Running head: BARRIERS FOR THE NURSE PRACTITIONER IN NEW YORK

STATE 1

Barriers for the Nurse Practitioner in New York State

Jennifer Lieberman

State University of New York Polytechnic Institute

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In the United States, there is an increasingly diminished number of primary care

physicians that come out of school each year; this is particularly evident in rural areas and lower

income regions (Pericak, 2011). It has been reported that nearly every county within New York

State has suffered the impact of physician shortage with populations being underserved (Pericak,

2011). Primary care is in jeopardy as there is a far greater number of individuals in need of

primary care services than there are providers (Pericak, 2011). It is predicted that by 2020, there

will be a projected deficit of 200,000 primary care physicians across the United States (Pericak,

2011). Nurse Practitioners can be found throughout the regions with 32% located in suburban

areas, 31% in the inner-city areas and 15% located rurally, filling a void in primary care

throughout the state (Pericak, 2011). Growth for Nurse Practitioners in primary care is excepted

to grow by 93% between 2013 and 2025, making it the fastest growing profession in healthcare

(Poghosyan, 2018). The issue therein lies with the restrictions or barriers placed upon Nurse

Practitioners to provide adequate patient care (Pando, 2017).

Scope of Practice

In New York State, the Nurse Practitioner (NP) is a Registered Nurse (RN) who has

completed education in the masters or doctorate setting and certified by the New York State

Education Department after successfully passing Certified Board Examinations (NYSED, 2017).

The Nurse Practitioner can practice in various fields that include adult health, family health,

gerontology, pediatrics, neonatology, school health, obstetrics, oncology, perinatology,

psychiatry, palliative care, holistic care, and women’s health (NYSED, 2017). The NP diagnoses

while providing therapeutic and corrective measures in the area that the NP is certified in

(NYSED, 2017). While in New York State it is not required for a physician to supervise an NP,

they are required to “collaborate” with one to practice (NYSED, 2017). These collaborative
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relationships, according to the New York State Education Law, are when communication

between a physician and NP occur telephonically, in writing, in person, or electronically specific

to the specialty involved to exchange information and provide comprehensive care (NYSED,

2017).

Literature Review of the Barriers

Nurse Practitioners are faced with different barriers that do not allow them to work to the

highest level of their education (Pando, 2017). Some of these barriers include physician

opposition, state laws and legislation, and reimbursement rates (Pando, 2017).

Physician Opposition

Organizations such as the American Medical Association, are under the impression that

due to the longevity of physician training versus the Nurse Practitioner, that the NP is incapable

of proving safe, quality care at the same level (Hain & Fleck, 2014). When a group of 39 NPs in

a study conducted by C. Pando was asked what was the biggest barrier they faced, 30 of them

reported that the primary barrier was opposition met from physicians (Pando, 2017). When

narrowed down as to the rationale, responses included 48.8% feeling that the physician felt the

NP would overstep their boundaries and 22% felt it was a control need for the physicians, with

views of the AMA contributing to 9.8% of the disapproval faced (Pando, 2017). In another

study as published in the New England Journal of Medicine, findings were highly suggestive that

primary care physicians were unlikely to embrace a movement for NPs to further expand upon

their roles as demonstrated in Appendix A (Donelan, DesRoches, Dittus, & Buerhaus, 2013). In

November of 2017, the AMA opposed the Advanced Practice Registered Nurse (APRN)

Compact, Resolution 214, which would allow the APRN holding one multistate licensure the
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ability to practice in all states holding the compact (Sofer, 2018). The AMA also strongly

opposes the movement against NPs practicing without a collaborative physician (Sofer, 2018).

Nursing organizations, however, such as the American Association of Nurse Practitioners have

referred to this AMA initiative as fear mongering for purposes of physician protectionist, with

the American Nurses Association calling it blatantly dishonest in their portrayal of NPs and their

practice (Sofer, 2018). The Nurse Practitioner Association of New York State feels strongly that

the statutory collaborative agreement serves no true purpose to the public and was a political

compromise made 20 years ago that is no longer relevant today (Muxworthy & Bowllan, 2011).

The organization also goes on to say that the collaborative agreement is in no way a substitute

for professional judgment; healthcare professionals must be fluent in their scope of practice and

safety in practicing within this parameter (Muxworthy & Bowllan, 2011). While the AMA

stands firmly that NPs can provide the safest and highest quality of patient care only with

physician supervision, numerous NP associations and the State of New York have fired back

with the American College of Physicians urging both sides to work together stating that each

group has special skill sets that complement each other and are synergistic (Muxworthy &

Bowllan, 2011).

State Laws and Legislation

The Nurse Practitioner Modernization Act of 2011 was brought to the forefront by NYS

Assemblyman Gottfried and Senator Young, to allow NPs the right to practice without the

statutory collaboration agreement and amend the education law to reflect this (Muxworthy &

Bowllan, 2011). Effective January 1st, 2015, the Nurse Practitioner Modernization Act was put

into Public Health Law and states that each NP with more than 3,600 hours of NP experience

may practice without the requirements of a written physician practice agreement (New York
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State Education Department, 2015). Another legislative barrier that has recently passed, is the

DNR Clean-Up Bill S7713A, authorizing the NP to witness the execution of a healthcare proxy

by the patient (The Nurse Pracitioner Association New York State, 2018). This legislation

allows for recognition in the Public Health Law that a qualified Nurse Practitioner, capable of

determining end of life decisions, may implement a healthcare proxy (The Nurse Pracitioner

Association New York State, 2018). This legislation passed with NYS Governor Cuomo’s

signature on November 5th, 2018, effective 90 days from the date of signing (The Nurse

Pracitioner Association New York State, 2018). The Nurse Practitioner Association of New

York State also recognizes multiple other agendas that remain barriers to the NP that include the

workers compensation legislation, to recognize NPs as providers within this system for care and

treatment of patients, and the mental health bill, authorizing the NP to admit mentally ill patients

(The Nurse Pracitioner Association New York State, 2018). L. Poghosyan discusses the barriers

of home health orders as a Nurse Practitioner, considering that this profession is the largest type

that delivers home care to large geographical areas, yet still necessitates physician signatures for

NP orders to be valid (Poghosyan, 2018). The Nurse Practitioner Association of New York State

also has supported A. 2718 legislation for the NP Ordered Home Care Services Law to clarify

that NPs may in fact write orders for services for Medicaid recipients (The Nurse Pracitioner

Association New York State, 2018).

Reimbursement

While policy varies from state to state, federal reimbursement through payers such as

Medicare, reimburses the NP for services provided at 80 to 85 percent of what the comparable

physician would receive (Fraser & Melillo, 2018). This particular barrier is two-fold as not only

the reimbursement rate is lower, it also directly impacts those APRNs who may practice
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autonomously without a collaborative agreement as they are unable to receive full

reimbursement without that physician present (Hain & Fleck, 2014). Payer policies vary and

some may not recognize the Nurse Practitioner as a primary care provider, thereby refusing to

credential and pay them for services rendered as a Nurse Practitioner (Hain & Fleck, 2014).

Importance in the Realm of Healthcare

This topic is important because with the constraints described throughout this paper,

Nurse Practitioners are restricted from working to the highest level of their ability and education.

The ability to advance the role of Nurse Practitioners to deliver high quality, compassionate

patient care, is dependent on the removal of barriers faced (Hain & Fleck, 2014). With such

restrictions in place, the NP is unable to fully contribute to the optimal functioning of the

healthcare team and the patient (Altman, Stith Butler, & Shern, 2016). This is especially true as

the need for primary care providers continues to grow and the number of clinicians in this field

diminishes (Gutchell, Idzik, & Lazaer, 2014). Uncoordinated systems of state regulations are

restrictive to the practice and development of the NP role in a manner that is consistent with their

education (Gutchell, Idzik, & Lazaer, 2014). This author finds it frustrating that these limitations

still exist when the goal is to take care of the patient in the best manner possible; something that

is often put by the wayside and overlooked as politics and mixed emotions take over.

Removal of Barriers

If barriers were removed, access to care would increase for patients by broadening said

access, improving the quality of care, decrease cost and overcoming the growing shortage of

primary care providers (Gutchell, Idzik, & Lazaer, 2014). Successful legislation of bills that
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would remove barriers would improve the capacity of the NP to meet the needs of the patients

they serve (Gutchell, Idzik, & Lazaer, 2014).

The American College of Physicians recognizes that Nurse Practitioners and physicians

both share the goal of providing high quality care for patients and hope to strengthen the

dialogue between the NP and physician community to improve upon future healthcare delivery

(Ginsburg, Taylor, & Barr, 2009).

Conclusive Thought

If this latter way of thinking as depicted by the American College of Physicians is

adopted by the AMA and other opposing physicians, and various legislative and payment

barriers removed, the outlook of healthcare will be stronger and more unified. As nurses and

APRNs, we need to continue fighting for what is best for the patient and advocating for

ourselves and our profession.

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References

Altman, S., Stith Butler, A., & Shern, L. (2016, February 22). Assessing Progress on the Institute

of Medicine Report: The Future of Nursing. Retrieved from NCBI:

https://www.ncbi.nlm.nih.gov/books/NBK350160/

Donelan, K., DesRoches, C., Dittus, R., & Buerhaus, P. (2013). Perspectives of Physicians and

Nurse Practitioners on Primary Care Practice. The New England Journal of Medicine,

1898-1906.

Fraser, M., & Melillo, C. (2018). Expanding the Scope of Practice of APRNs: A Systematic

Review of the Cost Analyses Used. Nursing Economics, 22-23.

Ginsburg, J., Taylor, T., & Barr, M. (2009). Nurse Practitioners in Primary Care. Retrieved

from American College of Physicians:

https://www.acponline.org/acp_policy/policies/nursepractitioners_pc_2009.pdf

Gutchell, V., Idzik, S., & Lazaer, J. (2014). An Evidence Based Path to Removing APRN

Practice Barriers. The Journal for Nurse Practitioners, 255-261.

Hain, D., & Fleck, L. (2014). Barriers to Nurse Practitioner Practice that Impact Healthcare

Redesign. The Online Journal of Issues in Nursing.

Muxworthy, H., & Bowllan, N. (2011). Barriers to Practice and Impact on Care: An Analysis of

the Psychiatric Mental Health Nurse Practitioner Role. Journal of the New York State

Nurses Association, 8-15.

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New York State Education Department. (2015). Collaborative Relationships. Retrieved from

Practice Requirements for Nurse Practitioners: http://www.op.nysed.gov/prof/nurse/np-

prfnp.pdf

NYSED. (2017, May 31). Nursing Practice Information. Retrieved from New York State Office

of the Professions: http://www.op.nysed.gov/prof/nurse/nursepracticefaq.htm#np

Pando, C. (2017). Barriers that Nurse Practitioners Face as Primary Care Providers in the United

States. Annals of Global Health, 110-116.

Pericak, A. (2011). Increased Autonomy for Nurse Practitioners as a Solution to the Physician

Shortage. The Journal of the New York State Nurses Association, 4-7.

Poghosyan, L. (2018, February). Federal, State and Organizational Barriers Affecting Nurse

Practitioner Workforce and Practice. Retrieved from Health Policy and Politics:

https://www.nursingeconomics.net/necfiles/2018/JF18/43.pdf

Sofer, D. (2018). AMA Resolution Opposed Independent Practice by APRNs. American Journal

of Nursing, 12.

The Nurse Pracitioner Association New York State. (2018, Novemeber 05). Legislative Agenda.

Retrieved from The NPA: https://www.thenpa.org/page/LegislativeAgenda

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Appendix A

Attitudes About the Scope of Practice of Nurse Practitioners (Donelan, DesRoches, Dittus, &

Buerhaus, 2013)