I would like to thank the Virginia Board of Nursing for offering me the opportunity to comment on Regulations Governing the Licensure of Nurse Practitioners [18 VAC 90 ? 30]. I am a professor of economics at Saint Francis University and director of the Knee Center for the Study of Occupational Regulation at Saint Francis University in Loretto, PA. Our academic research center focuses exclusively on the topic of occupational regulation. I am also a Senior Affiliated Scholar with the Mercatus Center at George Mason University. Based on my own research on the effects of permitting nurse practitioners to practice and use the skillsets that they have acquired through their specialized training, I believe that this change represents an important first step to improving access to primary care in the state of Virginia. I would encourage policy makers in the state to consider going further and use other states as a model for future reform.

Like many other states, Virginia is facing challenges providing primary care to patients. National trends continue to suggest a declining population of primary care physicians.[i] Nurse practitioners can potentially help fill this gap, but is important that the existing law does not tie their hands and prevent them from practicing to the full extent of their specialized training.

On January 7, 2019, a law was temporarily put into effect until June 6, 2020 by Governor Northam and the Committee of the Joint Boards of Nursing and Medicine. The law permits nurse practitioners in the state of Virginia to apply for full practice autonomy after achieving the equivalent of five years of full-time clinical experience. This policy change is similar to one that was permanently enacted in New York State in 2015. It is important to note, however, that the clinical experience requirement in the temporary law in Virginia is more excessive—New York law requires only 3,600 hours of clinical practice. Moreover, the bordering state of Maryland enacted a more expansive law in 2015 that recognizes nurse practitioners as primary care providers in the state and requires 18 months of clinical experience before autonomy can be received. District of Columbia law serves as a model for other states and jurisdictions—permitting nurse practitioners full practice autonomy immediately upon successfully completing the requirements for licensure.

Nurse practitioners are often restricted by state law to apply the skills that they have learned and alleviate challenges that vulnerable populations encounter to receive primary care. Prior to this temporary change, Virginia belonged in this category—requiring nurse practitioners to enter into collaborative practice agreements and work in a team setting managed by a physician. Research consistently shows that these restrictions on nurse practitioner scope of practice result in longer driving times to receive primary care[ii] and reductions in the volume of care provided by nurse practitioners.[iii] In addition, researchers consistently find that nurse practitioners are more than capable of providing quality care to patients.[iv]

In my own research examining how changes to nurse practitioner scope of practice affect Medicaid patients, we find evidence that permitting nurse practitioners to practice autonomously is associated with patients receiving more care without increasing cost.[v] It should be noted, however, that our research suggests that the positive effects of granting nurse practitioners autonomy are only fully realized when they are granted full practice authority. The change is quite large—we estimate an 8% increase in the amount of care that Medicaid patients receive. There are no measurable differences observed between states like Virginia and West Virginia where nurse practitioners are required to enter into collaborative practice agreements to write prescriptions. It is only when states move to an environment like Washington DC, or the thirteen other states that have granted nurse practitioners the ability to practice autonomously without experience requirements, that the full benefits of nurse practitioner autonomy can be realized by vulnerable communities.

To conclude, the temporary law change to grant nurse practitioners the ability to practice autonomously after five years in Virginia is an important first step. Policy makers, however, should consider going further and use states and jurisdictions like New Hampshire, Rhode Island, and the District of Columbia as a model for future reform.

Edward Timmons, PhD

Professor of Economics

Director, Knee Center for the Study of Occupational Regulation

Saint Francis University

Senior Affiliated Scholar

Mercatus Center

George Mason University