Let nurses fix NC’s health care shortage

A series of new billboard messages along I-77 outside Statesville both call attention to the problem of declining access to health care across North Carolina and propose a solution:

Rural America is Dying. We Need Nurses. Not Government Roadblocks.

These bright orange billboards stand in stark contrast to the surrounding rural North Carolina landscape, a region that is home to one of the worst nursing shortages in the country. Many of the counties cut across by I-77 are federally designated as primary care health profession shortage areas (HPSA), meaning that residents often have to drive hours to access basic health care services. Altogether, 93 of North Carolina’s 100 counties are designated as primary care HPSAs.

Nurse practitioners, a type of nurse with advanced training and the authority to diagnose conditions and prescribe medications, can help improve access to primary care in North Carolina’s rural communities. Historically, nurse practitioners have filled gaps left by physicians in rural America. But the state’s current regulatory regime makes it nearly impossible for these qualified providers to increase access to care.

North Carolina is one of only 12 states that still requires nurse practitioners (NPs) and other advanced practice registered nurses (APRNs) to maintain a costly, physician‑supervised collaborative practice agreement before they can see patients on their own. These collaborative practice agreements ultimately restrict North Carolina residents’ access to care by limiting the outreach of nurse practitioners and making it more difficult for patients to see a provider.

NPs are well-trained, licensed, certified, and accountable to professional boards. But under North Carolina law, an NP can’t order routine lab work, prescribe a common medication, run a small-town clinic in an HPSA, or otherwise practice to the full extent of their training without paying a physician collaborator. These agreements are costly. The average monthly fees for a collaborative practice agreement in North Carolina are $703.

In other words, NPs are paying their direct competition over $8,400 a year for the privilege of working. That’s money that NPs can’t direct toward patient care or clinic needs.What collaborative practice agreements really do is create an expensive barrier to entry for entrepreneurial NPs aiming to expand health care access and fill North Carolina’s provider gap. Meanwhile, North Carolina has the eighth-worst nursing shortage in the country.

Most states don’t hamstring NPs with CPA requirements. Research conducted by Pacific Legal Foundation into collaborative practice agreements found that 36 states and the District of Columbia either allow NPs to practice independently or have a limited collaborative practice agreement requirement that provides a path to independent practice. Research has shown that patients in these states have greater access to health care without any decrease in quality or safety.

North Carolina should be making it easier for NPs to fill the state’s provider gaps, and research has shown that NPs are more likely to practice in primary care HPSAs in states without collaborative practice agreements. In Nebraska, for example, the NP workforce increased in 20 primary care shortage areas within five years after lawmakers adopted a path to independent practice for NPs. Similarly, three years after Nevada implemented independent practice for nurse practitioners in 2013, the state saw a 33% increase in NPs, with many relocating from other states. Eliminating collaborative practice agreements in North Carolina could yield similar results by attracting new practitioners and expanding access to underserved communities.

Collaborative practice agreements don’t protect patients. By giving physicians control over whether NPs can practice, these agreements only serve to drive up costs, limit competition, and worsen North Carolina’s health care shortage. Nurses can fix North Carolina’s health care shortage, but government must get out of the way.