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OPINION | DAVID T. MITCHELL: Let them practice

Loosen primary-care restrictions by DAVID T. MITCHELL SPECIAL TO THE DEMOCRAT-GAZETTE | March 13, 2021 at 8:36 a.m.

When Arkansans get sick, especially in rural areas, there aren't enough primary health-care providers. Fortunately, some legislators are taking action to solve the problem.

One cause of our primary-care shortage is Arkansas' excessively restrictive medical scope of practice laws. These laws don't allow qualified, independently practicing nurse practitioners (NPs) to meet Arkansans' needs in areas where there aren't enough physicians practicing.

That may soon change. House Bill 1254 would allow NPs to be Medicaid primary-care providers, and House Bill 1258 would enable them to attain full practice authority after a three-year transition period. These are great steps toward a healthier Arkansas.

NPs are registered nurses who have earned a master's degree or a doctorate in nursing practice. Like physicians, NPs can pursue various specialties, but most choose primary care, i.e., comprehensive treatment for ailments that do not require a specialist, which is just the kind of care that Arkansas needs more of.

The primary-care shortage affects most of the state. Only five counties in Arkansas are not designated as health professional shortage areas by the U.S. Health Resources and Services Administration. Sixteen counties are partially designated as health professional shortage areas. That leaves the other 54 counties completely designated as a health professional shortage area. To make matters worse, most of Arkansas has greater than average need, even as health-care supply is short.

NPs have less training than doctors, and some services, such as surgery, are above their pay grade, but plentiful research indicates that they are perfectly good substitutes for physicians for most primary-care purposes. A recent research article in Health Services Research found that "patients reassigned to NPs experienced similar outcomes" and used fewer services relative to medical doctor patients. This continues a long research tradition going back to a randomized control trial published more than 20 years ago in The Journal of the American Medical Association, which found that NPs provide quality primary care. A long list of reputable organizations including the National Governors Association and the AARP have picked up on this research and endorsed expanding NPs' scope of practice.

NPs can legally practice in Arkansas today, but the law mandates that they maintain cumbersome and expensive "collaborative practice" agreements with physicians. A 2020 study published in Nursing Economics of NPs in Florida found that they paid an average of $1,048.47 per month to collaborating physicians. Worse, the risk that physicians will cancel these agreements is a deterrent to NPs investing in practices that depend on these agreements.

By removing these mandates, Arkansas can attract more NPs and let them spend more time helping patients. According to a National Bureau of Economic Research paper by Emory University Professors Dr. Sara Markowitz and Dr. E. Kathleen Adams, nurse practitioners in states with expanded scope of practice work more hours.

According to an article in the Journal of Labor Research by Shippensburg University Assistant Professor Dr. Shishir Shakya and Southern Illinois University-Edwardsville Assistant Professor Dr. Alicia Plemmons, NPs are more likely to move to states with expanded scope of practice, and less likely to leave those states.

NPs are a rapidly growing profession. A 2020 article in Health Affairs by David Auerbach, Montana State University Professor Dr. Peter Buerhaus and Dartmouth College Professor Dr. Douglas Staiger found that between 2010 and 2017, the number of NPs in the U.S. more than doubled from approximately 91,000 to 190,000.

Scope-of-practice reform is a way to help patients while saving the state money. Independently practicing NPs would reduce costs to the health-care system. In general, NPs are paid less than physicians are. More primary care often saves money by detecting and treating problems early, when they are easier to address. Patients who can get a primary-care appointment with an NP don't need to go to the emergency room for care.

Whether Arkansas will enjoy this healthier future depends critically on what state legislators do over the next few weeks. If passed into law, HB1254 will increase the financial viability of moving to areas where most patients are on Medicaid. Full practice authority enabled by HB1258 would be even more helpful.

Let's hope legislators take this opportunity to make Arkansas a healthier place.


David T. Mitchell, Ph.D., is director of the Arkansas Center for Research in Economics and associate professor of economics at the University of Central Arkansas. The views expressed are the author's and do not necessarily reflect those of UCA.

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