The doctor (or nurse practitioner) will see you now: Competition and the regulation of advanced practice nurses

The FTC employs many experts in competition, consumer protection, and economics. We embrace our special role in helping other policymakers understand how the competitive process benefits consumers, and encouraging them to adopt rules that promote competition. In particular, the FTC has a long history of promoting competition in health care markets, utilizing a wide range of enforcement and advocacy tools. Today we reveal the newest tool in our competition advocacy toolkit: a policy paper focused on the competitive implications of mandatory physician supervision requirements for Advanced Practice Registered Nurses (APRNs). Here are “nutshell” answers to three questions you might ask: what is competition advocacy; what is a policy paper; and what does the FTC have to say about APRN regulation?

What Is Competition Advocacy?

Competition advocacy enables the FTC to share our competition expertise with other policymakers and, ideally, enhance their understanding of the competitive process. (We sometimes offer our expertise to judges, as well, in the form of amicus briefs.) As we often observe, even when laws and regulations are developed with the best of intentions, they may unnecessarily restrict competition and thereby harm consumers. Our goal is to provide a framework that integrates competition principles when thinking about public policy issues, to ensure that consumers benefit from competition to the greatest extent possible. In essence, we urge decisionmakers to consider:

  • the likely competitive impact of proposed legislation or regulations;
  • how consumers would be affected;
  • what justifications might exist for any restrictions on competition; and
  • whether less restrictive alternatives would adequately protect consumers and fulfill other public policy goals.

What Is A Policy Paper?

Until now, most of our advocacy documents (other than amicus briefs) have taken two forms. Upon request or in response to public comment opportunities, we typically issue relatively short comments on proposed legislation or regulations that may raise competition issues. At the other extreme, we often delve deeply into topics by holding workshops and issuing substantial reports.

We have created a new policy paper format to add to the range of our advocacy deliverables.

A policy paper is longer, more deeply researched, and more detailed in its analysis than a typical staff advocacy comment, but shorter and more focused than most FTC reports. It provides another mechanism for FTC staff to share our expertise and learning, outside the context of a specific legislative or regulatory proposal. A concise policy paper enables us to synthesize previous agency study, related advocacy comments, pertinent outside research, and ongoing analytical work by FTC staff.

Drop us an email at opp@ftc.gov to let us know what you think about the policy paper concept!

What Does The FTC Have to Say About APRN Regulation?

This policy paper builds on a series of FTC staff competition advocacy comments focused on proposed state-level changes to statutes and rules governing the “scope of practice” of APRNs. In particular, the policy paper focuses on various physician supervision requirements imposed on APRNs in many states. These requirements may raise competition concerns because they effectively give one group of health care professionals (doctors) the ability to restrict access to the market by another, competing group of health care professionals (APRNs).

The APRN policy paper recognizes the importance of consumer health and safety when regulating the health professions. But competition also benefits health care consumers – by controlling costs, improving quality, promoting innovation, and expanding access to care. As detailed in the policy paper, many experts have concluded that independent APRNs provide safe and effective care. When scope of practice restrictions restrain competition and are not closely tied to legitimate policy goals, they may do more harm than good.

Competition by APRNs is especially important because APRNs are expected to play a critical role in alleviating provider shortages and expanding access to health care services for “medically underserved” populations, including rural and low-income Americans. In addition, unnecessary and rigid supervision requirements may make it more difficult to innovate new models of health care delivery – including collaborative, team-based care that is not always physician-led.

Therefore, when faced with proposals to narrow APRN scope of practice via inflexible physician supervision requirements, we encourage legislators to apply a competition-based analytical framework. In particular, we urge them to carefully scrutinize purported health and safety justifications. In many instances, legislators may discover that claims of patient harm are not substantiated. Even if health and risks are credible, those concerns should be balanced against the benefits that will be lost if competition is restricted. Regulations should be tailored narrowly, to ensure that any restrictions on independent APRN practice are no greater than patient protection requires.

In short, we think American health care consumers will be well served if – as a result of increased competition – more of them hear the reassuring words, “The nurse practitioner will see you now.”

The author’s views are his or her own, and do not necessarily represent the views of the Commission or any Commissioner.

Comments

As a former General Counsel of the American College of Nurse-Midwives, author of ACNM's 1996 Handbook on State Regulation, (and former staff attorney in the Bureau of Competition Health Care section), I applaud this policy paper and thank the Commission and staff for researching and publishing it. In 30 years of law practice representing midwives, nurse-midwives, and advanced practice nurses, I have witnessed first-hand the harm to competition and consumers that results when overly-restrictive practice laws or rules restrain autonomous practice of these health professional groups. While the competition advocacy program has been very useful on a state-to-state basis, I believe this policy paper will convey even greater credibility, and achieve more widespread acceptance, among state -- as well as federal -- policymakers. I look forward to the upcoming Workshop Examining Health Care Competition, in which I will be submitting comments on behalf of my clients, the American Association of Birth Centers and the Big Push for Midwives Campaign.
Thanks! We'll see you at the conference.
What a coincidence!! I received this, here I am debating how to proceed; when after opening a sucessful primary health care practice only a year and a half ago on a part time basis (I am still working at my former job as an NP) where I offer access to health care to 600 active underserved patients from the community and my "collaborating physician" tells me he can no longer be part of this agreement. Do I close my practice?? Do I just continue to see my patients that are in so much need of health care?and health education? Do I just sit around and wait for this new law to pass where we NP's shoul not need a physician to just sign an agreement? my collaborator has not even been to visit my practice; hardly I have found the need to call him with any question.
Has there been a policy paper about physician assistants?
Hi, there has not been a policy paper about physician assistants. Thanks.
Was lucky to hear Tara Isa Koslov speak at the AANP Health Policy conference yesterday speak to this policy paper. What a treat. Thank you to the authors, the commissioners and everyone at the FTC!
Thank you, FTC! Sorry, I missed the conference. Looking forward to more documents on the topic, especially, whether or not there is competition in the FQ sector or if physician concerns for public safety only extend to the "profitable/insured" sector.

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