a rule allowing three types of APRNs (NPs, CNMs, and CNSs) who work within the VA to have unrestricted practice authority for their work in the VA regardless of the state in which the individual VA hospital or facility is located (US Department of Veterans Affairs, 2016U.S. Department of Veterans Affairs. (2016). VA grants full practice authority to advance practice registered nurses. Retrieved from https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847Google Scholar). 2017: The ACA is in jeopardy, and an additional 14 million U.S. citizens would be without health insurance in 2018 (Congressional Budget Office, 2017Congressional Budget Office. (2017). H.R. 1628, American Health Care Act of 2017. Washington, D.C. Congressional Budget Office. Retrieved from https://www.cbo.gov/publication/52752Google Scholar). Proposed cuts to reproductive health and family planning reimbursement and essential health benefits threaten the health of our most vulnerable citizens (Congressional Budget Office, 2017Congressional Budget Office. (2017). H.R. 1628, American Health Care Act of 2017. Washington, D.C. Congressional Budget Office. Retrieved from https://www.cbo.gov/publication/52752Google Scholar). Health care is a human right; as such, the increasing health care needs of the public, existence of disparities, and decreasing availability of primary care providers are of concern to the academy. Allowing APRNs to have FPA has the potential to improve health equity while providing care that costs patients, health care systems, and payers less money. Furthermore, APRNs who are able to work to the full extent of their education and training have greater potential to identify creative approaches for solving problems within these systems, which will benefit nursing as a discipline, the larger health care community, and most importantly the public whom we serve (Safriet, B.J. 2011Safriet, B. J. (2011). Federal options for maximizing the value of Advanced Practice Nurses in providing. In The future of nursing: Leading changes, advancing health (pp. 443–475). Washington, D. C.: The National Academies Press.Google Scholar). Therefore, the academy stands with the NCSBN, National Academies of Sciences, Engineering, and Medicine, RWJF, American Association of Retired Person (AARPs), CCNA, VA, National Governor's Association (National Governors Association, 2012National Governors Association. (2012). Nurse practitioners have potential to improve access to primary care. Retrieved from http://www.nga.org/files/live/sites/NGA/files/pdf/1212NursePractitionersPaper.pdfGoogle Scholar), American Hospital Association (American Hospital Association, 2013American Hospital Association. (2013). Workforce roles for redesigned primary care. Retrieved from http://www.aha.org/content/13/13-0110-wf-primary-care.pdfGoogle Scholar), Federal Trade Commission (Federal Trade Commission, 2014Federal Trade CommissionPolicy perspectives: Competition and the regulation of advanced practice nursing.2014https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced-practice-nurses/140307aprnpolicypaper.pdfGoogle Scholar), and others in favor of removing all practice restrictions on APRNs, allowing them to practice independently and to the full extent of their education, training, and experience. We are also in favor of eliminating barriers to FPA such as BOM and BOP oversight and mandated CPA requirements. Furthermore, APRNs must be recognized for the quality of care that they provide and should be able to be reimbursed directly and at the same rate as physicians. To this end, we provide the following recommendations:•Congress should (a) reform the public and private payment systems to allow equitable independent reimbursement for APRN delivery of primary care in all settings, allowing direct remuneration from Medicare, Medicaid, and private payers for the care that is provided by APRNs; (b) enact global signature authority to allow APRNs to sign or complete forms related to patient care within their state, including ordering home health care; (c) allow nurse-led programs such as nurse-managed health centers to be acknowledged as essential community providers and reimbursed by Medicaid at 100%; (d) allow APRNs to join and independently operate accountable care organizations; and (e) standardize reimbursement reporting policies to help facilitate more throughput in health care systems (Josiah Macy, 2010Josiah Macy Jr. FoundationWho will provide primary care and how will they be trained. Josiah Macy Jr. Foundation, Durham, NC2010Google Scholar).•State Boards of Nursing should (a) remove all barriers and restrictions for APRNs in all four roles, in all states and federal agencies and clarify credentialing requirements for each role; and (b) ensure that scope of practice regulations conform with the NCSBN Practice Act and Model Nursing Administrative Rules (National Council of State Boards of Nursing, 2012National Council of State Boards of NursingNCSBN model act.2012https://www.ncsbn.org/14_Model_Act_0914.pdfGoogle Scholar) as suggested in The Future of Nursing report.•State and federal legislators, policymakers, and public and private payers should use provider neutral language (e.g., replace physician with clinician or provider) in all state and federal health care legislation and reimbursement-related policies.•The VA should continue to support FPA for NPs, CNMs, and CNSs by making FPA mandatory in all VA facilities and amend the rule to grant CRNAs FPA as well.•The Workforce Commission and Health Research Services Administration should be fully funded to provide leadership and develop infrastructure for collecting and analyzing interdisciplinary health care workforce data in collaboration with state licensing boards to assist in planning of future workforce needs (Schirle and McCabe, 2016Schirle L. McCabe B.E. State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states.Nursing Outlook. 2016; 64: 86-93Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar).•Nursing organizations and consumer-based organizations should work together to develop messages targeting consumers that aim to improve the public's understanding about the role and duties of APRNs (Safriet, B.J. 2011Safriet, B. J. (2011). Federal options for maximizing the value of Advanced Practice Nurses in providing. In The future of nursing: Leading changes, advancing health (pp. 443–475). Washington, D. C.: The National Academies Press.Google Scholar) and that "projects the image of APRNs as … professionals who are strong and competent" (Lugo, 2016Lugo R.M. Full practice authority for advanced practice registered nurses is a gender issue.Online Journal of Issues in Nursing. 2016; 21: 6Google Scholar) to provide health care services in all practice settings and all individuals, and who do so in collaboration with other members of the interdisciplinary care team. The academy acknowledges the work of the members of the Primary Care Expert Panel.
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