Three Factors Affecting the Kentucky Mid-Level Practitioner Workforce, Part One
Tuesday, January 27, 2015

As more Kentuckians gain access to health care as a result of the Affordable Care Act, healthcare workforce shortages for primary care providers becomes problematic particularly in rural Kentucky. Never before have mid-level practitioners been more important. The Health Resource and Services Administration (“HRSA”) estimates that there will be a shortage of 20,400 primary care ­physicians by 2020, but this number could be drastically reduced – as low as 6,400 – with an abundant increase in the autonomous practice of mid-level providers[1]. The same HRSA study concluded that a fully-utilized workforce of mid-level practitioners could account for 28% of all primary care by 2020. Three factors make mid-level practice more attractive than ever in Kentucky.

Collaborative Agreements and Autonomy

Even though the American Association of Nurse Practitioners lists Kentucky as a “reduced practice” state[2], the trend in Kentucky lately has been towards increased autonomy of mid-level practitioners. A study by the American Nursing Association[3] determined that autonomy might be a factor in mid-level providers choosing to practice in rural areas. Kentucky’s recent legislative changes in midlevel practice in that direction should ostensibly have a positive effect on the ability of mid-levels to establish independent practices. With a shortage of primary care providers, particularly in rural Kentucky, nurse practitioners have new opportunities to establish independent clinics without physician collaboration or oversight.

Until recently, Kentucky required all Advance Practice Registered Nurses (“APRNs”) to enter into collaborative agreements with doctors to prescribe medications. These agreements fell into two categories based upon whether the drug is classified as a controlled substance. Senate Bill 7, passed during the 2014 legislative session, modified this rule to allow for a new group of APRNs that will no longer require these agreements after four years of experience. Experienced APRNs are now free to treat patients and prescribe medications like antibiotics without a collaboration agreement, which is a great advantage for mid-level practitioners in Kentucky. Prescriptions for controlled substances, such as Adderall and Hydrocodone[4], will still require a collaborative agreement, but this new rule strikes a balance between those who worry that newer mid-level practitioners won’t have the necessary experience to make choices concerning prescription drugs and those who feel that experienced mid-level practitioners are more than capable to do so. The importance of the ability to practice without physician collaboration cannot be overstated; nurse practitioners have paid as much as $100,000 for physicians to enter into collaboration agreements. The amounts paid to physicians by nurse practitioners for these agreements has been unreasonable in some instances, and elimination of the physician collaboration rule for non-controlled substances reduces costs for APRNs and creates opportunities to establish clinics.

Come back on Thursday to learn more about what affects mid-level practitioners.

[1] U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Projecting the Supply and Demand for Primary Care Practitioners Through 2020. Rockville, Maryland: U.S. Department of Health and Human Services, 2013. Available here.

[2] American Association of Nurse Practitioners, State Practice Environment here.(last visited Jan. 14, 2015)

[3] Susan M. Skillman, et al., Understanding Advanced Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider Identifier Data (2012) here.

[4] For more on this, please see here


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