Edward Balaban: Independent NPs won’t solve Pennsylvania’s deeper healthcare problems
As a physician serving Pennsylvania’s communities, I’m deeply concerned about the push for full independent practice for nurse practitioners (NPs) as a solution to rural healthcare shortages. Access to care is a deeply pressing issue in our Commonwealth and while NPs are an important member of the healthcare team, granting independent practice from physicians is not the solution.
Removing physician oversight ignores the real issue, systemic barriers that prevent sustainable care in underserved areas.
There is legislation being considered in Harrisburg now to let nurse practitioners practice independently without physician oversight. In Pennsylvania, NPs are required to have a collaborative agreement with a physician, which provides clear boundaries for their practice and additional experience and extensive training to the care team. However, the push to loosen this requirement and allow independent practice won’t improve access to high quality care.
There is a misconception that allowing non-physician providers to practice independently will expand access to care in rural and underserved communities and that new practices will just open up immediately. However, studies by the American Medical Association, which mapped the locations of primary care physicians and nurse practitioners in 2013, 2018, and 2020, found that both tend to practice in the same areas, regardless of scope of practice laws.
States like California and Texas granted full practice authority years ago, yet rural shortages persist. The real question is, if NPs can already practice in these areas through collaborative agreements, why aren’t they? Market forces which deter physicians like lower reimbursement rates, professional isolation, and resource gaps, similarly discourage nurse practitioners
The answer lies in addressing those systemic barriers and the sustainability of healthcare in rural communities. It’s not sustainable to open practices in these areas, not for healthcare offices or even larger health systems.
According to the Center for Rural Pennsylvania, 28 percent of rural hospitals are at risk of closing, and more than 150 hospitals have closed nationwide since 2010. When a rural hospital closes, the area loses both its healthcare facility and often the healthcare workers who serve it. The real issue isn’t that an NP can’t practice in rural areas, they already can. The problem is that it’s hard to keep healthcare practices running in these communities due to financial and logistical challenges. Low reimbursement rates, particularly from Medicare and Medicaid, significantly impact the financial stability of healthcare providers. According to the American Hospital Association (AHA), Medicare and Medicaid often pay hospitals less than the cost of providing care, and rural hospitals are especially vulnerable.
Lawmakers should take a more comprehensive approach to rural healthcare. Expanding telemedicine services can be an effective way to provide care to remote communities, offering convenience and accessibility for patients who otherwise might not have access to a provider.
Telemedicine connects patients in remote areas with healthcare professionals who may not otherwise be available. This is especially important in regions where hospitals and medical practices are scarce, and where healthcare professionals may not be willing or able to relocate.
Additionally, increasing the availability of loan repayment programs would encourage healthcare professionals to work in underserved areas by reducing their financial burden to work in these regions. The Primary Care Loan Repayment Program is a far more effective solution to addressing healthcare shortages in rural areas than expanding the scope of practice for nurse practitioners. This program already incentivizes healthcare professionals to work in underserved communities by offering loan repayment in exchange for a two-year commitment to practice in these areas.
The push for independent practice for NPs is not a solution to the healthcare access challenges in Pennsylvania. Instead of expanding the scope of practice for non-physician providers, lawmakers should focus on expanding access to telemedicine, and offering loan repayment incentives to encourage healthcare providers to work in rural areas.
Expanding NP independent practice might sound like an easy fix, but it’s a Band-Aid on a much larger problem. If we truly care about fixing rural healthcare access, we must invest in solutions that work.
By tackling the root causes of rural healthcare shortages, we can create a more stable healthcare system that serves all Pennsylvanians, regardless of where they live.
Edward Balaban, DO, is a Montgomery County physician specializing in hematology and oncology and the vice president of the Pennsylvania Medical Society.
