MPCA’s Data & Policy Specialist Jon Villasurda, MPH submitted this testimony on SB 481 on behalf of Michigan Health Centers to the Senate Health Policy Committee June 6, 2012. This bill introduced by Michigan Senator Mark Jansen would amend the Public Health Code to create a new licensing process for Certified Nurse Midwives, Certified Nurse Practitioners, and Clinical Nurse Specialists under the Board of Nursing. The board would create rules and requirements for each of these categories of certification. In addition, this legislation would expand prescriptive authority for these practitioners as well. The MPCA Board of Directors has voted to support this bill (and companion HB 4774).
Michigan Health Centers operate over 190 sites across the state, which collectively care for more than 600,000 of Michigan’s most vulnerable residents. Every site serves a Medically Underserved Area or Population. Currently in Michigan, there are 216 federally designated Primary Care Health Professional Shortage Areas and 116 Medically Underserved Area or Population designations. These deem over 1.1 million Michigan residents as underserved. Put simply, the presence of these designations means there are not enough medical providers to adequately serve these areas and populations. In order to immediately quell today’s shortages, the US Health Resources & Services Administration cites that 520 provider FTE would be required.1
Data on Michigan’s looming health workforce crisis is stark. A 2006 Michigan workforce study projected that Michigan will be short 4,400 primary care physicians in 2020.2 Furthermore, a 2008 study showed that, among active physicians, about 47 percent are age 55 or older and will reach retirement in the next 10-15 years. In addition to aging physicians, it is well established that the overall aging of Michigan’s population due to the baby boom phenomenon will drive greater demand for services. If these facts are accepted, then Michigan policy makers are compelled to develop a plan that will help increase the numbers and types of providers that will enter the medical field in our state.
As an association that delivers primary care to Michigan residents, we believe part of the plan must include more effective use of APRNs, which would be afforded with passage of SB 481. APRNs play a vital role in providing primary care services in Michigan, especially because they tend to disproportionately provide care for the underserved populations in both urban and rural areas.3, 4 Since the passage of the public health code in 1978, the training and practice of nursing has changed dramatically. Nurses are now training in clinical practice in record numbers and Michigan needs to create an environment that not only takes advantage of these potential practitioners, but also invites them to practice and remain in our state.
Currently, 18 states and DC allow Nurse Practitioners (NPs) to independently prescribe and practice without written physician delegation. Michigan is competing with these states for health care providers no differently than we are competing for businesses to come to the state. The same cases can be made for both. As a result, we must create an environment that delivers safe and high-quality care, and is also friendly and open to people seeking to practice in Michigan.
Unfortunately, Michigan’s current regulatory environment precludes APRNs from practicing within their fully trained scope. A 2007 study indicated that Michigan is ranked 44th out of 51 states, including DC, in terms of having a regulatory environment for NPs that is conducive to patient choice – that earned Michigan a grade of F.5 This restrictive environment creates a disincentive for APRNs to practice in Michigan, which is manifested in the State’s current supply of NPs. In fact, despite having the twelfth most NP schools, Michigan has the sixth fewest NPs per 100,000 population in the entire nation.6,7
One argument often raised is that patient safety is compromised with care provided by NPs. I would offer that the actual evidence overwhelmingly shows that NPs deliver high-quality primary care services. In fact, literature shows that NPs care for patients as well as physicians in multiple areas of clinical practice.8 Furthermore, out of more than 100 published reports, none have concluded that NPs provide inferior services in comparison to physicians for overlapping scopes of practice. Other research focused on patient satisfaction shows that consumers are highly satisfied with the care delivered by NPs.9
More effective use of APRNs within their training is also cost effective for both direct and indirect practice costs. In times when the cost of health care is constantly discussed, this is particularly pertinent. In 2008, the average compensation for NPs was approximately $92,000 compared to $162,000 for primary care physicians.7 Moreover, literature shows that the cost of care for a particular service is typically lower for NPs in comparison to primary care physicians, all while maintaining similar outcomes in both groups.8 This is primarily due to lower costs for prescriptions and laboratory or other diagnostic testing. With regards to indirect costs, a recent analysis from the National Practitioner Data Bank (NPDB) indicated that NPs have much lower rates of malpractice claims in addition to lower costs per claim.9
Given these facts, the Michigan Primary Care Association stands in full support of SB 481.