States that allow highly trained nurses to work independently see better health outcomes than those that require physician supervision, according to a new study.
Coincidence? University of Missouri researchers don't think so — and they are on a mission to improve access to health care in all communities.
Alisha Johnson, an assistant professor in the Sinclair School of Nursing, is well aware of the growing shortage of health care providers in the United States and the serious consequences it has on access to care.
She knows that advanced practice registered nurses (APRNs), who hold graduate degrees enabling them to diagnose illness and prescribe treatment, can play a crucial role in addressing provider shortages. However, only 27 states grant APRNs "full practice" authority, allowing them to work independently. The rest have "reduced practice" or "restricted practice" laws that require physician oversight.
Curious about how varying state laws affect health outcomes and access to care, Johnson recently led a study examining the Commonwealth Fund, which ranks the health care system of all 50 states based on a variety of health outcomes.
The team found that full practice states ranked much higher — on average, 16 to 18 places above those with reduced and restricted practice laws.
That's because states that grant full practice authority give nurse practitioners greater autonomy, which in turn improves access to care, according to Johnson.
For example, in some restricted practice states, an individual can only work as an APRN if they are located within a certain number of miles of a physician who reviews their work. Johnson recalls a colleague — an APRN who ran a mental health clinic in a rural area — who saw firsthand the limits this restriction can have on access to care.
"When her collaborating physician relocated, she was no longer within the required miles and had to close her practice," Johnson said. "She was devastated thinking about the people who no longer had access to her health care services."
Increasing access to care is a key priority for the Sinclair School of Nursing, which will open its first on-site initiative in Holts Summit, Missouri, in October to bring care directly to the community.
"Our vision is to broaden this model across Missouri, especially in areas with limited local access to health care," said Julie Miller, director of faculty clinical practice in the Sinclair School of Nursing and co-author on the study. "We are preparing a workforce ready to step in and serve, and we can do even more in an environment with fewer barriers."
Because APRNs in full practice states are allowed to work wherever they want, full practice laws are linked to a 374% increase in APRNs starting their own practices, which makes access to care easier for patients.
"With full practice authority, our APRNs can be the first door to care for thousands of Missourians," said Lori Popejoy, dean of the Sinclair School of Nursing and co-author on the study. "We want to be part of the solution to Missouri's health care shortages to ensure all patients have access to care."
In states that allow full practice authority, expanding access to care can significantly improve health outcomes. Nursing homes can employ more APRNs that interact with residents regardless of location, resulting in timelier care and creating a trickle-down effect that leads to better health outcomes.
Johnson's colleagues in full practice states love the freedom to reach their full potential.
"They feel empowered to do their job without always having to ask themselves, 'Do I have a collaborating physician?'" Johnson said. "'Have I paid them this month? Have they looked over my charts? Am I allowed to see this patient? Where can I set up shop? If my physician moves, what do I do now?' Those restrictions create insecurity and impact their ability to do their jobs."
Johnson knows that nursing homes and other long-term care facilities are a particular area where provider shortages are an increasing concern as the population of the United States ages. In 2022, nearly 58 million Americans were 65 or older — a number projected to exceed 78 million by 2040.
"Each year, the number of trained physicians going into the field of geriatrics is going down, but the number of APRNs is going up," Johnson said. "I ultimately want APRNs to reach their full potential so they can improve access to care and health outcomes, especially with our aging population. More full practice laws can allow us to empower more APRNs without restrictions."
Certain restrictions can have financial impacts as well. Since APRNs in restricted practice states must pay doctors to review their work, those added costs often get passed on to the patients.
"Going forward, I want to look at the economics of this issue by studying what the cost of care per Medicare patient is in full practice states compared to restricted practice states, knowing that APRNs often cost less than physicians both for health care systems and patients," Johnson said. "If we can improve access to care while reducing costs, that is a win-win."
"Solution to improve state health outcomes and access to care for Medicare beneficiaries: Full practice of APRNs" was published in the Journal of the American Medical Directors Association. Marilyn Rantz, a Curators' Professor Emerita in the Sinclair School of Nursing, and Isabella Zaniletti, an adjunct professor in the College of Arts and Science, were also co-authors on the study.
