Liberating Nurses Won’t Harm Patients

By John Hood

RALEIGH — Given our state’s population growth and ever-rising cost of medical services, North Carolina ought to be a leader in health care innovation. Alas, we are a laggard.

For example, North Carolina is one of only a handful of states that severely limit the freedom of nurse practitioners to deliver services for which they are licensed without the oversight of a physician, who naturally take a cut of the revenues generated. By hiking overhead and limiting competition, our regulatory system makes health care less affordable while also reducing access to services, especially in the rural counties of our sprawling state.

I’ve long advocated scope-of-practice reform as one way to address this concern. Its opponents, primarily organizations that represent doctors, contend that giving nurses more independence would increase risk to patients. Physician oversight ensures proper diagnosis and treatment, they argue, which means that better patient outcomes justify the higher expense that may come with North Carolina’s tighter regulation of nurses.

In theory, perhaps. But as far as I can determine, the available empirical evidence simply doesn’t support their assertion. States that allow nurses a broader scope of independence don’t appear to exhibit higher rates of illness and mortality or lower rates of patient satisfaction. That’s why most states allow it, and why there’s no groundswell of public agitation for new regulations.

During the COVID pandemic, some states with significant scope-of-practice restrictions decided to loosen them to help the medical system cope with a surge of demand for services. Other states kept their rules in place. Economists Bobby Chung and Noah Trudeau compared outcome measures across these two sets of states and found no difference in COVID mortality rates. “The very argument of regulating workers in the form of occupational licensing is consumer protection,” they wrote in the journal Contemporary Economic Policy, but “in the wake of the most strenuous time on U.S. healthcare this century, we find no evidence that expanding scope of practice hurt consumers.”

In another study, published earlier this year in Health Economics, Shishir Shakya of Shippensburg University and Alicia Plemmons of West Virginia University studied a similar issue in a different way. They tracked the performance of nurse practitioners possessing the same skills but choosing to work either in physician-supervision states or independent-practice states. Focusing on the prescription of opioids to Medicare Part D patients, Shakya and Plemmons found no effect on “opioid prescribing behavior or other non-habit-forming pharmaceutical medications.”

“With the primary health care shortage,” they wrote, “allowing nurse practitioners to work independently and to the full extent of their training increases access to primary care and reduces wait times” without sacrificing patient outcomes.

In yet another new study, this one published in September in the Journal of Health Economics, the University of Alabama’s Benjamin McMichael focused on the frequency of avoidable hospitalizations for diabetes and other chronic conditions. Again, he found no adverse effects in states where nurses enjoy broader practice authority.

Indeed, in this case the arrow pointed in the other direction. He found that greater freedom for nurses to practice independently was associated with lower rates of avoidable hospitalization. McMichael concluded that relaxing scope-of-practice laws “allows the healthcare system to function more efficiently and better match the level of treatment intensity to patients’ needs.”

And in a summary of the academic literature published a couple of months ago by the American Action Forum, scholars Michael Baker and Nicolas Montenegro observed that when non-physician providers (NPPs) such as nurse practitioners, certified registered nurse anesthetists, and physician assistants are permitted full practice authority, “the quality of care delivered is comparable to services furnished by physicians.”

“In addition to the analogous standard of care,” they continued, “NPP-led services in many settings have been associated with enhanced cost-effectiveness, as workforce resources are utilized more adeptly, access to care increases, and downstream health status improves.”

Again, there’s nothing radical about allowing these medical professionals to operate independently. Most states already do so. North Carolina ought to join them.

John Hood is a John Locke Foundation board member. His books Mountain Folk, Forest Folk, and Water Folk combine epic fantasy with American history (FolkloreCycle.com).