Overview

The Pearson Report

A National Overview of Nurse Practitioner Legislation and Healthcare Issues^©

Linda J. Pearson, DNSc, FPMHNP-BC, FAANP

Family Psychiatric Mental Health NP

For the past 22 years, I have written an annual report that summarizes nurse practitioner legislation in each state. This annual report includes a review of pertinent state legislation and of rules and regulations that affect NPs, along with pertinent government, policy, and reimbursement information. The report continues to be widely disseminated, discussed, and utilized to promote legislation to allow NPs to practice to their full potential..

In previous years,The Pearson Report has been published in its entirety or near-entirety in the February issue of The American Journal for Nurse Practitioners, and it has been available on the NP Communications website. The overview and synopsis, including two boxes, are provided here, in the print journal, as well as online at www.webNPonline.com.  To gain full access to all of the highly detailed, individual state reports, as well as four highly informative tables, you will be asked to pay a nominal one-time charge. The Pearson Report will continue to be available free of charge if you subscribe to the online version of AJNP. More information is available at www.webNPonline.com.The maps, tables, and boxes summarize these pertinent data areas:

• Map 1: This map provides an overview of diagnosing and treating aspects of NP practice, and shows which states have no requirement for any physician involvement in NP diagnosing and treating practice. There was no scope of practice (SOP) role expansion in any state relative to the status in 2008.
• Map 2: This map provides an overview of prescribing aspects of NP practice, and shows which states have no requirement for any physician involvement in NP prescribing practice. In 2009, two states were added to the category No Requirement for Physician Involvement: COLORADO (no physician requirement for NP prescribing after a one-time physician signature on an Articulated Plan) and UTAH (no physician requirement for NP prescribing of non-scheduled drugs or devices or for controlled substances Schedules IV-V).
• TABLE 1: This 2010 Pearson Report Summary presents an overview of all 50 states and the District of Columbia in five areas: whether a Doctorate NP can legally be addressed as “Dr,” which NP titles are legally recognized, whether physician involvement is required for NP diagnosing and treating, whether physician involvement is required for NP prescribing, and whether any expansion in the NP SOP occurred in 2009. Consistent with the trend observed over the past 30 years of legislative or regulatory SOP role expansion for NPs, the following states succeeded in obtaining various degrees of additional SOP expansion: ALABAMA,  ALASKA, ARIZONA, CALIFORNIA, COLORADO, FLORIDA, GEORGIA, HAWAII, IDAHO, KENTUCKY, LOUISIANA, MAINE, MISSISSIPPI, MONTANA, NEW HAMPSHIRE, NEW JERSEY, NEW MEXICO, NEW YORK, NORTH DAKOTA, OHIO, OKLAHOMA, OREGON, PENNSYLVANIA, RHODE ISLAND, SOUTH DAKOTA, TENNESSEE, TEXAS, UTAH, VIRGINIA, WASHINGTON, and WEST VIRGINIA.
• TABLE 2 : This table presents a state-by-state comparison of the reported number of NPs in 1999 and in 2009, a calculation of the percent change over this 10-year period, and a listing of the number of NP schools in each state. Of special note, the District of Columbia reported a 458% increase in the number of NPs over the past 10 years; Arkansas came in second, with a reported 437% increase. There are now almost 158,000 NPs in the United States, representing a 107% increase from 10 years ago. There are a reported 360 educational institutions that graduate NPs each year.
• TABLE 3: This table presents a state-by-state comparison of the 2010 Pearson Autonomy “Grades” and six comparison ratios of National Practitioner Data Bank (NPDB) and Healthcare Integrity and Protection Data Bank (HIPDB) reports for NPs, DOs, and MDs.
  • Column 1 lists an NP autonomy “grade” for each state based on the 2007 Consumer Choice Ranking of the state’s NP regulation and on the Descriptive Ranking, a groundbreaking study that assessed the regulatory environment for NP practice and consumer healthcare choice for each state by evaluating NPs’ legal capacity, patient access to NP services, and patient access to NP prescriptions [Lugo NR, O’Grady ET, Hodnicki DR, Hanson CM. Ranking state NP regulation: practice environment and consumer healthcare choice. Am J Nurse Pract. 2007;11(4)]. The 2010 Pearson Report has raised the grade of a few states that have granted notably increased autonomy to NPs since the 2007 ranking: COLORADO, HAWAII, ILLINOIS, MAINE, MASSACHUSETTS, OKLAHOMA, and RHODE ISLAND.
  • Columns 2-4 present ratios of the total number of NPDB filings (ie, total accumulated malpractice and adverse actions) for the period 9/90-9/09 for NPs, DOs/interns/residents, and MDs/interns/residents to the total number of NPs, DOs/interns/residents, and MDs/interns/residents, respectively, in each state. Provider # calculations are based on (1) the # of NPs reported from Boards of Nursing (BONs) for the 2010 Pearson Report; (2) the # of DOs as of June 2009, according to the American Osteopathic Association (www.osteopathic.org); and (3) the # of MDs from Kaiser State Health Facts (www.StateHealthFacts.org); these data are for December 2008. Because “Adverse Licensure Actions” against “non-physicians” are not reportable to the NPDB, these actions were not included in the totals reported for MDs within each state. National legislation related to the Health Care Quality Improvement Act (1986) created the NPDB to help improve the quality of medical care. The NPDB’s goal is to encourage state licensing boards, hospitals, and other healthcare entities and professional societies to identify and discipline providers who engage in unprofessional behavior, and to restrict the ability of healthcare providers to move state to state without disclosure or discovery of previous medical malpractice payment and adverse action history. Source: http://www.npdb-hipdb.com/annualrpt.html
  • Columns 5-7 present ratios of the total number of HIPDB filings (ie, accumulated adverse action reports, including licensure actions and any other negative actions, findings, or adjudicated actions, and civil judgments or criminal conviction reports submitted) for the period 8/99-9/09 for NPs, DOs/interns/residents, and MDs/interns/residents to the total number of NPs, DOs/interns/residents, and MDs/interns/residents, respectively, in each state. Provider # calculations are based on (1) the # of NPs reported from BONs for the 2010 Pearson Report; (2) the # of DOs as of June 2009, according to the American Osteopathic Association (www.osteopathic.org); and (3) the # of MDs from Kaiser State Health Facts  (www.StateHealthFacts.org); these data are from December 2008. The Health Insurance Portability and Accountability Act of 1996 created the HIPDB to combat fraud and abuse in health insurance and healthcare delivery. The HIPDB is primarily a flagging system whose goal is to alert users that a comprehensive review of a practitioner, provider, or supplier’s past actions may be prudent. Source: http://www.npdb-hipdb.com/annualrpt.html
  • Items of note:
    • The overall ratio—that is, the total number of NP NPDB malpractice reports (1990-2009) to the total number of NPs in the nation—for NPs is 1:166.
    • The overall ratio—that is, the total number of DO NPDB malpractice reports (1990-2009) to the total number of DOs in the nation—for DOs is 1:4.
    • The overall ratio—that is, the total number of MD NPDB malpractice reports (1990-2009) to the total number of MDs in the nation—for MDs is 1:4.
    • The overall ratio—that is, the total number of NP HIPDB Filings (1999-2009) to the total number of NPs in the nation—for NPs is 1:215.
    • The overall ratio—that is, the total number of DO HIPDB Filings (1999-2009) to the total number of DOs in the nation—for DOs is 1:14.
    • The overall ratio—that is, the total number of MD HIPDB Filings (1999-2009) to the total number of MDs in the nation—for MDs is 1:20.

• Tables 4 : This table presents a comparison of the number of NPs and MDs in various state groups, and it lists NPDB and HIPDB ratios for NPs, DOs, and MDs when the states are grouped according to the degree of NP autonomy granted legislatively. Presenting data on the ratios of malpractice reports and HIPDB occurrences within the rankings of the degree of NP autonomy is new to The Pearson Report. Data are presented in this format because of the number of special requests I received from last year. The main request from readers was to ascertain whether NPs from autonomous practice states caused an increase in their physician colleagues’ malpractice report (ie, NPDB) rates. The answer from this year’s data compilation and presentation is “no.” It does appear that NP NPDB rates are higher in states in which they are practicing autonomously, but this finding appears to have no impact on physician NPDB rates. In addition, in those states in which NPs are practicing autonomously, their safety ratios are still 23 times better than those for physicians in the same states. Of interest for NPs, the second highest NPDB reporting rate comes from NPs in the states allowing the least practice autonomy.

  On first inspection of these ratios, skeptical observers might challenge that (1) MDs and DOs handle riskier cases; (2) MDs and DOs have a broader SOP than do NPs; and (3) the total numbers of providers on which these ratios are based may not be accurate. Responses to these arguments are as follows: (1) Although many DOs and MDs handle a difficult caseload, one cannot discount the fact that a broad, deep, and consistent difference exists in the number of reported malpractice events (and HIPDB occurrences) among the providers, a difference that cannot be fully explained by “difficulty of cases” (also, NPs are practicing independently in increasingly stressful, complicated, and difficult positions and situations); (2) At the very least, these solid NP safety ratios demonstrate that the requirement for NPs to have physician supervision for safety’s sake is baseless; and (3) The lack of precision regarding the number of active providers likely applies evenly across all three professions.

Perspectives on 2009

During my Fall 2009 compilation of each state’s updates (provided from state NP and nursing leaders and BONs), along with subsequent data analysis, I felt a strong urge to present a 2010 Pearson Report Poster Award (Box 1) to specific states and official entities. This urge arose because of notable acknowledgments (eg, the Montana BON), joyful restriction removals (eg, Oregon and Oklahoma), raw realities (eg, Texas legislators), and paradigm-shifting realizations (ie, the number of NPs compared with the number of MDs matters). I hope you, dear Readers, will agree that the awards given this year are truly deserved. As you read each state’s update at http://www.webNPonline.com, please provide feedback to me at .(JavaScript must be enabled to view this email address), as well as any additional reactions or ideas you want to share regarding states or other entities deserving of future awards.

Box 1. 2010 Pearson Report Poster Awards

Best Board of Nursing Stance: Montana Board of Nursing’s written response (ie, Notice of Amendment and Adoption of Cosmetic Procedure Standards) to one commenter who opined, “the proposed amendments unnecessarily jeopardize patient safety by allowing APRNs to supervise LPNs or RNs in cosmetic procedures.” The BON responded, “APRNs are allowed by law and administrative rule to supervise RNs and LPNs in all circumstances. Since certain APRNs possess the knowledge, skills, and abilities to perform cosmetic procedures independently, it is within their SOP to supervise RNs and LPNs in performing these procedures. The Board notes that APRNs and dermatologists both implement patient safety as a primary concern.”  

Best Restriction Removal to Allow Appropriate Provider Title: Oregon and Oklahoma removed their previous restrictions against allowing doctorally educated NPs from being addressed as ‘Dr’ in the clinical setting (with proper specialty clarification).

Best Demonstration of “Money Talks” as Explanation for Loosening NP Autonomy Restrictions: A Texas 2009 bill that broadened NP SOP was passed because of an agreement between major owners of retail clinics and medical organizations.

Best Demonstration of “The Power of Numbers” as One Contributing Factor to NP Autonomy Restrictions: These states have the highest ratios of NPs to MDs (ie, 1:2 or 1:3): ALASKA, DISTRICT OF COLUMBIA, MISSISSIPPI, MONTANA, NEW HAMPSHIRE, SOUTH CAROLINA, and WYOMING [Note: All but the two states from the Deep South received an A grade for NP Autonomy.]

These states have the lowest ratios of NPs to MDs (ie, 1:8, 1:9, or 1:11): ILLINOIS, LOUISIANA, MARYLAND, MICHIGAN, NEVADA, NORTH CAROLINA, OHIO, and OKLAHOMA [Note: All but two states received a D or an F grade for NP Autonomy (with the two outliers receiving a C).]

Throughout 2009, I continued monitoring the issue of practice safety by closely inspecting data compiled in the NPDB and the HIPDB. Data from both banks represent the number ofaccumulatedmalpractice and adverse actions, licensure actions (and any other negative actions, findings, and/or adjudicated actions), civil judgments, and criminal conviction reports submitted against NPs, DOs, and MDs. I determined the ratios of the number of accumulated reported occurrences to the number of persons in each of the three groups of healthcare professionals: NPs, DOs, and MDs.

I continue to be struck by the demonstrated NP safety record (as evidenced by the relative low ratio of NP malpractice reports to NP number) when compared with the safety records of our DO and MD colleagues. Clearly, one cannot assume that the DO and MD NPDB Malpractice Report national average ratio of 1:4 means that, on average, one in four DOs or MDs commits a malpractice event. However, one may reasonably conclude that NPs have a strikingly and consistently lower ratio of reported malpractice events—rightfully rebutting any charge that NPs are unsafe providers. Even in states (ranked A) in which NPs have a similar degree of practice autonomy as physicians, NPs still have a much more favorable ratio of NPDB reports than their DO and MD colleagues (1:93 for NPs versus 1:4 for DOs and MDs). SeeBox 2for additional comparisons.

Box 2. Comparison of NPDB and HIPDB Rates Among  Providers: Two Years and the “Worst” States

1. NPs must use these malpractice and malfeasance ratios and figures to show legislators that the rationale for physician supervision over NPs is unfounded.
2. NPs have been providing safe, top-notch primary care for decades. As FactCheck.org has explained, humans tend to cling to previously held beliefs and reject or ignore new ideas offered by a new person. This propensity undoubtedly explains, at least in part, why healthcare policy analysts sometimes exclude NPs from serious discussions about healthcare reform and problems related to the lack of primary care providers. NPs must remind all policymakers of their value in helping solve the nation’s healthcare crisis. As President Obama persuasively articulated, "Yes We Can!"
3. NPs must continue to strive to remove statutory restrictions that prohibit NPs with earned doctorates from being addressed as ‘doctor." Many states have no requirement that doctorally-prepared NPs declare or clarify that they are NPs, and I also commend those states that have legislatively allowed qualified NPs to be addressed as “doctor” in the clinical setting as long as these doctorally-prepared NPs clarify that they are NPs. My concern centers on the eight states — Arkansas, Connecticut, Georgia, Maine, Mississippi, Ohio, Oklahoma, and Oregon — that have statutory restrictions against doctorally-educated NPs being addressed appropriately as “Doctor NP.” Kudos to Iowa’s NPs and legislature, who removed this legislative restraint in 2008.

Conclusion

Nurse practitioners, as part of the nursing profession, rate among the most trusted healthcare providers because we have earned consumers’ trust. NPs must continue our crusade to increase NPs’ legislatively sanctioned autonomy. Lack of NP practice autonomy robs citizens of a solution to some of the nation’s worst healthcare problems: access, quality of care, and affordability.

In 2009, 31 states reported some degree of an expanded legislative or regulatory NP SOP (See Summary Table 1). This number is up from 22 states that expanded their NP SOP in 2008 and 19 states that did so in 2007. We are moving in the right direction. The road map has been created by the Consensus Document to guide future regulatory directions. We must continue to encourage our legislators to do what is best for our nation—removingallbarriers to autonomous NP practice.

Nurse practitioners are powerfully important healthcare providers who are available to help our nation improve its healthcare outcomes and lower healthcare costs. We are almost 160,000 strong! One unwavering, fervent goal continues forThe Pearson Report—that NPs will share this annual updated legislative information with their legislators to help promote the truth that NPs are safe, competent, accessible, affordable, and high-quality healthcare providers. Barriers to fully autonomous NP practice mustbe removed to afford our citizens the care they deserve and desire from nurse practitioners.

Acknowledgments

Once again, I thank George and Louise Young on behalf of NPs nationwide—without you,The Pearson Report would not exist. I also appreciate the efforts of the hundreds of colleagues who answered my survey questions to help clarify their own state’s statutes, rules, regulations, and/or practice realities. I am deeply grateful for your time and expertise. I also thank two special people who have helped me with this year’s report, Dr Loretta C. Ford, the founding mother of our profession and a dear friend and colleague without whose help and counsel I would be lost; and Jennifer Hayden, MSN, RN, Research Associate for the National Council of State Boards of Nursing (NCSBN) in Chicago, who has been a great help on data verification and suggestions. As always, I welcome corrections/additions/updates for next year’s report. Please contact me at .(JavaScript must be enabled to view this email address)

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