Prescriptive Authority for Nurse Practitioners
Submitted by Lacy Kusy
The passage of the Affordable Care Act (ACA) will provide many more Americans access to health care. The ACA will reduce the cost of receiving health care, while also enabling uninsured Americans access to insurance and more affordable healthcare. The Act will “promote prevention, wellness, and the public health” (Legislative Counsel, 2010, p. 463). Although the ACA will increase accessibility to primary care and prevention of diseases, there must be an adequate number of healthcare providers who can see these patients. The Association of American Medical Colleges estimates a shortage of 46,000 primary care physicians by the year 2025 (Rouston, 2010). Nurse Practitioners can easily step into the role of primary care. There are currently 150,000 nurse practitioners in the United States, and 5,500 practitioners graduate every year (Rouston, 2010). State legislatures, however, regulate Advance Practice Registered Nurses (APRN), and only 12 states currently have no restrictions for APRN prescriptive rights (Future of Nursing, 2011). For APRNs to fully care for patients at the primary care level, state legislatures must remove prescriptive restrictions throughout the United States.
Nurse practitioners can and should help fill a void in providing primary care. As mentioned earlier, only 12 states currently allow nurse practitioners to prescribe medications without restriction; whereas the other 38 states require physician collaboration or restrictions on controlled substances (Future of Nursing, 2011). Patients routinely visit their family practice providers with concerns such as a sore throat, backache, or anxiety. The nurse practitioner is adequately trained, has completed a national certification examination, and possesses a license to care for these issues. However, only in certain states can these APRNs prescribe the necessary treatment for these patients. The practitioner may not be able to fulfill the need of the patient in states with stringent regulations limiting APRN prescription rights. In these states, the APRN must refer the patient to or consult with a physician to meet the patient’s medical needs, thus delaying medical treatment. For example, a nurse practitioner in Florida caring for a patient with a persistent cough and sore throat cannot prescribe cough medicine with codeine for the patient’s comfort (Nursing License Map, 2012). Therefore, the patient must see a physician to obtain a prescription for relief from a sore throat and cough, which both delays treatment and increases health care costs associated with a second visit.
Patients will benefit from minimizing restrictions on prescription authority. Not only will patients have greater access to health care with less wait times; but patients will also benefit from continuity of care. This benefit is especially true in rural areas of the United States, where an even greater shortage of primary care physicians exist (Anguita, 2011). Another problem with the prescription restrictions for controlled substances is that nurse practitioners can care for patients receiving these medications but cannot adjust or prescribe the medications. For example, a patient with generalized anxiety disorder takes Xanax, a controlled substance, and visits her nurse practitioner for a physical examination. The nurse practitioner must take into account the effects Xanax has on her patient; however, she is not allowed to write for or adjust this medication. Furthermore, nurse practitioners have authority to prescribe significantly more dangerous medications. In the state of Florida, for instance, a nurse practitioner may prescribe a potassium replacement or Coreg, a cardiac medication. These medications, if taken inappropriately, can have fatal effects on the patient, such as lowering the patient’s blood pressure or causing a fatal cardiac arrhythmia. To allow the ARNP the right to prescribe such dangerous medications but limit the use of controlled substances is not logical or appropriate (The Florida Senate, 2008).
Nurse Managed Care Centers (NMCC) are prime examples of medical clinics that would benefit from lifting prescriptive authority constraints for APRNs. An NMCC offers primary care services, particularly in underserved and unemployed populations across the United States. These clinics promote wellness, disease prevention, and education for their patients. Three NMCCs exist in the state of Florida. Although most care centers have a collaborating physician who prescribes controlled substances, the physician’s purpose at these clinics is also to collaborate with the nurse practitioners to maintain high quality care. This physician should not be hindered with his care because he prescribes medications the nurse practitioner cannot prescribe (Turkeltaub, 2004). Nurse Practitioners have consistently demonstrated they provide the same quality of care as physicians, but at a lower cost. In fact, in 2009, the average cost of a nurse practitioner visit was 20% less than a physician visit. The state of Massachusetts conducted a study to determine it could save 8.4 billion dollars over a 10-year period by increasing use of nurse practitioners. Patients who have greater primary care access to nurse practitioners will also benefit from cost savings associated with a reduced number of emergency room and hospital visits (The Cost Effectiveness, 2011). Unfortunately, this data does not account for the cost benefit of providing nurse practitioners full prescriptive authority. As it stands now, many nurse practitioners refer their patients to a physician for certain prescriptive needs.
Physicians are among the majorities that disagree with releasing the restrictions for controlled substances prescribed by nurse practitioners. In fact, according to an article by the Sunshine State News, The Florida Medical Association stated that, “the ability to prescribe controlled substances is limited to medical doctors for a reason: to protect patient safety. Physicians go to medical school to learn how to prescribe controlled substances safely and without interacting with other medications. ARNPs do not” (Derby, 2010, para. 9). A Fort Worth, Texas physician, Dr. Gary Floyd states that nurse practitioners should attend medical school and receive additional training if they wish to have more responsibility and function independently (Ramshaw, 2010). A study published in the Journal of the American Medical Association; however, proves the assumption that nurse practitioners cannot provide adequate care and prescribe controlled substances false. This randomized study was conducted among medical clinics in states where nurse practitioners and physicians have the same prescriptive authority. The study determines if the outcomes of patients receiving nurse practitioner care or physician care differs. At the end of one year, the study proved that patient outcomes were comparable and no significant difference existed between the care provided by nurse practitioners and physicians (Mundinger, Kane, & Lentz, 2000).
Another notable objection to granting nurse practitioners full prescriptive authority in all 50 states is the fear that doing so will increase liability claims. In a study done at the University of Central Florida, a researcher compared malpractice claims among physicians and nurse practitioners in states that allow full prescriptive authority and in those that have restrictions. The study researched malpractice claims from the National Practitioner Data Bank. In states where nurse practitioners have full prescriptive authority, including the ability to prescribe controlled substances, this study revealed that per 1000 nurse practitioners and physicians, the average rate of malpractice claims was seven claims per 1000 nurse practitioners and 234 claims per 1000 physicians (Chandler, 2010). Therefore, according to this study, the argument that increasing prescriptive rights for nurse practitioners would increase malpractice claims is not legitimate. In fact, according to an article by Kaplan and Brown (2004), liabilities may actually increase for physicians in states where the nurse practitioner does not have full prescriptive authority. Because of the restrictions, the nurse practitioner is not able to write for such medications as Ritalin for a child with Attention Deficit Disorder. Therefore, the physician may write prescriptions for patients with whom he may not be adequately familiar. (Kaplan & Brown, 2004).
In conclusion, with the expectation for nurse practitioners to appease the primary care shortage, these practitioners must be able to meet the needs of patients. Regulating the APRNs ability to order such controlled substances as Xanax or Ritalin will not only inconvenience the patient, but will also diminish continuity of care. Nurse practitioners are more cost-effective than physicians, while continuing to provide the same quality of care. Time and time again, patient satisfaction and respect for nurse practitioners is extraordinary. The appropriate action for state legislatures is to remove prescriptive restrictions permitting nurse practitioners to provide the care they were trained to provide.