Expanding Access to Medical Care in Rural North Carolina

• Far too many rural North Carolinians lack adequate access to medical care
• Physician shortages in rural counties is a primary cause
• Eliminating restrictions on Advanced Practice Registered Nurses would go a long way toward alleviating the problem

Most observers would readily agree that two major issues confronting health care in North Carolina are the rising cost of coverage and care and the limited access to care facing most of our rural populations.

But what if there was a simple way to address both of those problems, basic legislation that has already proved to be effective in more than a dozen states?

The Problem

Rural North Carolina counties face a significant doctor shortage. Access to care for our state’s rural population has become so acute that a new legislative study committee was formed to develop policies to address the issue. The Committee on Access to Healthcare in Rural North Carolina held its first meeting in January. Legislators heard testimony from health and economic experts about the problems facing healthcare in rural parts of the state.

As reported in North Carolina Health News, the experts informed legislators that “Rural areas have a shortage of almost every type of provider. In North Carolina, 20 counties do not have a pediatrician; 26 counties do not have an OB-GYN; and 32 are without a psychiatrist, according to the interactive North Carolina Health Professions Data System.”

Some of the alarming statistics discussed at the committee meeting included:

• Nationally, only 11 percent of physicians choose to practice in rural areas
• 70 of 80 rural counties in NC are currently designated “medical deserts” for their lack of primary care availability[i]
• 79 North Carolina counties are designated as “primary care health professional shortage areas”[ii]
• A decade later, only 3 percent of North Carolina medical school grads from the class of 2008 are currently providing primary care in rural areas[iii]

 

Expanding Nursing Scope of Practice

Like many professional restrictions and licensing practices, limiting the scope of practice for nurses harms consumers, drives up prices and is designed to benefit specific incumbent professionals. Current North Carolina law restricts the scope of care that registered nurse practitioners, advanced practice registered nurses, and physician assistants can provide, while also requiring a certain level of supervision by a licensed physician.

With so few licensed physicians choosing to practice in rural areas, laws restricting the ability of highly-trained medical care providers to provide much-needed care are devastating to rural populations.

“Our nurses are our best source of practitioners in our rural areas,” Senator Ralph Hise (R-Mitchell) said in a 2016 Joint Health and Human Services Oversight Committee meeting examining a bill to loosen regulations on registered nurses. “You want the most likelihood of someone practicing in a rural area? It’s someone who attends a community college in a nursing program and even goes on to higher degrees that is most likely to serve in a rural area.”

Why maintain a decades-old restriction on nursing scope of care, when freeing them to perform many of the basic evaluation and treatment functions — currently limited to physicians — would drastically improve rural populations’ access to health care?

Those favoring the status quo may invariably bring up safety concerns, but those are misguided at best. Advanced Practice Registered Nurses (APRNs) are highly-trained professionals that require masters-level education. As North Carolina Nurses Association President Mary Graff argued, “Nursing is the most trusted profession in the country, but opponents to this bill imply that nurses can’t be trusted to practice to the full scope of their training and education. That simply doesn’t add up.”

Not only would increasing the scope of care for APRNs increase access to care for rural patients, it would generate significant healthcare savings and create thousands of jobs in the healthcare industry.

Dr. Chris Conover, a health economist at Duke University, explained in that 2016 committee meeting that APRNs are being underutilized due to restrictive regulations. Conover discussed the findings from his research which showed that expanding scope of practice for APRNs could not only improve quality and access to care but also save more than $433 million per year in North Carolina.

Further, Conover’s research estimated that at least 3,800 jobs would be added to the economy statewide.

The increased competition for patients – mostly in rural areas – would help to drive down costs, while breaking the shackles of restriction would enable and attract more APRNs to practice across the state.

Who would oppose a measure to expand rural access to medical care while driving down healthcare costs? The primary opposition would come from the licensed physicians, who want to see continued restrictions to competition, which work to drive up the prices they can charge.

 

A Recipe for Success

A growing number of states are recognizing the advantages to expanding the scope of care for APRNs. Since 2010, twenty-two states have removed their physician supervision requirements, while 14 have moved to “full practice authority” for APRNs, nurse practitioners and nurse anesthetists.

When Arizona removed the physician supervision of nurse practitioners, the number of nurse practitioners serving rural areas jumped by 73 percent within five years.[iv] North Carolina can do the same for nearly 15,000 advanced practice nurses and physician assistants.

Indeed, a 2010 Institute of Health study declared “Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.”

The study also found alleged safety concerns to be baseless, concluding “States with broader nursing scopes of practice have experienced no deterioration of patient care.”

In a 2015 presentation to Pennsylvania legislators on this topic, Duke University researchers in concert with the Bay Area Council Economic Institute, pointed out that “The National Governors Association has reported that nurse practitioners have been shown to provide comparable quality care to physicians and recommended that states consider easing scope-of-practice restrictions and modifying reimbursement policies to encourage greater NP (nurse practitioner) involvement in primary care.”

The presentation also called legislators’ attention to the fact that the Federal Trade Commission has emphasized concerns that “scope-of-practice laws may deprive consumers of quality and cost benefits by placing unnecessary or overbroad competition restrictions on the primary care market.”

The presentation highlighted research analyzing what impacts on access, quality and cost of health care Pennsylvania could expect from expanding scope of practice in their state. Their findings suggested that “Full Practice Authority could benefit Pennsylvanians by increasing access to comparable or higher quality health care and it could lower costs in the process. Reform would save Pennsylvanians at least $6.4 billion over a decade, increase the statewide nurse practitioner workforce by 13%, and improve the overall quality of primary care.”

Similar benefits no doubt would materialize in North Carolina if state lawmakers were to take the prudent step of expanding the scope of practice for APRNs.

 

Conclusion

Lack of access to medical care in North Carolina’s rural areas is an urgent problem, causing unneeded suffering and arguably higher death rates for our rural populations. While not a cure-all, eliminating the restrictions on scope of practice for Advance Practice Registered Nurses would go a long way toward reducing this problem.

State legislators should recognize the significant benefits in terms of access to care, job growth, and cost savings such a measure would bring to rural North Carolinians. The highly-trained, and highly-trusted APRNs are fully capable of alleviating the urgent problem of doctor shortages in rural areas. It’s past time to break down the barriers preventing them from doing so.

 

[i] “Rural Economic Development & Health Care Access,” Presentation to Committee on Access to Healthcare in Rural North Carolina (LRC) January 8, 2018. John Coggin Director of Advocacy, NC Rural Center. Available online at: https://www.ncleg.net/documentsites/committees/bcci-6715/January%208,%202018/5.%20Coggin,%20Rural%20Healthcare%20and%20Economic%20Success.pdf

[ii] Maggie Sauer, MS, MHA Department of Health and Human Services, NC Office of Rural Health. Presentation to the Committee on Access to Healthcare in Rural North Carolina. Jan. 8, 2018. Available online at: https://www.ncleg.net/documentsites/committees/bcci-6715/January%208,%202018/4.%20Sauer,%20Overview%20of%20Rural%20Healthcare.pdf

[iii] “Access to Healthcare in Rural North Carolina”. Mark Holmes, Director, Sheps Center and Associate Professor, UNC Gillings School of Global Public Health. Presentation to the Committee on Access to Healthcare in Rural North Carolina. Jan. 8, 2018. Available online at: https://www.ncleg.net/documentsites/committees/bcci-6715/January%208,%202018/3.%20Holmes,%20Rural%20Healthcare%20by%20the%20Numbers.pdf

[iv] Howard J. Eng, Joe Tabor, Alison Hughes, Arizona Rural Health Office, University of Arizona. “Arizona Rural Health Workforce Trend Analysis; A Report Prepared for the Arizona Health Education Centers Program.”  April 2011. Available online at: http://azahec.uahs.arizona.edu/sites/default/files/u9/azworkforcetrendanalysis02-06.pdf