Health Policy$ense

PA House on Verge of Historic Vote for Nurse Practitioners

Policy lessons from the past

Sometimes you have to look back to see the path forward. As the Pennsylvania House of Representatives considers legislation to modernize Pennsylvania’s antiquated regulations for nurse practitioners, we might learn something by reviewing the history of the Rendell Administration’s similar battle to expand scope of practice nearly 10 years ago. And if history is a predictor, there is reason to be optimistic.

In Pennsylvania, nurse practitioners and other advance practice registered nurses (APRNs) must have a formal written collaborative agreement with two physicians to practice and prescribe. This requirement represents an unnecessary barrier to health care access, particularly for individuals living in rural and low-income urban settings. In July 2016, the Senate passed Senate Bill 717  by an overwhelming margin (41-9).  With House approval, the legislation would eliminate the requirement for formal written agreements for APRNs to practice in Pennsylvania. While important, this legislation isn’t groundbreaking – 21 states and DC have already passed similar bills. Now it’s Pennsylvania’s turn.

So what are the barriers to passing this legislation? A strong medical lobby in the state, led by the Pennsylvania Medical Society, argues that passing such legislation would eliminate teamwork between APRNs and physicians. However, there is no evidence that the removal of collaborative agreements poses any actual threat to patient safety or quality. In fact, states with no collaborative agreement requirements have seen an increase in access to primary care. And according to a recent study conducted by Duke University School of Law, Pennsylvania stands to save millions of dollars in health care costs over the next decade, if APRNs are able to provide unrestricted access to care. Four decades of evidence and hundreds of studies in leading scientific journals confirm the safety of care provided by advance practice nurses. None have shown that patients cared for by APRNs have worse outcomes than those cared for by physicians. Nevertheless, proponents of SB717 face an uphill battle in the House and the fate of independent practice for APRNs in the state remains uncertain.

Some History Lessons

This is not, however, Pennsylvania’s first experience attempting to modernize its scope of practice regulations. In a new study, published in Policy, Politics & Nursing Practice, we and co-authors Kelly Wiltse Nicely and Julie Fairman explore Pennsylvania’s previous scope of practice expansion battle fought during the Rendell administration. We detail how Gov. Rendell advocated for expanding APRN scope of practice as a part of a comprehensive strategy (Rx4PA) to cope with spiraling state health care costs and concerns over access to health care. At the time, nearly a million Pennsylvanians were uninsured, and one of every 10 lacked a primary care provider. Pennsylvanians were 11% more likely than all other Americans to use the emergency room.

Rx4Pa was met with bitter opposition, particularly from the Pennsylvania Medical Society, which cited concerns over patient safety.  In fact, Rx4PA was being debated in much the same way that SB717 is today. But after a protracted period of negotiation, Rx4Pa was passed into law on July 20, 2007, expanding the ability of APRNs to provide a broader range of health care services, such as ordering physical, respiratory, and occupational therapy, initiating dietician referrals, prescribing durable medical equipment, and issuing oral orders in long-term care. Given the fairly contentious nature of the debate, we asked a fairly straightforward question, how did the scope of practice legislation outlined in Rx4Pa pass?

To unpack the process, we interviewed 12 individuals from a variety of backgrounds and organizations who were directly involved in the Rx4PA legislation. After in-depth interviews, key strategies for successful policy change emerged, including the nursing proponents’ ability to build a solid ground game at local levels, broad professional and organizational support, and strong political leadership and allies.

At the time, APRNs were represented by a number of organizations and historically lacked coordination and cooperation. However, during the push to pass this legislation, diverse nurse leaders and nursing organizations worked together to support the hiring of a professional lobbyist, develop a white paper, define legislative goals, and leverage years of grass roots advocacy. These efforts allowed nursing leaders to speak with a clear voice and with a consistent message.  In our review of the successful passage of Rx4Pa one key component loomed large—the presence of a strong political figure, Gov. Rendell, who was able to wield tremendous power and influence during the negotiation process, as well as members of his cabinet, which included financial services heavyweight Rosemarie Greco, who served as the Executive Director of the Office of Health Care Reform. Rendell held the carrots and the sticks, and in so doing was able to convince groups traditionally opposed to one another to come to the table to craft legislation that both sides could support.  

Fast forward back to 2016

These lessons, including the importance of leveraging years of grass roots advocacy, identifying political allies, and recognizing mutually beneficial compromises, are still relevant nearly a decade later, as scope of practice is back on the table in Pennsylvania. At the same time, the state faces a growing health care provider shortage across its rural and urban settings. Utilizing APRNs to their full potential could relieve our strained system. The scope of practice bill currently sitting in the House holds the support of many stakeholders, including the Hospital & Healthsystem Association of Pennsylvania and AARP. Similar to Rx4Pa, the current legislation will require vocal support from allies within and outside of the nursing community, a strong push from political insiders, and coordinated pressure from constituents in districts with representatives standing in the way of change.

Margo Brooks Carthon is an LDI Senior Fellow and Assistant Professor of Nursing at Penn; Danielle Altares Sarik is Director of Research for Nursing at the Nemours/ AI duPont Hospital for Children.
This work was funded by the Robert Wood Johnson Foundation.