Similar to 23 other states, Pennsylvania requires nurse practitioners to maintain a collaborative practice agreement (CPA) with a physician as a condition of state occupational licensure. In a recent LDI seminar, Dan Gilman, Attorney Advisor of the Federal Trade Commission’s Office of Policy Planning, provided a relevant framework to consider how mandatory CPAs may undermine the delivery of health services to consumers.  

Licensure laws define entry to the health workforce and determine service availability across a multitude of markets. In Pennsylvania, nurse practitioners must sign a CPA with two physicians to meet state licensure requirements. The agreement is a written contract that outlines the services a nurse practitioner may provide and the terms of physician involvement in care delivery. A nurse practitioner without a CPA cannot practice. As Gilman noted, CPAs for nurse practitioners challenge two tenets of competition advocacy with regard to occupational licensure policy: Do the regulations cause harm? And, do the regulations efficiently address proposed risks?

Causing Harm

CPAs can cause harm through their impact on patient care and on the health workforce. Breaches to the CPA as a result of physician relocation or retirement, for example, could disrupt patient care, sometimes without adequate time for providers and patients to establish new plans. 

Sometimes a nurse practitioner cannot locate a collaborating physician, which may happen in rural and outpatient settings with fewer physicians. The nurse would be unable to enter practice in the markets with the greatest need. Roughly 35% of Pennsylvania residents report unmet primary care needs. Although the state has above average numbers of medical students, less than one-third go on to practice here. Stringent occupational licensure requirements tethering nurse practitioners to a limited number of physicians exacerbates workforce shortages, despite well-established evidence for the safety of nurse practitioners as primary care providers.

In the absence of substantiated patient safety concerns, debate over the rationale for CPAs should consider patient needs. Two nurse practitioners graduating from the same accredited graduate program and passing the same national certification exam are not equally permitted to provide patient care services in Pennsylvania when compared to, say, Maryland. Documented improvements in patient outcomes in states with less restrictive nurse practitioner occupational licensure are likely the product of improved patient access and not variability in provider training.

Addressing Risks

The second consideration posed by Dr. Gilman is whether the regulations efficiently address proposed risks. To date, the terms of CPAs between nurse practitioners and physicians are unknown. In Pennsylvania, the agreements are maintained at the nurse practitioner’s practice institution without a requirement for review by the state board of nursing or board of medicine. Only the names of the collaborating physicians are recorded at the state level. There is no evidence that the agreements contribute to decreased risk and better safety or quality.

A signed CPA does not denote what collaborative services, if any, are provided to the nurse practitioner. The model and frequency of physician collaboration are not standardized by statute or regulations. Physician collaboration may include on-site case consultation for all patient encounters with a nurse practitioner or co-signature of patient records. In Florida, examination of CPAs revealed significant variability in the collaborative services actually provided. In a national study of nurse practitioners, the majority of nurse practitioners perceived no improvements in patient safety or quality under a CPA.

Scrutiny of restrictive nurse practitioner occupational licensure is occurring across the country, including Pennsylvania. In 2017, the Pennsylvania reintroduced legislation in SB 25 and HB 100 that would allow nurse practitioners to practice without a CPA. Further debate of this issue is likely in the setting of an aging population, unmet health needs of Pennsylvania residents, and forward progress in other states granting nurse practitioners independent practice. As we consider the rationale and consequences of restrictive state occupational licensure for nurse practitioners, a “dose of competition” is needed to inform future research and policy planning.

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Ashley Z. Ritter, MSN, CRNP, is a Robert Wood Johnson Foundation Future of Nursing Scholar and doctoral student in Penn’s School of Nursing.