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Need answer to the question using the attachements, need apa references The Association of American Medical Colleges estimates that, by 2034, there will be a shortage of between 17,800 and 48,000 primary care physicians in the United States (AAMC, Feb 23, 2023). Despite this, the American Medical Association continues to oppose full-practice authority for nurse practitioners.Idaho was the first state to authorize full-practice authority (FPA) for advanced practice registered nurses (APRNs). This occurred in 1971, yet here we are fifty years later and there are still states restricting APRN practice. Despite evidence that authorizing FPA increases patient access to care, increases care options, lowers health care costs, and increases APRN satisfaction, some states still restrict practice. As of 2023, there are 32 states and the District of Columbia who have authorized FPA. Of these, 19 offer FPA at the time of licensure and 14 others have mandatory provisional periods that must be completed after licensure. The remaining states have reduced practice or restricted practice.Detail the practice abilities of APRNs in your state. If your state has FPA, when was it authorized and who were the supporters of this legislation?It is estimated that 83.7 million people in the US live in designated primary-care health professional shortage area (HPSA), with a need for nearly 15, 000 practitioners to meet the demand. Is your practice site or residence identified as a HPSA? What did you notice when looking at the map of your state?Look at one of the states with FPA and investigate the process that achieved this. Identify supporting professional nursing organizations, legislative supporters (medical background or not), attempts needed to get legislation passed? What opposition was there, and by whom?

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TYPE:
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JOURNAL TITLE:
Journal of nursing regulation
USER JOURNAL TITLE:
Journal of Nursing Regulation
ARTICLE TITLE:
The Economic Burden and Practice Restrictions Associated With Collaborative Practice
Agreements: A National Survey of Advanced Practice Registered Nurses
ARTICLE AUTHOR:
Brendan Martin, Maryann Alexander
VOLUME:
9
ISSUE:
4
MONTH:
1
YEAR:
2019
PAGES:
22-30
ISSN:
2155-8256
OCLC #:
641269139
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This material may be protected by copyright law (Title 17 U.S. Code)
The Economic Burden and Practice
Restrictions Associated With Collaborative
Practice Agreements: A National Survey
of Advanced Practice Registered Nurses
Brendan Martin, PhD, and Maryann Alexander, PhD, RN, FAAN
The U.S. healthcare system is facing workforce shortages in rural and primary care settings. Despite growing demand for
providers and comparable quality metrics, advanced practice registered nurses (APRNs) still face significant barriers to
independent practice due to reduced scope of practice regulations. In this study, APRNs working in rural areas and APRNmanaged private clinics were one and a half to six times more likely to be assessed Collaborative Practice Agreement (CPA)
fees, often exceeding $6,000 and up to $50,000 annually. Similarly, APRNs subject to minimum distance requirements, fees
to establish a CPA, and supervisor turnover reported a 30% to 59% uptick in restricted care. Such unnecessary regulation
risks diverting health services away from and increasing costs in traditionally underserved areas, contributing to inequities
in care. It is incumbent on state legislatures to address these disparities and make their constituents’ access to high-quality
care a top priority.
Keywords: APRN, advanced practice registered nurse, collaborative practice agreement, supervising physician
O
ver the past 2 decades, numerous studies have documented a multitude of challenges facing the U.S.
healthcare system. Chief among these are shortages in
the provider workforce in rural areas and primary care settings
(Green, Savin, & Lu, 2013; Petterson et al., 2012). These trends
have been exacerbated by an aging population and recent coverage expansions under the Affordable Care Act, which preliminary evidence suggests have led to longer wait times (Ku, Jones,
Shin, Bruen, & Hayes, 2011; Polsky et al., 2017). To address
this projected shortfall, research examining scope of practice regulations has begun to explore the possible economic and patient
safety implications of allowing advanced practice registered
nurses (APRNs) to practice to the full extent of their education
(Adams & Markowitz, 2018; DesRoches et al., 2013; Fairman,
Rowe, Hassmiller, & Shalala, 2011; Federal Trade Commission,
2014; Institute of Medicine, 2011; APRN Consensus Work
Group, 2008). According to the National Council of State Boards
of Nursing (NCSBN, 2018), APRNs are granted full practice
authority depending on the restrictiveness of state scope of practice regulations, which can vary considerably. Thus, the regulatory landscape and the corresponding challenges it presents
APRNs and their patients differ based on geographic location
(Kuo, Loresto, Rounds, & Goodwin, 2013; Reagan & Salsberry,
2013; Xue, Ye, Brewer, & Spetz, 2016). These differing regula22
Journal of Nursing Regulation
tions compound pre-existing inequities in care by erecting further barriers to access in traditionally underserved and vulnerable
populations (DesRoches et al., 2013; Kuo et al., 2013; Reagan
& Salsberry, 2013; Xue et al., 2016; Chapman, Phoenix, Hahn,
& Strod, 2018; Loresto, Jupiter, & Kuo, 2017; Neff et al., 2018).
Currently, 21 states grant all APRN roles full practice authority, which means a written Collaborative Practice
Agreement (CPA), supervision, and conditions on practice are
not required (NCSBN, 2018). The remaining 29 states mandate
reduced scope of practice on at least one APRN role. In these
markets, a CPA specifies the scope of practice with a general or
direct supervision requirement by a clinician. Similar to the state
laws that mandate these formal agreements, CPA frameworks
vary considerably in terms of financial and professional requirements. In many instances, physicians require APRNs to pay them
for signing on to a CPA and often entail patient medical record
reviews, shared billing procedures, regular in-person or electronic
communication, and patient referral pathways (DesRoches et al.,
2013; Reagan & Salsberry, 2013; American Academy of Family
Physicians, 2018; Rudner & Kung, 2017). Nonetheless, statemandated requirements on distance restrictions between APRNs
and their supervising providers, the nature and volume of patient
medical record reviews, and the fees governing such arrangements
are often not uniform.
Despite inconsistencies in what scope of practice restrictions require and how they are applied, proponents of CPAs often
cite patient safety concerns as justification for their perpetuation
and expansion. Common themes that emerge are whether APRNs
have sufficient education and whether they have the breadth of
experience to provide the same level of care as their physician
counterparts (American Academy of Family Physicians, 2012;
American Medical Association, 2010; Federation of State Medical
Boards, 2005). Survey findings suggest the answers to these questions often depend on whom you ask, with physicians’ responses
and APRNs’ responses typically inversely related (Donelan,
DesRoches, Dittus, & Buerhaus, 2013). Additional research
has also examined physician wage loss as a potential corollary
to increased APRN scope of practice (Perry, 2009; Pittman &
Williams, 2012). Regardless of the motivation, controversy persists as to the appropriate amount of autonomy APRNs should be
granted in their day-to-day practice.
Evidence in support of full practice authority has allayed
public safety concerns. Many studies document comparable clinical outcomes (Reagan & Salsberry, 2013; Loresto et al., 2017; Dill,
Pankow, Erikson, & Shipman, 2013; Fung, Chan, & Chien, 2014)
and high patient satisfaction ratings for APRN-managed care
(Laurant et al., 2008; Mundinger et al., 2000; Roblin, Becker,
Adams, Howard, & Roberts, 2004). Furthermore, longstanding
research indicates APRNs are more likely to serve traditionally
underserved and minority populations (DesRoches et al., 2013;
Xue et al., 2016; Neff et al., 2018; Buerhaus, DesRoches, Dittus,
& Donelan, 2015; Barnes, Richards, McHugh, & Martsolf, 2018).
Adding to this existing body of evidence, new lines of inquiry
on the economic benefits of removing CPA restrictions have
shed light on the potential cost savings states could accrue with
expanded scope of practice regulation (Conover & Richards, 2015;
Hooker & Muchow, 2015; Timmons, 2017). To make these findings more actionable, additional information on which CPA components place undue financial and practice restrictions on APRNs
is necessary.
To date, much of the research on scope of practice regulations has focused on strategies to address projected provider
shortfalls and the inevitable gaps in care that result. Of particular concern are shortfalls among primary care, mental health,
and midwifery providers (Chapman et al., 2018; Declercq,
Paine, Simmes, & DeJoseph, 1998; Huang & Finegold, 2013).
Utilization trends and broader workforce issues, such as general
practice patterns and perceptions of provider care, also received
much attention. By contrast, less information is available in the
scientific literature on specific CPA components, including financial requirements, provisions regarding the extent and frequency
of collaboration, and particularly restrictive/beneficial aspects. To
augment the literature on these important topics, the NCSBN
designed a cross-sectional study to identify current APRN practice trends in states that require CPAs and to ascertain the potential benefits and challenges such formal arrangements present.
Volume 9/Issue 4 January 2019
TABLE 1
Sampled States
Collaborative Practice Agreement States
Maryland
Alabama
Maine
Arkansas
Michigan
California
Mississippi
Florida
Missouri
Georgia
Nebraska
Illinois
New Hampshire
Indiana
New Jersey
Kansas
New York
Louisiana
North Carolina
Maine
Ohio
Oklahoma
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Virginia
Wisconsin
Methods
Sample
A stratified random sample of 8,701 APRNs practicing across
29 states that mandate reduced scope of practice on at least one
APRN role comprised the final study sample (Table 1). A demographic analysis compared the breakdown of respondent sex,
race, and age to the APRN characteristics identified in the 2017
National Nursing Workforce Survey to assess for potential nonresponse bias (Smiley et al., 2018). Table 2 confirmed the overall
sample and role-specific cohorts aligned with national estimates.
Participants were contacted via postcard and email between
September and November 2017. An online survey was administered using Qualtrics (Provo, UT). The instrument consisted of
47 questions divided across four content areas: (a) baseline demographics, (b) CPA framework, (c) practice patterns, and (d) CPA
benefits/challenges. The study was determined to be exempt by
the Western Institutional Review Board.
Data
Dependent Variables
The majority of survey items in the analysis used participants’ raw
response values; however, several covariates were recoded to facilitate further analysis. One of the two primary dependent variables,
CPA fee requirements, is an amalgamation of APRN responses to
two survey questions. The first asked respondents whether they
or their facility had to pay a fee to establish their CPA, whereas
the second solicited information on whether they or their facility had to pay a fee to maintain their CPA. As either arrangement
represents an additional financial burden on practicing APRNs
or their employers, responses to these two items were combined.
The second dependent variable was assessed in its raw form as a
dichotomous outcome (yes/no) asking whether APRNs experience any practice restrictions associated with their CPA.
Independent Variables
A “career stage” variable was derived from participants’ raw
numeric responses related to years in practice. Respondents below
the 25th percentile (5 years) were considered early career, whereas
www.journalofnursingregulation.com
23
TABLE 2
Study Demographic Profile Compared to
2017 Workforce Characteristics
Group
Demographic
Variable
2017 Workforcea
Study Sample
NP
Sex (female)
92%
91%
Race (White)
84%
86%
CNM
CRNA
CNS
Total
Age (median)
51
52
Sex (female)
100%
99%
Race (White)
87%
92%
Age (median)
57
57
Sex (female)
62%
55%
Race (White)
88%
84%
Age (median)
52
53
Sex (female)
93%
95%
Findings
Race (White)
83%
90%
Demographics
The mean age of APRN respondents was 52 years (SD = 11.1),
with a median of 13 years of work experience (IQR = 5–20)
(Table 3). The majority were White (n = 6,653, 86.7%), female
(n = 6,926, 89.7%), and certified nurse practitioners (CNPs)
(n = 6,218, 80.0%). A master’s degree was the most frequent
level of nursing education reported (n = 5,860, 75.3%), but a
sizeable proportion of respondents also indicated having a doctor
of nursing practice degree (n = 1,003, 12.9%). Most respondents
worked in large health facilities/systems (n = 4,515, 58.0%) in
urban areas (n = 5,264, 67.9%). Few respondents reported practicing in two or more states (n = 295, 3.8%), but about one-fifth
did indicate they work under more than one CPA (n = 1,894,
21.8%). Patient populations are fairly diverse, with most APRNs
reporting family/individual across lifespan (n = 3,139, 31.4%),
followed by adult/gerontology (n = 2,808, 28.1%) and women’s
health (n = 1,337, 13.4%).
APRN majorities reported discussing at least one patient
case (n = 5,866, 93.7%) with and/or referring at least one patient
case (n = 4,923, 78.7%) to a member of their physician team
in the past month. Despite APRNs’ active role under CPAs,
physician activity was less consistent. Only half of respondents
(n = 3,143, 50.2%) indicated they communicate in person with
their supervising physician at least once per month. A similar
proportion (n = 3,850, 61.5%) also indicated they communicate
with their supervising physician via phone/text/email at least
once per month. Approximately half of respondents (n = 3,551,
56.6%) reported their supervising physician conducts medical
record reviews.
Age (median)
60
58
Sex (female)
90%
90%
Race (White)
81%
87%
Age (median)
53
52
Note. NP = nurse practitioner; CNM = certified nurse midwife; CRNA = certified registered nurse anesthetist; CNS = certified nurse specialist.
a Weighted estimates reflect population characteristics.
those between the 25th percentile and median were considered
midcareer, and those at or above the median (13 years) were considered established. Furthermore, respondents who reported practicing in multiple states or working under two or more CPAs
were re-classified into two binary predictors (i.e., one = 0, two or
more = 1). CPA authorship was also dichotomized to distinguish
between any level of APRN involvement versus no input. Finally,
as more than 85% of respondents were reportedly “White/
Caucasian,” all other racial/ethnic categories were collapsed into
a single minority group.
Statistical Analysis
A descriptive summary of the final respondent sample included
frequencies and proportions for all categorical variables.
Continuous variables were expressed as means and standard
deviations or medians and interquartile ranges (IQRs) based on
their underlying distributions. Univariable and multivariable
binary logistic regression models were used to examine CPA fee
requirements and restrictive care trends (Hosmer, Lemeshow,
& Sturdivant, 2013). As a measure of global fit, the composition of the final multivariable models was determined using only
those parameters that best minimized Akaike’s information criterion. An alpha error rate of p ≤ .05 was considered statistically
significant.
24
A supplemental latent class analysis was used to further
classify APRNs into more discrete groups based on their practice
profiles. The final number and composition of the latent cohorts
was determined based on APRN responses regarding self-payment to establish or maintain their CPA, as well as the perceived
restrictions, benefits, disadvantages, and challenges associated
with CPA enforcement. Facility payments were excluded from
this follow-up analysis to better account for the particularly onerous nature of out-of-pocket expenses. Bayesian information criterion estimates were assessed to determine the final number of
groups used in the analysis. As a measure of accuracy, the proportion of respondents expected to belong to each subgroup, known
as class membership probabilities, are reported (Collins & Lanza,
2013). All analyses were conducted using SAS 9.4 (Cary, NC).
Journal of Nursing Regulation
CPA Fees
One in five respondents reported that either they or their facility
had to pay a fee to a collaborating physician (n = 1,275, 20.3%).
Of this subtotal, notable proportions of respondents reported
paying directly out of pocket to establish (n = 228, 17.9%) or
maintain (n = 263, 20.6%) their CPA. This APRN cohort was
largely comprised of CNPs (87%) working in primary care settings (50%). For these direct payments, the median fee to establish a CPA was $650 (n = 198, IQR = $150–$1,500). However,
establishment fees ranged considerably, from $10 to $50,000.
Twenty-four respondents indicated they paid in excess of $5,000
to establish their CPA, with eight of those reporting figures
greater than $20,000. By comparison, the median fee to maintain a CPA was $500 per month (n = 213, IQR = $200–$1,000).
Maintenance fees also ranged widely, from $4 to $4,167 per
month. Ninety-six respondents indicated they paid more than
$500 per month, with 40 reporting monthly figures over $1,000.
Baseline demographics, such as age, sex, race, and education level, and the number of states in which an APRN reported
practicing were not meaningfully associated with mandatory
fee payments (results not shown). On multivariable analysis,
APRNs practicing in rural areas were 52% (adjusted odds ratio
[AOR] = 1.52, 95% CI [1.32, 1.75], p < .001) more likely to report needing to pay a fee to establish or maintain their CPA (Table 4). Those working in a private practice setting established and managed by APRNs reported similar trends. APRNs who worked in large health facilities/systems (AOR = 0.31, 95% CI [0.24, 0.39], p < .001), who worked in private practices run by physicians (AOR = 0.16, 95% CI [0.12, 0.22], p < .001), or who were self-employed (AOR = 0.63, 95% CI [0.41, 0.97], p = .04) were all 37% to 84% less likely to pay CPA fees compared to those who worked in a private practice managed by APRNs. APRNs working remotely from their supervising physician were also 2.68 times (95% CI [2.23, 3.23], p < .001) more likely to report a required fee to establish or maintain their CPA compared to those located in the same office/clinic. Similarly, APRNs working under two or more CPAs were 27% (AOR = 1.27, 95% CI [1.10, 1.47], p = .001) more likely to pay CPA fees compared to those who only reported one. CPA fees varied by patient population but often aligned with facility setting. Respondents who work in family/individual lifespan (AOR = 1.64, 95% CI [1.41, 1.90], p < .001) or psychiatric mental health (AOR = 1.47, 95% CI [1.18, 1.82], p < .001) areas were more likely to report paying fees. Both services were offered more frequently in private APRN practices (both p Purchase answer to see full attachment