policybrief | January 2021 NURSE PRACTITIONER SCOPE OF PRACTICE REFORM REWRITING THE PLAYBOOK IN PENNSYLVANIA Putting Patients at the Center Pennsylvania is one of 28 states that has not expanded the scope of forward. This policy brief summarizes their recommendations to practice in its licensure laws for certified registered nurse practitioners update scope of practice regulation to better meet the primary care (NPs), who must maintain formal collaborative agreements with needs of Pennsylvanians. physicians to practice. For many years, proposals to update licensure and adapt it to make it more compatible with current models of collaborative care could not overcome legislative logjams. Often, RECOMMENDATIONS these proposals were seen as primarily “turf wars” between NPs and In breakout sessions, workshop participants delved into three physicians, without full consideration of the impact on patients and intersecting themes: lessons learned from rapid changes in practice public health. Growing evidence indicates that these legal oversight due to the pandemic; ways to foster collaborative relationships requirements impair professional entry to practice, increase costs of among NPs, physicians, and other health professionals; and options care, impose administrative and cost burdens on health systems and to move legislation forward in the next legislative session. Each NPs, and impede access to high-quality, cost-efficient health care. recommendation individually represents a tangible and feasible Both chambers of the Pennsylvania General Assembly acted to approach to improve access to care and achieve public health goals. expand scope of practice during the 2019-2020 session—although Together, they represent a “symbiotic opportunity” to change the to different extents. S.B. 25 would have expanded opportunities for narrative that has produced political stalemate. NPs across the state, while a compromise amendment to H.B. 100 proposed a six-year pilot program that would have removed physician LESSONS FROM COVID-19 CHANGES oversight requirements for NPs in primary care shortage areas only. Neither piece of legislation passed both chambers before session In response to the pandemic, many states relaxed or suspended their expired. A University of Pennsylvania analysis showed that H.B. requirements for physician oversight of NPs, allowing them to expand 100, as amended, would have affected fewer than 50 NPs who now their practice capabilities — all within the scope of their education and practice in these shortage areas, which have a combined population training. Pennsylvania relaxed certain restrictions during the declared of more than 200,000 people. It would not have changed the practice emergency, such as limiting NP practice to a specific clinical specialty restrictions on the vast majority of more than 11,000 NPs practicing or prohibiting NPs from prescribing drugs outside of an established across the state, often in rural and high-poverty areas. formulary. Since the legislation was introduced in 2019, the landscape for While there is extensive evidence about the benefits of full SOP reform has shifted, as the COVID-19 pandemic rapidly transformed and access, quality, and cost of care, workshop participants noted health care and revealed striking health disparities. Recognizing an that temporary expansions in NP practice in Pennsylvania and other opportunity to break the logjam, the University of Pennsylvania states could yield state-specific information on quality and efficiency held a virtual workshop on November 20, 2020, bringing together of NP care. They recommended that we see this as an opportunity researchers, health professionals, and consumers to chart a new path to update regulation by codifying the temporary changes and further LDI.UPENN.EDU | @PENNLDI | NURSING.UPENN.EDU | @PENNNURSING develop, spread, and scale innovative models of care. To apply the • P ublic and private payers provide incentives for lessons of the pandemic, and build consensus among stakeholders, collaboration and team-based care, by including NPs in participants recommended that: both risk and reward. Greater parity in reimbursement levels • T he state and external groups collect outcomes data to for similarly-coded services would promote efficient use of evaluate the recent changes in practice. Although most all team members. These levels are often driven by federal participants agreed that strong evidence already exists on the policy and Medicare regulation. Alternative payment models outcomes of care delivered by NPs with full practice authority in in which providers take on financial risk for outcomes should other states, they also saw the persuasive value of state-specific, include participation by the entire team, including NPs and data-driven evaluations of how the changes in scope of practice physicians. The group noted that such incentives would produce have affected access to and quality of primary care. collaborative processes that improve patient care and public health to a much greater extent than a regulatory requirement • N Ps build coalitions with physician partners and other for a pro-forma contract. health professionals with whom they have worked before and during the pandemic. The participants pointed out that MOVING SCOPE OF PRACTICE LEGISLATION a large group of natural allies already exists among health FORWARD IN PENNSYLVANIA professionals who collaborate routinely in practice. In a session focused on the most promising steps to take advance • A dvocates stress the business case for expanding NP scope scope of practice reform, participants considered the years of of practice, particularly in light of the pandemic-related legislative impasse and the polarizing dynamics of a “trade war” recession and the resulting pressure on state budgets. between entrenched professional interests. They called for changing Participants suggested that this emphasis could broaden the the narrative by engaging the public around how the public interest appeal to groups that value free market access, choice, and can best be served by future legislation. They recommended that: competitive marketplaces, including employer, employees, and consumers. • L egislators hear from consumers directly, about the importance of NPs as care providers in Pennsylvania. FOSTERING COLLABORATIVE RELATIONSHIPS Members of the General Assembly need to understand how policy reform could benefit their constituents, particularly in In a session jointly led by an NP and a family physician, participants providing access to primary care. Participants noted that first- discussed the nature of collaborative practice. While current person accounts from the public and patients can make the Pennsylvania regulation calls for a collaborative practice agreement, issue salient for legislators, especially for the 96 new members participants noted that real professional collaboration involves seated in the past two years who may not be as familiar with the more of a process and relationship than a “check box” or payment opportunities and benefits of expanded practice authority for for a contract. These contracts often require the NP, or health NPs. system employing NPs, to pay significant fees to the collaborating physician to fulfill the legal requirement. As presently structured, • L egislators reconsider the proposed compromise of the last collaborative practice agreements impose administrative burdens and session. Participants agreed that the evidence base for expanding costs upon the health system, without adding value or delineating NP scope of practice is strong, and that a pilot program, as services that foster robust interprofessional relationships. Participants currently proposed, would add little additional information. recommended that: • G iven the experience of many states in expanding NP scope • T he contractual, transactional aspects of collaborative of practice to meet critical health needs during the pandemic, practice agreements be changed to instead outline legislators should consider granting full practice authority collaborative arrangements with provisions for physician to NPs as a key ingredient to assuring access to care for all consultations. Institutions might develop and improve Pennsylvanians. templates for these arrangements, with input from physicians, • If legislators choose to reintroduce the pilot program, NPs, and other health professionals. The fees involved in these they should revamp the conditions in terms of eligibility, arrangements should reflect the consultations provided. geographic areas, and duration. Participants suggested • C ollaborative arrangements and residency programs be expanding the pilot to include specialty care as well as used to ensure that consultation is available to new NP counties with shortage areas (or even the entire state) and graduates, to support their transition to practice. Institutions reducing the length of the program. Legislators should clarify could consider investing in NP residency programs as a longer- the questions that a pilot program can answer, in the context term strategy to develop team-based models of care and foster of data already available from other states. interdisciplinary teamwork. This Policy Brief was authored by Janet Weiner, PhD, MPH and reflects rich discussions at the November 20, 2020 virtual workshop sponsored by Penn LDI and Penn Nursing. We thank all workshop participants for their insight; the recommendations herein do not imply endorsement by each participant nor a consensus statement among them.