[00:00:00] Lilly Gwinney: Hello and welcome to Facts Matter, a podcast by Citizens Research Council of Michigan. I’m Lily Gwinney. I’m a reporter at Gongwar News Service and I’ve been covering an issue recently that’s come to the forefront of the legislature and I’m guest hosting the Facts Matter podcast today with Carly Abramson, who’s a health policy researcher for the Citizens Research Council.

So we’ve recently been writing about and talking about the same thing. Which is Expanding Scope of Practice for Nurse Practitioners in the State of Michigan. Can you give just a little overview of what that means and why it’s an issue for folks in Michigan right now.

[00:00:37] Karley Abramson: Sure. So generally scope of practice laws are in place to restrict what various health professionals can do with their license and training. And so these laws are usually put in place to protect the health professionals. public health, so that people who are appropriately qualified to deliver care are the only ones actually delivering that care.

And recently we’ve seen legislation across the country in different states that has expanded scope of practice for various health professionals. Nurse practitioners is one that is discussed a lot because there’s a shortage of primary care doctors across the country and in Michigan in particular, nurse practitioners and primary care providers.

have a lot of overlap in some of the work that they do. And so this new legislation is trying to expand the scope of practice laws for nurse practitioners. Michigan has passed an expansion of scope of practice laws for pharmacists, you know?

So this has been done before in Michigan and in other states. And so this particular legislation would allow certain qualified nurses to operate independently of physicians as of now nurse practitioners need to be supervised by a physician. And so there’s, you know, there’s a range of different scope of practice laws in terms of what they allow and what they don’t.

But expanding them in some capacity has been shown to kind of relieve the burden on the primary care providers so that more people can access care. So that’s the general goal of these, these, these laws. expansions of scope of practice.

[00:02:10] Lilly Gwinney: There’s a bill in the state Senate right now sponsored by Senator Jeff Irwin from Ann Arbor, and that would do all of what you just described to give those nurse practitioners a bit more independence in their practice.

And there’s some pretty heavy opposition to it, mostly from physicians and associations that represent them. Can you explain why that is?

[00:02:33] Karley Abramson: Sure. Physicians and, groups like the AMA are very concerned about the quality of care that is provided to patients. And their concern is that physicians and nurse practitioners are not trained the same.

So Physicians have to undergo thousands and thousands of hours of training. Their education level is different, and so the concern is that quality of care will suffer if we allow nurse practitioners to deliver that care. There’s another concern that this might lead to more expensive healthcare, as there’s been some research that has shown that nurse practitioners tend to over prescribe or have to refer to other physicians at a higher rate.

And so we’re kind of over utilizing the healthcare industry leads to higher costs. So there’s a variety of different concerns about nurse practitioners taking on this role. So that’s where most of the concern comes from. But then that has to be kind of contrasted with the overall problem of the shortage of primary care providers.

And, we kind of have to balance those risks and concerns about quality of care with the risks and concerns about not being able to access any provider at all, whether, you know, PCP or a, a, a, Nurse practitioners. So that’s where you go to look at the research to try to assess that like cost benefit analysis.

Yeah, for sure.

[00:03:50] Lilly Gwinney: So when we it would be 2 weeks ago now that we saw this bill come before the Senate Health Policy Committee, there was some pretty heated debate about the benefits for patients of having access to a care provider who would order more tests and perhaps would it. Prescribe more medication especially for women and people of color who might feel, shortchanged or not believed by their doctors when they raise a medical issue.

Can you speak to that a little bit and how, nurse practitioner scope of practice could be? Could maybe remedy that issue.

[00:04:25] Karley Abramson: Sure. That relates to the issue of there’s been research about whether or not expanding scope of practice for nurse practitioners will help with reducing health disparities overall.

And so that might be, a potential benefit of nurse practitioners perhaps being slightly better trained to deal with. more vulnerable populations or more willing for whatever reason to provide more care to those populations. So there is some research just in general that access to nurse practitioners helps to reduce health disparities that might not be directly related to the, like the prescribing issue and the referral issue.

But there is some of that research to show that as well. So that is a factor in like that overall cost benefit of what is actually both financially and in terms of quality of care, what is, being improved and what do we have to be concerned about?

[00:05:19] Lilly Gwinney: You wrote your paper on this before we even knew that legislation would be coming forward about it.

What would you hope lawmakers keep in mind about scope of practice as they consider this bill?

[00:05:31] Karley Abramson: Yeah, I think I would hope that lawmakers keep in mind the perspective of the state. And so, the state’s job is not just to consider the potential costs and risks, their job is to consider that overall cost benefit.

And so to assess the scope of the problem and the disadvantages and the risks of the lack of primary care providers and weigh that against this potential risk of expanding scope of practice and to really look at the research to try to assess that risk. And the research as of now.

There is some research, that shows that potential over prescribing, but there is very little evidence to suggest that patients receive. poor quality of care. And there’s some mixed research about patient satisfaction overall, but there isn’t the evidence that these patients are really going to suffer in terms of their care if they see a nurse practitioner.

So we have to balance those potential risks with the fact that people are currently suffering right now from not having access to care at all. And so keeping in mind that. Some of this just needs a little bit more insight. We need to do a little bit more of a more thorough analysis of actually that risk and cost to the potential benefit and so not just counting the, potential downsides.

Of this legislation, but just to appropriately weigh it against the current problem and assess as a state, if we think we are in a position to kind of take that risk at that, we think that would be more helpful than harmful.

[00:07:07] Lilly Gwinney: Yeah. I was going to say, I think in the report, you said to weigh against the status quo, not towards an ideal.

[00:07:13] Karley Abramson: Correct. Yes. Because ideally everyone would get, care from the most qualified but that can’t necessarily be our benchmark when we are facing a crisis. And so we have to kind of readjust our standards to try to create a situation in which more people are getting access to better care, not everyone’s getting access to ideal care.

[00:07:36] Lilly Gwinney: So can we talk for just a second about what does it take to become a nurse practitioner in the state of Michigan?

[00:07:43] Karley Abramson: Okay. Great. Sure. So I’m not as much of an expert on like the whole training. But what I will say is that, it’s a rigorous path to become an NP. It may not be the thousands of hours, but it is in the hundreds of hours of training.

There’s the hands on experience as well. The education level is usually a master’s degree of some sort. And the legislation itself is not authorizing any nurse practitioner to be able to practice independently of a physician. The legislation lists out more specific qualifications on top of what it already takes to become a nurse practitioner in the state.

So this is not just like any nurse practitioner can now practice independently. This is a certain subset who also meet these additional qualifications and standards will be able to. And so, The legislation takes into account that there’s even more experience and training that we want these nurse practitioners to have on top of the baseline that they get to become an NP in the state.

[00:08:46] Lilly Gwinney: When I was covering this hearing a couple of weeks ago, Two of the folks who spoke were medical residents from Michigan State University, and their concern was obviously a lack of a residency equivalent when you’re getting an education to become an NP. And they said something about, well, they didn’t believe that NPs got any sort of hands on patient, direct patient care experience during their master’s degree, but corrected that they did get it during their undergrad.

And the whole room started laughing. When they said that nurse practitioners didn’t get that experience. So I got the feeling that people, feel pretty strongly that they do get that experience at some point in their education.

[00:09:24] Karley Abramson: Yeah. The structure of it is a little bit different than a medical residency, but all health professionals, there is incorporating that hands on experience, even if it’s just once they start their job because medical residents they’re still in their training, but they are acting.

As doctors on the job, and so that’s the same with nurses and nurse practitioners who have to kind of get that training as they are engaging in the actual job itself. So that combination of on the job training with your education just takes a different form for nurse practitioners than it does for doctors.

And like I said, the legislation keeps in mind that. So, we want to make sure they have that kind of hands on training before we would expand the scope of practice.

[00:10:04] Lilly Gwinney: Mhm. So, can you tell me a little bit about how scope of practice expansions have functioned in other states and what it looks like when there’s less restriction?

How is Michigan different?

[00:10:14] Karley Abramson: So Michigan is one of the most restrictive there’s usually kind of three different levels. There’s like full scope of practice, reduced scope of practice, and restricted. Scope of practice. And this can mean a lot of different things depending on the state, because this includes, can they prescribe certain drugs or can they, see certain patients, can they make certain diagnoses?

And, so it can get very specific but it’s generally categorized into one of these three areas and I, about half of states have expanded it to just full practice authority, which essentially gives nurse practitioners. A certain percent or a certain subset of nurse practitioners, the same scope of practice as any PCP.

And then there’s more of this reduced, which is more towards what Michigan would be going for with being able to operate in independently, but for that, like subset of nurses and then there are states like Michigan that are just like completely restricted. They have to be supervised by a physician.

And I think there’s Medicaid reimbursement only, so there’s, these restrictions in place, that really limit what nurse practitioners can do. But we are seeing those across the country and over half of states are operating very differently.

[00:11:29] Lilly Gwinney: Yeah. So a few of the things that nurse practitioners brought up to lawmakers a couple weeks ago, about this relationship between a nurse practitioner and their supervising physician is that it can often lead to delays and administrative hiccups when it comes to prescriptions and paperwork and ordering tests and ordering treatment.

What do you know about how that might change if scope of practice is expanded?

[00:11:54] Karley Abramson: There’s not much research on that. I imagine those administrative burdens would be less just based on that anecdotal experience of the nurses themselves. Just being able to kind of smooth out that administrative process seems like it would be a likely outcome that that would be more efficient.

I didn’t come across any evidence about those administrative burdens being an issue for quality of care or anything like that. So I imagine it would get better, but whether or not that would have a direct influence on quality of care, there hasn’t been research on that.

[00:12:24] Lilly Gwinney: Yeah, I think it was something that was mostly anecdotal evidence. I, I’d imagine that someday we might have some sort of formal data on that and I’d be interested to see it because that was something that came up quite frequently. It was the idea that, providing people with an NP who might be more accessible than a physician would, open up a lot of doors to care for people.

And that seemed to be the main point that a lot of folks were making in support of the bill.

Definitely. One of the other things that was brought up when we were talking about, the idea of access and the idea of giving everyone in the state and access to primary care providers. Some of the concern over NPs is that They mostly practice in the same areas that physicians do, they’re going to go to suburbs and urban areas.

And some people were saying, that warrants not expanding scope of practice because you’re not going to actually reap the benefit of NPs going to rural areas or underserved communities. Have you seen anything about that? And, and if so, , Is that a concern?

[00:13:28] Karley Abramson: No, there is some research that supports that concept that it might not actually expand access in the areas that we most need it.

And my response to that is basically that may be a concern, but that just might be an indicator that we need to do other policy initiatives to increase access in those types of areas that might not be reason enough to dismiss expanding the scope of nurse practitioners, because there, it would still be a benefit in the areas, even if there isn’t a high need for it.

And it’s possible that once that scope of practice is expanded, that will trickle out into other areas. More vulnerable and underserved areas as well. And so to me, that is a sign that we need to be pulling other policy levers in addition to this and not just rely on this to solve all of our access problems.

[00:14:25] Lilly Gwinney: Yeah. I know some of the things that were brought up, I mean, pay and benefits for the profession. obviously contribute cost of living in these areas versus in rural or suburban spots. And it makes sense, that this isn’t a one size fits all or a quick fix situation. It’s part of a bigger whole.

[00:14:46] Karley Abramson: Correct. Right. And there’s policy strategies that try to incentivize doctors to work in those areas. There could also be those strategies employed for, to try to incentivize nurse practitioners to work in those areas as well. So there are ways to address that problem more directly.

[00:15:01] Lilly Gwinney: Yeah. So overall, how many other states are dealing with this problem of access to care and do we know how many states have expanded scope and is there anything we can learn from it?

[00:15:12] Karley Abramson: So I, half the states. Like 26 or 27 have expanded to full practice authority and it’s pretty regionalized.

Most of the Midwest states around Michigan have reduced practice authority. Interesting. And then there’s Michigan and some kind of southern states that are dealing with the same thing. So I don’t have as much. knowledge or awareness about really the details of what’s going on in other states.

I don’t know what current legislation is going on. But I’m pretty sure that the pushback is the same across states. The AMA very, very strongly opposes expansion. And so my guess is other states are experiencing the same types of conversations that Michigan is having.

[00:15:55] Lilly Gwinney: For sure. I think there seemed to be almost this fear among these physicians who testified against this bill that if this were to pass and if scope of practice were to be expanded for nurse practitioners, then the roles of residents or physicians assistants would become obsolete which was interesting to hear.

Because I don’t know that this legislation would certainly replace physicians roles.

[00:16:21] Karley Abramson: And there’s certainly no evidence of that happening in the other states in which this legislation has passed. There’s no evidence that is something that has occurred. There’s really no evidence that quality of care has gone down.

And so some of those fears, based on how this legislation has performed in other states, based on the research we have about it, Are a little unfounded, but there are some legitimate concerns that we just need more analysis and the state needs to kind of dig deeper about.

[00:16:49] Lilly Gwinney: Yeah. And do you think some of those concerns can only really be researched or studied if this bill is passed and we do expand scope of practice?

[00:16:59] Karley Abramson: Not necessarily. Because what we’re trying to assess more of the current cost as well. And so we need a better understanding of what things are currently cost us with this lack of access to care and shortage of PCPs.

And and so being able to compare that to the potential risk , and also looking at what has happened in other states, we can more directly. Kind of weigh that cost benefit. So it doesn’t necessarily rely on the passage of the bill to do that. Certainly if it did pass, we could then amass data over the next, however many years.

But I don’t think it’s required for the state to get more information about it.

[00:17:38] Lilly Gwinney: Yeah. So, one of the things that some healthcare providers who testified in support of this brought up was that allowing NPs to expand scope of practice. would actually ease some burden on physicians. And that was something where some folks testified that they had had physicians promising hires turn down jobs in Michigan because they didn’t want to quote unquote babysit a nurse practitioner or have to deal with the administrative load that comes with being a supervising physician.

Can you speak to that a little bit?

[00:18:11] Karley Abramson: Yeah. So I don’t have much information, like I don’t have much information about that from a research standpoint. That type of testimony is important to consider because anything that we can get about the day to day experience of what it’s like working as a PCP or an NP is something that’s important to hear because that’s something that research can’t really capture.

But I think that really shows that there’s a whole range of positive and negatives that could potentially happen. And so for every, kind of risky thing or negative experience. Someone else has a, well, this is how it could help me. And so really as a state trying to sort through all of those things and really decide if those risks are worth that potential benefit.

Is, is kind of where we need to have to be focused.

[00:18:59] Lilly Gwinney: And so if this were to pass, this would not be the first time in the last few years, even that scope of practice has been expanded for medical professionals in the state. Can you tell us a little bit about what that looked like for pharmacists during, during the COVID 19 pandemic?

[00:19:15] Karley Abramson: Yeah, so that was expanded for pharmacists to be able to prescribe and provide certain vaccines. And so that was a program that was supposed to be temporary and was successful and people were reporting, higher satisfaction with access to care, and it wasn’t showing any positive results.

negative impacts. And so it was decided to keep it going. I don’t have as much knowledge about that whole history with pharmacists because my research is focused more on the NPs. But there still isn’t evidence that this is having any sort of negative impact on patient outcomes.

on, primary care providers. And so we can use that as it’s only been a couple of years, like you said, but it based on that trajectory, we haven’t seen the kind of risks come to life, that some of the doctors and AMA are most fearful of, at least hasn’t happened with pharmacists.

[00:20:11] Lilly Gwinney: Yeah. And I’m, I’m sure back when that was on the table, there was the same discussion about qualifications and training and whether or not pharmacists were well equipped to do the work that scope of practice expansions had them doing. So I think it’s an interesting comparison to draw. So we’re going to watch this legislation work its way through the Capitol in the next few months, I imagine.

It has not been voted on yet by the health policy committee, to my knowledge. And so, we will see it come before the Senate and maybe come before the house and the governor’s office. But I think. this conversation about the status quo and access to care is one of the most interesting things we can talk about right now in Michigan.

And I really appreciate just getting to hear about all of this from you and your research. So thanks so much for that.

[00:20:59] Karley Abramson: Thank you for talking to me. Yeah.

[00:21:01] Lilly Gwinney: I’m Lily Gwinney with Gongre News Service, and I’ve been speaking with Carly Abramson. of the, with the CRC of Michigan online at crcmich.

org and on Twitter at crcmich. This is Facts Matter, a podcast presentation of the Citizens Research Council.