Pennsylvania is one of 28 states that has not expanded the scope of practice in its licensure laws for certified registered nurse practitioners (NPs), who must maintain formal collaborative agreements with 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, these proposals were seen as primarily “turf wars” between NPs and physicians, without full consideration of the impact on patients and public health. Growing evidence indicates that these legal oversight requirements impair professional entry to practice, increase costs of care, impose administrative and cost burdens on health systems and NPs, and impede access to high-quality, cost-efficient health care.

Both chambers of the Pennsylvania General Assembly acted to expand scope of practice during the 2019-2020 session—although to different extents. S.B. 25 would have expanded opportunities for NPs across the state, while a compromise amendment to H.B. 100 proposed a six-year pilot program that would have removed physician oversight requirements for NPs in primary care shortage areas only. Neither piece of legislation passed both chambers before session expired. A University of Pennsylvania analysis showed that H.B. 100, as amended, would have affected fewer than 50 NPs who now practice in these shortage areas, which have a combined population of more than 200,000 people. It would not have changed the practice restrictions on the vast majority of more than 11,000 NPs practicing across the state, often in rural and high-poverty areas.

Since the legislation was introduced in 2019, the landscape for reform has shifted, as the COVID-19 pandemic rapidly transformed health care and revealed striking health disparities. Recognizing an opportunity to break the logjam, the University of Pennsylvania held a virtual workshop on November 20, 2020, bringing together researchers, health professionals, and consumers to chart a new path forward. This policy brief summarizes their recommendations to update scope of practice regulation to better meet the primary care needs of Pennsylvanians.

Recommendations

In breakout sessions, workshop participants delved into three intersecting themes: lessons learned from rapid changes in practice due to the pandemic; ways to foster collaborative relationships among NPs, physicians, and other health professionals; and options to move legislation forward in the next legislative session. Each recommendation individually represents a tangible and feasible approach to improve access to care and achieve public health goals. Together, they represent a “symbiotic opportunity” to change the narrative that has produced political stalemate.

Lessons from COVID-19 Changes

In response to the pandemic, many states relaxed or suspended their requirements for physician oversight of NPs, allowing them to expand their practice capabilities — all within the scope of their education and training. Pennsylvania relaxed certain restrictions during the declared emergency, such as limiting NP practice to a specific clinical specialty or prohibiting NPs from prescribing drugs outside of an established formulary.

While there is extensive evidence about the benefits of full SOP and access, quality, and cost of care, workshop participants noted that temporary expansions in NP practice in Pennsylvania and other states could yield state-specific information on quality and efficiency of NP care. They recommended that we see this as an opportunity to update regulation by codifying the temporary changes and further develop, spread, and scale innovative models of care. To apply the lessons of the pandemic, and build consensus among stakeholders, participants recommended that:

• The state and external groups collect outcomes data to evaluate the recent changes in practice. Although most participants agreed that strong evidence already exists on the outcomes of care delivered by NPs with full practice authority in other states, they also saw the persuasive value of state-specific, data-driven evaluations of how the changes in scope of practice have affected access to and quality of primary care.
• NPs build coalitions with physician partners and other health professionals with whom they have worked before and during the pandemic. The participants pointed out that a large group of natural allies already exists among health professionals who collaborate routinely in practice.
• Advocates stress the business case for expanding NP scope of practice, particularly in light of the pandemic-related recession and the resulting pressure on state budgets. Participants suggested that this emphasis could broaden the appeal to groups that value free market access, choice, and competitive marketplaces, including employer, employees, and consumers.

Fostering Collaborative Relationships

In a session jointly led by an NP and a family physician, participants discussed the nature of collaborative practice. While current Pennsylvania regulation calls for a collaborative practice agreement, participants noted that real professional collaboration involves more of a process and relationship than a “check box” or payment for a contract. These contracts often require the NP, or health system employing NPs, to pay significant fees to the collaborating physician to fulfill the legal requirement. As presently structured, collaborative practice agreements impose administrative burdens and costs upon the health system, without adding value or delineating services that foster robust interprofessional relationships. Participants recommended that:

• The contractual, transactional aspects of collaborative practice agreements be changed to instead outline collaborative arrangements with provisions for physician consultations. Institutions might develop and improve templates for these arrangements, with input from physicians, NPs, and other health professionals. The fees involved in these arrangements should reflect the consultations provided.
• Collaborative arrangements and residency programs be used to ensure that consultation is available to new NP graduates, to support their transition to practice. Institutions could consider investing in NP residency programs as a longer- term strategy to develop team-based models of care and foster interdisciplinary teamwork.

• Public and private payers provide incentives for collaboration and team-based care, by including NPs in both risk and reward. Greater parity in reimbursement levels for similarly-coded services would promote efficient use of all team members. These levels are often driven by federal policy and Medicare regulation. Alternative payment models in which providers take on financial risk for outcomes should include participation by the entire team, including NPs and physicians. The group noted that such incentives would produce collaborative processes that improve patient care and public health to a much greater extent than a regulatory requirement for a pro-forma contract.

Moving Scope of Practice Legislation Forward in Pennsylvania

In a session focused on the most promising steps to take advance scope of practice reform, participants considered the years of legislative impasse and the polarizing dynamics of a “trade war” between entrenched professional interests. They called for changing the narrative by engaging the public around how the public interest can best be served by future legislation. They recommended that:

• Legislators hear from consumers directly, about the importance of NPs as care providers in Pennsylvania. Members of the General Assembly need to understand how policy reform could benefit their constituents, particularly in providing access to primary care. Participants noted that first- person accounts from the public and patients can make the issue salient for legislators, especially for the 96 new members seated in the past two years who may not be as familiar with the opportunities and benefits of expanded practice authority for NPs.
• Legislators reconsider the proposed compromise of the last session. Participants agreed that the evidence base for expanding NP scope of practice is strong, and that a pilot program, as currently proposed, would add little additional information.
  • Given the experience of many states in expanding NP scope of practice to meet critical health needs during the pandemic, legislators should consider granting full practice authority to NPs as a key ingredient to assuring access to care for all Pennsylvanians.
  • If legislators choose to reintroduce the pilot program, they should revamp the conditions in terms of eligibility, geographic areas, and duration. Participants suggested expanding the pilot to include specialty care as well as counties with shortage areas (or even the entire state) and reducing the length of the program. Legislators should clarify the questions that a pilot program can answer, in the context of data already available from other states.

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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.