Introduction

Advanced practice registered nurses (APRN) are nurses with advanced education and specialization in different categories. The categories include nurse anesthetists who work in the surgical field and nurse midwives who work in women and the related field of reproduction. In the US, a nurse must have at least a master’s degree to become an APRN. They train on assessment, prescription of medicine, diagnose as well as managing patients. They can, therefore, perform the same duties as doctors to offer primary healthcare. Despite their abilities to carry out such duties, there are restrictions from different authorities. In the US, the federal and States governments, as well as Medicare, restrict the nurses in different ways from carrying out some of those duties like prescriptions. Most of those restrictions disadvantage the hospitals and patients because the number of doctors is low and the salary they need is high in comparison to APRNs. This study analyzes the restrictions of APRN from Medicare, Federal and States governments as well as their roles to see how they would save patients and hospitals treatments cost as well as improve health outcomes.

Restrictions for APRN

Although the federal state has laws restricting APRN from some practices, individual states make their policies. There are also policies, which hospitals make towards the scope of APRN. There are some states, which recognizes APRN as primary healthcare providers and therefore, allows them to carry out any duty without restriction. Some states on the other hand partially acknowledge the ability of the nurses and thus give them partial right to carry out doctor’s roles. They only allow them to perform the duties when the attending doctor allocates them. Also, the APRN in those states can perform some duties up to certain levels. The last category is that of states which do not allow APRN to perform specific roles regardless of the circumstance. APRN can only be present when their supervisors are attending the patients to help them.

Drug administration Prescriptive Authority

One of the restricted perceptive roles is on drugs. The federal and various states have different levels through which NP can prescribe, administer, administer or even dispense drugs to Patients. The Drug Enforcement Administration (DEA) divides prescription drugs into four categories on the bases of their effect and addiction in human. The classes are schedule 2/2N, 3/3N, 4/4N as well as 5/5N. The first category 2/2N is highest in addiction with a probability of having severe mental and physical side effects. The intensity of addiction and side effects reduces with numbers, 5/N5 being the list in effect. The restriction varies depending on the state. There are those states, which allow APRN to administer, procure and even prescribe all of the four categories without restrictions. Such states include Hawaii, Arizona, and Colorado. Those states like Colorado consider APRN as primary healthcare providers and therefore have full right to prescribe any of the drugs. However, for the nurses to work independently without supervision, they must work under preceptorship within a given duration of time given in terms of hours. In Colorado, for example, nurses are supposed to work under supervisions for 1800 hours after which they can prescribe any drug without restrictions.

Other states have restrictions to prescription under physician collaboration. One such state is Florida where the ARNP prescribes drugs subject to practitioner approval. Where the ARNP need to order or dispense controlled substances, they must make those arrangements with their supervisors. An additional restriction to prescription is on the requirement to have a certificate in a program, which leads to a master’s degree in a clinical specialty area and training in a particular practitioner skill. The state also restricts the prescription of substances related to psychiatric mental health. Another category of states is those, which do not allow APRN to prescribe drugs at all. Examples of such states include Missouri and Georgia.   In those states, APRN must collaborate with their supervisors to prescribe the controlled substances.

Physical examination and admission

The federal government allows APRN to see new patients without any restrictions. However, different states have different policies on the issue. There are some states, which enable the APRN to see new patients without any restrictions. Some of those states include Hawaii, Idaho, and Colorado. However, there are other states, which will only allow   APRN to attend to new patients with authority form their supervisors. The nurses can call the supervisor and request to see the patient on behalf. The states allow doctors to give nurses the authority to see patients when they are not available. Examples of such states with reduced responsibility to attend patients for the first time include Pennsylvania, New York, and New Jersey. There is another category of states, which do not allow APRN to see patients for the first time even with authority from the supervisors. The only time when the APRN can see patients in such states is when they collaborate with the doctor. The doctor must be present and make a diagnosis for the patient alongside the one done by the APRN. Such states with full restrictions include North Carolina, Oklahoma, Michigan, and Massachusetts.

Referrals and orders

The federal government, through the Medicare & Medicaid Services, does not allow APRN to write orders or make referrals for patients. The claim from the two bodies is that the nurses cannot write orders and make referrals a situation, which creates financial and logistic challenges in hospitals. However, there are some states, which allow the APRN to make orders and referrals without restrictions. The states recognize APRN to have the ability to handle such cases have gone through the required training. Once such requests are made, the doctors do not have to check and confirm them. Examples of such states include Wyomia, Washington and Vermont.

In other states, APRN has partial right to admit and write laboratory orders related to patients. The APRN can admit with directions from the supervising doctor. The attending doctor gives an order or delegation to the nurse through word of mouth or writing. In addition to the delegation, the doctor signs the admission forms at the time of patient discharge. Where there are no such signs, the APRN and the attending doctor can fail to get their payments through the Medicare. Examples of such states include Pennsylvania, Ohio and New York. The third category of states is those, which do not give APRN any right to make patient orders or referrals. Medicare does not make payments of such requests made by the nurses. However, they can be present or collaborate with doctors to make orders and referrals.

Treatment

Restrictions under the examination and treatment category include treating chorionic pain, setting fractures suturing a laceration, provision of anesthesia, making first-term aspiration abortions or laser treatments. The federal government does not allow the APRN to make such treatments even in situations where the nurses are specialized in the given area. At the state level, different states have different views and policies on APRN treatment of patients. The first category of states is those, which allows the nurses to make treatment without interference from the doctors. They include Lowe, Idaho, and Hawaii. The other category is that of states which allows only nurses with specialized skills to carry out treatment. However, even in those treatments, the nurses should have authority from the attending doctor. Among those states includes Mississippi, Louisiana, and Kentucky. Other states have strict policies, which do not allow APRN to make treatments on patients even with a delegation from the attending doctor. The states include Florida, Georgia, Michigan, and Massachusetts.       

Certification and commitments

There are several certificates and declarations, which doctors make or issue within the medical field. They include death and birth certificates. Also, doctors are supposed to declare the death of a patient to the family and other concerned parties as well as issue marriage health rules. The federal government does not allow APRN to issue such declarations or certificates. However, there are some states, which enable the APRN to carry out such duties without limitations, for example, Arizona and Alaska. Other states allow nurses to assume such tasks with a delegation from the attending doctors for example Arkansas. Despite the ability and capacity of the APRN to carry out such declaration and issuance of certificates, some states like California and Georgia restricts nurses from such roles.

Medicare law

The federal government carries out regulation of the APRN practices through policies and Medicare. Medicare offers insurance to patients who apply for medical services. It also sets some guidelines on those medical services it can reward depending on who performs them similar to the federal and state governments. The insurance group restricts APRN to carry out some roles, which includes certifying patients to access coverage on hospice and home health services. Home and hospice services which Medicare covers for the beneficiaries include monitoring of serious illness at home, education for the caregiver and the patient, as well as wound care. It means that APRN under Medicare cannot admit patients for such services because their admission will not receive remunerations form the insurance. However, the insurance organization allows APRN to document the home health services and deliver them to the attending doctor who will make a narrative and later certification.

Medicare allows APRN to offer post-hospitalization care services in facilities. The insurance gives APRN to sign certificates, which will enable patients under Medicare program to get to post-acute care for medical conditions, which are complex including heart failure, stroke as well as joint replacement. Other restrictions, which Medicare places on APRT, are those, which the state law also recognizes.  Medicare requires APRN to have specific academic qualification and accreditations to perform the services, which the state or the federal governments allow. One of them is a master’s degree in a particular clinical field and from an institution with accreditation. The nurses should also have a certificate from the American Nurses Credentialing Center to show that they are specialists. The nurses should have a license to operate from the states they practice.

APRN under Medicare can perform all doctor’s roles which require an independent treatment and evaluation of the patient situation. Such services include X-rays interpretations and minor surgeries. Medicare allows APRN to perform any duty in collaboration with the supervising doctor as long as the state or federal law allows. The doctor can delegate the responsibility with instructions on how to handle the situation such that they do not have to be present. However, even without a state law, Medicare will recognize the collaboration but only after the APRN documents the kind of relationship they have with the doctor to handle such a variety of issues outside the practice.

There are some duties which Medicare does not allow APRN to perform regardless of whether the state or federal governments restriction or acceptance. They include regular foot care as well as physical checkups. Also, the organization does not allow APRN to offer services which are not meant to diagnose or treat injuries and illness and also to improve the functionality of a malformed part of the body. Although nurses may have qualifications and right to perform such duties, Medicare does not compensate them unless a doctor is in charge.

Valuable services from APRN

One of the APRN roles, which the federal and state governments do not restrict, is education provision to caregivers and patients on strategies to prevent diseases. Also, the nurses teach on the lifestyle choices which can help improve the health conditions of patients. While the doctors diagnose and treat a specific disease, APRNs looks at the holistic health of the patient’s and smooth recovery without cases of readmission. Although the federal and most states governments do not focus on disease prevention, it is the best strategy towards public health. One advantage is saving money for the treatment of minor diseases, which are preventable. Through education on disease prevention, APRN is, therefore, able to save hospitals money, which they would use to research and treat an outbreak. Diseases such as cholera, tuberculosis, arthritis are preventable. APTN teaches people on how to avoid the agents of such illness and therefore, prevent outbreaks.

Education on lifestyle is essential to improve the health outcomes of patients and therefore, save patient and hospital’s money. One on one dialogue with people and the community influence them to change their behaviors towards healthy ones. The nurses carry out the roles of social marketers.  There are some diseases and conditions, which require lifestyle changes to contain them. An example is diabetes where a patient should avoid some food substances, which have much cholesterol and instead take enough iron and other minerals. The foods are better compared to drugs, which increase insulin in the body. The APRN saves patient’s money, which they would use to buy the expensive insulin control and other drugs. Others do not have a specific cure but good lifestyle changes. Good lifestyles ensure that the patient’s leave hospital earlier than it would be without practices such as physical exercises and dietary. Also, the practices help to avoid readmission due to worse conditions. Hospitals can save money and time they would focus on patients for a long time while patients save money they would pay for readmission.

APRN manage different chronic conditions like diabetes and high blood pressure. Such chronic diseases do not have a permanent cure, and patients leave with them for the rest of their lives. However, there are some situations when they become severe, threatening patients’ lives or making them experience much pain. APRN help the patients to manage those conditions in ways that will not reach to severe conditions. They carry out the role through regular check up of the patients to evaluate the need for a different drug in every stage of the patient’s life. The continuous taking of one particular drug may lead to other conditions in patients. APRN checks the patients to ensure that there are no other conditions, which would arise because of the current disease and treatment. Also, most of those diseases require a regular change of diet to control the amount of different minerals like iodine and iron in those people with gastric disorders. Managing such diseases helps the patient to avoid readmission for severe conditions and instead, maintain a healthy outcome. Also, hospitals do not incur much money in treating readmissions from the severity of such diseases.

In the process of management of patient’s conditions, nurses go beyond the diagnosed illness to other states, which may reverse the illness. Some diseases are brought about by other states which doctors do not pay attention to the treatment time. APRN goes ahead to evaluate other conditions present or leading to the illness. Management of such conditions helps to ensure complete recovery of patient’s. They support the patients to avoid revisiting the hospital for the same state in the future thereby saving costs.

APRN supervises and manages the health and well-being of women from preconception to parental, gynecological issues among other primary needs. Women have different regular health conditions which most of them do not understand and therefore seek medical advice. Nurses assist attending doctors in the examination of such minor issues, which would require the hospital to incur much money paying a specialist doctor attending such women.  Also, patient’s save money through APRN which they would pay when a specialist serves them. Some of those conditions may be a foundation of complex illnesses once they fail to have proper early management. The nurses help and advice patients early on how to manage the conditions. They determine the need for a specialist early thereby avoiding the severity of the illness later. Early monitoring and management of the conditions help the patients recover smoothly and therefore improve their health compared to when the disease is severe. They save the hospital and patient’s money, which they would spend in treating a complex condition later.

Management and supervision of women and the fetus health early help to avoid unnecessary charges like CS during delivery. There are some cases when the midwives and doctors may order for a CS, which was manageable early. High blood pressure for example, which would prevent standard delivery, is manageable to the right levels before the due date to avoid an operation. APRN guides women through their reproduction to avoid such high charges thereby saving them from spending a lot. Also, hospitals do not spend much money in severe conditions of women when nurses control them early. The health of women improves well and quickly after delivery when nurses manage them throughout their gestation period.  APRN also supervise the fetus growth to ensure healthy development. The advantage of supervision is to allow early management of conditions, which may arise at the time of birth. Initial management saves mothers and hospitals money that they would use to treat the conditions at advanced stages. The nurses can control the baby weight to avoid keeping them in nurseries after delivery, which would cost the mother and the hospital.

Another unrestricted role of APRN is the treatment of minor injuries. The nurses can pay more attention to the injuries compared to specialized doctors. Over 80 percent of patients trust treatment form APRN compared to doctors. Nurses can listen to patients better and pay more attention. Such trusts enable the patients to adhere to drugs and therefore improve their health outcome as well as avoid frequent visits, which would be costly. They offer better treatment and follow up on such patients thereby helping to improve their health outcomes. The nurses are readily available to attend the patients immediately other than making a queue or appointment with the limited doctors. Immediate treatment helps to manage the injuries early to avoid additional complications, which would cost the patient’s health and money. Also, through follow up, they ensure that the patients do not make frequent visits to the hospital thereby saving them money. Such minor injuries would cost the patient and the hospital more money when contacting a specialist. APRN costs are low, and therefore patients and hospitals do not spend a lot.

Effect of reduced APRN restrictions By Medicare

In one of the limitation, Medicare does not allow APRN to carry out hospice services. Hospice service is provided to those patients with a terminal illness at home or as impatiens. Medicare does not let any nurse practitioner make narrations and therefore follow up of such patients. The organization insists that a doctor must be present and APRN can only collaborate with their supervisors. In their billing reimbursement schedule, Medicare does not accept any from hospice service that APRN signs. Having a doctor make follow up of such patients is very expensive since the remuneration is almost twice as that of a nurse practitioner. Charges, when APRN are making follow up, are low because their salaries are also low. Hospitals can keep wages of nurse practitioners low because their education program is 20 to 25 cheaper compared to that of physicians in the US (Connect Your Care, 2019).  However, it is good to note that the study fee difference does not show how APRN are under qualified. They have the same teachings and skills with specialist only that the program they went through is different. Most of them have experience of at least two years before they enroll for masters in their areas of specialization.

Allowing APRN to make hospice follow-ups will save hospitals much money, which they would pay doctors in such roles.  There are so many visits that these doctors make to patient’s home which nurses can do to lower the amount of money the hospital charges patients. Families of such patients will, therefore, save much money by when an APRN attends them. Apart from attending to the patients, APRN will educate the families of such patients on strategies of giving care. They have the training to cover an all-round program and not diagnosis and treatment alone. Training families on how to take care of the patient reduce the number of visits, which the hospital requires to offer. The cost of follow up for the family and the hospital will therefore reduce.

Another area through which the patients lose much money in treatment is when they seek private therapy because they cannot get a doctor who can admit them through the Medicare program. Medicare restricts APRN from admitting several cases into their programs. For example, a nurse practitioner cannot carry out physical and first time examination, make referrals and specific orders as well as prescribe particular categories of drugs. The number of doctors in the US is low compared to the population they are supposed to serve. It means that patients have to queue waiting for one specialist. Those who are in chronic pain and cannot wait decides to seek private services which do not offer or cannot treat through Medicare support.  Those patients end up using much money, which they could save through the insurance organization. Changes, which allow APRN to admit patients through Medicare, would ensure that every patient in the program benefits at every hospital visit.

Another restriction, which Medicare can avert, is on regular checkups, which do not aim at treating or diagnosis of a condition or examine injuries but improve body functions. Checkups reduce admissions of patients from severe and chronic diseases. Such regular checkups are essential to identify any symptoms of a disease or improve patient’s health and recovery process. APRN have training on such services, but the Medicare restricts them. Allowing such services will minimize admissions from conditions which nurses can control their symptoms. APRN can advise patients on the right thing to do in case they discover any signs such as those of high blood pressure. One of the APRN roles is to prevent diseases. The only way they can exercise that duty is when they meet patients. Through regular checkups, nurses will be able to advise patients depending on how they have found the body condition. They can advise on regular exercise to lower body weight, which would cause blood pressure, or dietary to take more iron which to prevent gastric conditions. Patient’s will cost which would come as a result of such conditions. Also, hospitals save since they will not have the burden of getting a specialist when such patients suffer from prevented conditions.

APRN can reduce the number of days, which patients stay in hospitals once Medicare allows them to sign different forms.  Medicare restricts the nurses to sigh most of the certificates and forms, which patients require to leave hospitals. The forms include prescription, discharge, and birth. Medicare only recognizes forms signed by doctors even in those cases there was collaboration or delegation with the nurse to write a narrative about the patient. Patients extend their days in hospital until the doctor is available to sign the forms. Doctors in the US are few, and therefore, their availability is low. The extended duration can reduce once APRN gets the right to sign the forms. Nurse practitioners are many and always available to the patient, and therefore, they would discharge patients on time. The patients will save the money they pay for extended days, and the hospital will lower the cost of taking care of them.

Allowing nurses to handle the initial examination, diagnosis as well as prescription will increase community-based clinics, which are cheap. Community clinics replace emergency rooms and care centers in hospitals. They offer services at low cost because the APRN is in charge. Patients, therefore, save much money, which they would spend in the hospital to be treated by doctors. The nurses at the local clinics can offer preventive services for common diseases at the community level. Prevention further reduces cost, which patients would incur in hospitals when they get sick. Hospitals save money they would use to treat such diseases, which nurses can prevent.

Conclusion

APRN have restrictions to their roles, which they are capable of carrying out. Their training offers skills, which can allow them, carry out similar primary care duties as doctors. However, the barriers from different authorities make them as assistant to doctors and can only engage in such roles with the delegation, collaboration or under supervisions. Their skills would help patients and hospitals in many different ways were there no restrictions. They can help to solve the challenge of a few doctors, and cost of treatment because their charges are low compared to treatment under a specialized doctor. The authorities restricting them should take an initiative of understanding their abilities to expand the scope of the duties they perform. They will help to save patients and hospitals much money by reducing the length of admission, some visits, readmissions among other costs.