Nurse Practitioners Challenge AMA on Practice Authority, Care Access

The American Association of Nurse Practitioners (AANP) has published an open letter to the American Medical Association (AMA), lambasting the group for its stance on nurse practitioner practice authority and how it can affect high-quality patient care access.

The letter, addressed to AMA President Susan R. Bailey, MD, and CEO and Executive Vice President James L. Madara, MDA, centered on two key arguments: nurse practitioners can effectively improve patient access to care, and nurse practitioners deliver high-quality care that yields high patient satisfaction.

This comes in response to recent debates about practice authority or scope of practice for nurse practitioners. NP scope of practice refers to the amount of autonomy or independence an NP may have when treating a patient and is entirely up to state law and regulation.

Narrow scope of practice means an NP must consult with an overseeing physician before making any treatment decisions.

As some states have considered expanding scope of practice for NPs, the AMA has voiced fierce opposition.

“During a global pandemic, while NPs and physicians are working diligently each day to care for millions of American patients sickened, hospitalized — and in the worst cases — dying from COVID-19, your association has chosen to focus its energies on an offensive campaign designed to alarm and misinform the public and policymakers,” wrote AANP President Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP. “This strategy is out of touch with the facts and the real challenges faced by our nation’s health care system.”

Currently, 22 states, the District of Columbia, two US territories, the Department of Veterans Affairs (VA), and the Indian Health Services (IHS) allow NPs to provide direct patient care. This means NPs are allowed to provide certain types of patient care without the signature of an overseeing physician.

That practice arrangement has been authorized by states, agencies, or jurisdictions, Thomas reiterated on behalf of AANP.

“In the remaining jurisdictions, outdated regulations that the AMA continues to defend and advocate for needlessly bottleneck health care access by making it illegal for patients to access NP-delivered health care services outside an antiquated, bureaucratic contract with a physician,” Thomas explained. “This outdated regulation needlessly creates geographic maldistribution of health care access, delays care and decreases the productivity of both NPs and physicians.”

And there is evidence for this, AANP reported.

In October, JAMA Network Open, a journal of the AMA, published a report finding that the density of primary care providers in rural regions is still something of concern. The study looked at annual percent change in provider density in urban and rural settings, and it was nurse practitioners who saw the highest percent change in density in both rural and urban settings.

Nurse practitioners outpaced physicians and physician assistants in practicing in either setting, the study found. These increases notwithstanding, the study authors concluded that rural regions need more providers to fill in care access gaps.

According to AANP, NPs can be instrumental in filling those gaps, but are stymied by narrow scope of practice laws for which AMA advocates.

“While AMA may prefer to ignore the facts, science and the needs of 80 million patients living in Health Provider Shortage Areas, NPs continue to deliver the care patients want and our nation needs in more than 1 billion patient visits each year,” Thomas wrote on behalf of AANP.

Nurse practitioners also deliver high-quality healthcare, the organization asserted, citing more than 200 studies looking into the matter.

“NPs have a more than 50-year proven track record of delivering high-quality, affordable, patient-centered care,” Thomas stated. “Patients receiving NP care have high satisfaction rates, shorter hospital stays, fewer avoidable emergency room visits and hospital readmissions and lower medication costs — not to mention significantly lower malpractice rates than their physician counterparts.”

Relatedly, NPs also see high patient satisfaction scores, Thomas said. Eighty percent of adults report that they or someone they know has received treatment from a nurse practitioner, and more than half (56 percent) said their NPs spend more time listening to them than other provider types, including physicians.

Ultimately, this debate comes down to delivering high-quality healthcare to more patients, in turn promoting access to care, AANP asserted. According to the organization, that is where AANP has and will continue to place its focus.

“We have no interest in playing gotcha games on Twitter; we’re committed to saving lives and building a health care system that works for patients and providers alike,” Thomas concluded. “AANP invites the AMA to step into the realities of the 21st century, respect the contributions and autonomy of other professions and partner with us as we rise to meet America’s health care challenges.”

This letter comes after lengthy debates about nurse practitioners and practice authority. In 2016 when the VA considered and ultimately finalized its decision to expand scope of practice for NPs, the AMA pushed back. The organization stated that effective care teams are led by physicians only.

“While the AMA supports the VA in addressing the challenges that exist within the VA health system, we believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans,” says AMA board chair Stephen R. Permut, MD, JD, said at the time. “We feel this proposal will significantly undermine the delivery of care within the VA.”

AMA has brought similar arguments into 2020. In the leadup to the finalization of Georgia state law allowing practice parity between physicians, advanced practice registered nurses (which include NPs), and physician assistants, AMA spoke out again. The law specifically expanded scope of practice to allow NPs and PAs to order imaging tests without a physician signature.

“All health care professionals play a critical role in providing care to patients; however, their skillsets are not interchangeable with that of fully trained physicians,” AMA and the Medical Association of Georgia wrote in a letter to Georgia Governor Brian Kemp.

“While nurse practitioners are valuable members of the health care team, with only two to three years of education, no residency requirement and approximately 500-720 hours of clinical training, they are not trained to practice independently.”

Physicians are required to complete four years of medical school, as well as between three and seven years of residency training and between 10,000 and 16,000 hours of clinical training.

To be clear, APRNs usually have to have completed a four-year bachelor’s program to become a registered nurse before applying for a two- or three-year advanced degree, totaling to between six and seven years of education. According to AANP, NPs receive more than six years of education and must complete national board certification and state NP licensure.

Kemp has since signed the bill in question.

At the time of publication, AMA has not publicly responded to AANP’s open letter.