FULL PRACTICE AUTHORITY MICHIGAN Impact of Full Practice Authority for Nurse Practitioners in Michigan: A Policy Analysis Olga Dmitryuk, RN-BSN, DNP-PMHNP Student Dawn Goldstein, PhD, PMHNP-BC Michigan State University College of Nursing 4/15/2024 FULL PRACTICE AUTHORITY MICHIGAN 2 Table of Contents Executive Summary ........................................................................................................................ 4 Domain 1: Problem Identification .................................................................................................. 5 Background ................................................................................................................................. 5 Problem Statement ...................................................................................................................... 7 Significance ................................................................................................................................. 9 Domain 2: Policy Analysis ........................................................................................................... 11 Framework ................................................................................................................................ 11 Domain 2A: Identify and Describe Policy Options ...................................................................... 12 Literature Search ....................................................................................................................... 12 Environmental Scan .................................................................................................................. 13 Identify ...................................................................................................................................... 15 Describe ..................................................................................................................................... 16 Enactment of SB 279 ............................................................................................................. 16 “Status Quo” / No policy change ........................................................................................... 20 Domain 2B: Assess Policy Options .............................................................................................. 22 Domain 2C: Prioritize Policy Options .......................................................................................... 23 Domain 3: Strategy and Policy Development ............................................................................... 24 Conclusion .................................................................................................................................... 26 References ..................................................................................................................................... 28 FULL PRACTICE AUTHORITY MICHIGAN 3 Table 1 - Literature Review Table ............................................................................................ 33 Table 2 - Policy Options Assessment Table.............................................................................. 36 Appendix A - State Practice Environment .................................................................................... 37 Appendix B - Timeline of Full Practice efforts in Michigan ........................................................ 38 Appendix C - How a bill becomes a law ...................................................................................... 39 FULL PRACTICE AUTHORITY MICHIGAN 4 Executive Summary Restrictions on the scope of practice for nurse practitioners (NPs) in Michigan hinder their ability to provide care to the full extent of their certification and education. Nurse practitioners are advanced practice registered nurses (APRNs) who hold master’s or doctoral degrees and have the skills to assess, diagnose, prescribe, and manage treatment in various settings. However, Michigan law mandates nurse practitioners to contract with a supervising physician to provide care to patients (MCNP, 2023). This creates unnecessary barriers to health care access, especially in rural and urban areas where there is a shortage of primary care providers (HRSA, 2016; MDHHS, 2020). Evidence shows that NPs with full practice authority (FPA) can increase access to safe, high-quality, cost-effective care and improve patient outcomes (AANP, 2021). FPA is the legal permission for NPs to practice to the full extent of their education, training, and certification without physician supervision. Twenty-seven states, the District of Columbia, and two U.S. territories have already recognized FPA for NPs, while Michigan’s current restrictive legislation continues to limit NPs’ ability to practice in the communities where they are needed most. Senator Jeff Irwin introduced Senate Bill 279, a bipartisan bill that authorizes FPA for NPs in Michigan, in March 2023. The Health Policy Committee is reviewing it, and it must pass the House to become law if approved. SB 279, if enacted, will address several critical issues in healthcare statewide that affect patient outcomes. This policy analysis project examines SB 279 using CDC’s policy analytical framework as a methodological approach and addresses the following questions: How does SB 279 align with the strengths, weaknesses, and gaps of the current NPs’ scope of practice? What are the factors that enable or impede the enactment of FPA legislation in Michigan? How can best practices and evidence-based research inform the implementation of FPA for NPs? FULL PRACTICE AUTHORITY MICHIGAN 5 Domain 1: Problem Identification Background Full practice authority (FPA) for nurse practitioners (NPs) in Michigan is essential for enhancing access and ensuring high-quality care, protecting patient safety, reducing health care costs, and offering patients a choice. FPA is defined as “the authorization of nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests and initiate and manage treatments — including prescribing medications — under the exclusive licensure authority of the state board of nursing” (AANP, 2023). Health professional shortages and unequal distribution of providers in urban vs. rural areas are expected to worsen, and the projected need for primary care providers in Michigan by 2025 is estimated at 1,000 physicians (HRSA, 2016). NPs stepping in as providers can bring a solution to the ongoing decline in population health outcomes as they provide safe, high-quality, and cost-effective care (Sheehan et al., 2021). NPs are advanced practice registered nurses (APRNs) who hold master’s or doctoral degrees and have the skills to assess, diagnose, prescribe, and manage treatment in various settings. The requirements for NP education, licensure and certification are consistent with national standards and are the same across the nation. One must hold a bachelor’s degree in nursing, become licensed as a registered nurse (RN), graduate from a nationally accredited graduate NP program that meets national standards for advanced didactic and clinical education and pass a national NP board certification exam (AANP, 2023). According to the Bureau of Labor Statistics’ 2022 Standard Occupational Classification, NPs role encompasses the following: - diagnose and treat acute, episodic, or chronic illness, independently or as part of a healthcare team, FULL PRACTICE AUTHORITY MICHIGAN 6 - may focus on health promotion and disease prevention, - may order, perform, or interpret diagnostic tests such as lab work and x rays, - may prescribe medication, - must be registered nurses who have specialized graduate education (BLS, 2022). Full practice authority is the legal permission for nurse practitioners to practice to the full extent of their education, training, and certification without physician supervision. Twenty-seven states, the District of Columbia, and two U.S. territories have already recognized FPA and allow NPs to practice to the full scope of their training without the requirement of a collaborative agreement with a supervising physician (NNCC, 2023). Appendix A State Practice Environment map shows the states with FPA in green, such as Alaska, Washington, Oregon, Montana, Utah, Arizona, Colorado, New York, etc. States highlighted in red pose the most restrictions on NP practice and include Michigan, California, Texas, Oklahoma, Missouri, Tennessee, South Carolina, North Carolina, Georgia, and Florida (see Appendix A). Michigan’s current restrictive legislation continues to limit NP’s ability to practice independently by mandating NPs to contract with a supervising physician to provide care to patients, which hinders NPs’ ability to practice in the communities where they are needed most. In March 2023, Senator Jeff Irwin introduced Senate Bill 279 (SB 279), a bipartisan bill that authorizes FPA for NPs in Michigan. The Health Policy Committee is reviewing it, and it must pass the House to become law if approved. Unlike other states with FPA, Michigan does not have the Nurse Practice Act (NPA) to regulate the nursing scope of practice. Instead, the Michigan Public Health Code “defines the practice of nursing in Michigan and empowers the Board [of Nursing] to establish qualifications for nurse licensure; to establish standards for FULL PRACTICE AUTHORITY MICHIGAN 7 education and approve nurse education programs; develop and implement criteria for assurance of continued competency” (Michigan Board of Nursing, 2023). Previous legislative efforts in Michigan (see Appendix B) included House Bill 5400 (2016), which passed both the House and the Senate and became Public Act 499 (2016), and Senate Bill 680 (2021), which did not pass the Senate and was blocked by the Health Policy Committee. PA 499 (2016) was successful in removing one of the NPs practice barriers as it granted the legal right to prescribe nonscheduled medications. However, NPs in Michigan are still required to practice under a physician’s authority, including the ability to prescribe controlled substances. In 2021 policymakers attempted to expand healthcare access in Michigan by removing these practice restrictions for nurse practitioners, but the conservative Republican majority comprising the Health Policy Committee at the time overturned SB 680. As the composition changes every two years, the Senate majority is currently Democratic (from January 2023 until December 2024), and there is hope that Senate Bill 279 (2023) will pass this time even though its language is identical to Senate Bill 680 (2021). To achieve full practice authority, SB 279 aims to amend the sections of the Public Health Code referring to licensed practical nurses and their scope of practice. The bill suggests expanding the authority of NPs to assess, diagnose, and prescribe, including prescribing controlled substances, without delegation from a physician. Problem Statement The purpose of this policy analysis project is to examine Senate Bill 279 (2023) and the problems it aims to resolve for the Michigan population. The analysis highlights the gaps in healthcare regulation on a state level aligning them with the potential impact of implementing full practice authority for nurse practitioners in Michigan. SB 279 is a much-needed legislation FULL PRACTICE AUTHORITY MICHIGAN 8 to remove outdated barriers to healthcare and improve the population health outcomes. Michigan ranks among the ten states with the strictest regulations for nurse practitioners, prohibiting them from practicing independently according to their full education and training. Currently NPs are legally required to contract with collaborating physicians to be able to provide care, and the cost of this collaboration is unregulated. Physicians have contracts with multiple NPs and charge anywhere between $300-$1,100 monthly while not seeing patients cared for by NPs and often not even located in the same building. Another part of the problem is the lack of the state Nurse Practice Act in Michigan. Instead, nursing practice is dictated by the Public Health Code (MPHC, 1978), which is not keeping up with the current national standards and practices. Under the existing licensing regulations, physicians can employ nurse practitioners to expand their practices. However, despite the often-minimal nature of required supervision, nurse practitioners are not recognized as independent providers. It is also reflected in the existing billing practice as clinics receive 100% reimbursement for physicians’ services and only 85% reimbursement for the same services provided by NPs (Bischof & Greenberg, 2021). Also, NPs’ services are often billed under a physician’s National Provider Identifier (NPI) number to get a higher reimbursement rate, which masks true data on NP provided care and diminishes the role of NPs. Senate Bill 279 aims to amend the Public Health Code sections related to the regulation of NP practice, allowing them full authority to provide high-quality and cost-effective care, therefore improving populations’ health outcomes. This project conducts a comprehensive policy analysis focusing on the implementation feasibility, budgetary implications, and economic considerations associated with SB 279. The examination contextualizes SB 279 within the framework of the current best practices while FULL PRACTICE AUTHORITY MICHIGAN 9 identifying potential legislative gaps. The primary objective of this policy analysis initiative is to address the following pivotal inquiries: To what extent does SB 279 align with the strengths, weaknesses, and existing gaps within the current scope of practice for nurse practitioners? What are the factors that enable or impede the enactment of FPA legislation in Michigan? How can best practices and evidence-based research inform the implementation of FPA for NPs? Based on the review, the project develops recommendations for policy implementation and provides the most recent updates on the status of SB 279 as it is being reviewed. Significance Restrictions on the scope of practice for NPs in Michigan hinder their ability to provide care to the full extent of their certification and education. As mentioned above, Michigan is one of the ten most restrictive states for NPs to practice as the state legislature requires them to contract with supervising physicians and limits the NP’s ability to assess, diagnose, and prescribe. Senate Bill 279, if passed by the state Senate and the House, will allow NPs to practice independently without a state-mandated contract with a supervising physician. Twenty-seven states, the District of Columbia, and two U.S. territories have already recognized FPA for NPs, while Michigan’s current restrictive legislation continues to limit NPs’ ability to practice in the communities where they are needed most. Passing SB 279 will significantly benefit Michigan residents by granting access to an increased number of healthcare providers. Senate Bill 279, if enacted, will address several critical issues in healthcare statewide that affect patient outcomes. The ratio of the population to one provider in Michigan is 765:1 and the ratio of the population to one psychiatrist is 9,371:1 (MDHHS, 2020). Health professional shortages and unequal distribution of providers in urban vs. rural areas are expected to worsen, and the projected need for primary care providers in Michigan by 2025 is estimated at 1,000 FULL PRACTICE AUTHORITY MICHIGAN 10 physicians (HRSA, 2016). According to the U.S. Health Resources and Services Administration, about 3.4 million Michiganders live in a federally designated primary care health professional shortage area where only about 50% of the need for primary care services is met (AANP, 2022). Even greater shortages are among mental health care providers affecting over 5 million people, with less than a third of Michigan population’s needs being met (AANP, 2022). Michigan Primary Care Needs Assessment government report (2020) highlights that with a total population of approximately 10 million people, 2,826,423 Michigan residents are underserved in terms of primary medical care resources and 4,225,899 Michigan residents are underserved in terms of mental health care resources (MDHHS, 2020). Population-to-provider ratios, including mental health providers, presented in the report point to a significant provider shortage that will only exacerbate according to the provider shortage projections. Michigan’s underserved populations are higher than the national average on many key health indicators such as health risk factors, health care access, and preventive services (including hospital stays related to mental health and/or substance use disorder (SUD), population to primary care provider FTE ratio, and population to psychiatrist FTE ratio), and morbidity and mortality indicators. Mental health-related mortality is one of the major public health concerns due to increasing rates of suicide and substance use in Michigan (MDHHS, 2020). The report identifies high-priority health areas such as substance abuse and behavioral health stating that opioid overdose death and suicide rates in Michigan are significantly higher than the national levels at 29.3 drug-induced deaths per 100,000 population. The number of inpatient stays related to mental and/or substance use disorders at 3,675 per 100,000 population in Michigan is also higher than the U.S. total (3,087) (MDHHS, 2020). FULL PRACTICE AUTHORITY MICHIGAN 11 The detrimental effects on the population’s health outcomes due to the rising lack of access to care within the state can be mitigated by updating and streamlining the legislation that would allow NPs to practice independently. Removing the barriers to nurse practitioner practice and enacting Senate Bill 279 into law will improve the key health indicator outcomes for millions of Michiganders. Nurse practitioners are highly qualified clinicians who can help fill the gap by providing high-quality and cost-effective care in underserved, rural, and urban areas (MCNP, 2023). According to the 2022 statewide survey, 75% of Michigan voters support this legislation. Research over the past 50 years has proven that NPs are providing high-quality, safe, and cost-effective care to patients positively affecting population health outcomes in the full practice authority states (AANP, 2023). Domain 2: Policy Analysis Framework The policy analysis project is utilizing the Centers for Disease Control (CDC) policy analytical framework (CDC, 2013) as a methodological approach. The framework has three domains: data collection and assessment, policy analysis, and strategy development. In Domain 1, Step 1 identifies the problem of limited access to health care and high costs due to the lack of full practice authority for nurse practitioners in Michigan. It also provides relevant research and data to support the need for legislative change. In Domain 2, Step 2a describes the policy options focusing on Senate Bill 279 which aims to remove barriers to nurse practitioners’ scope of practice. It also reviews the literature and best practices from other state(s) that have implemented full practice authority. Step 2b assesses the policy options based on their public health impact, feasibility, and economic impact. Step 2c compares and ranks the policy FULL PRACTICE AUTHORITY MICHIGAN 12 alternatives. In Domain 3, a strategy for advancing the adoption of the preferred policy solution is developed. Literature Search Domain 2A: Identify and Describe Policy Options For a policy analysis project traditional literature search in databases such as Cumulative Index for Nursing and Allied Health Literature (CINAHL) and PubMed for peer-reviewed sources would not be conducted due to the topic. Instead, a targeted search was conducted to locate organizations that comment and conduct research on the subject. The core of the current project was comprised of the review and critical analysis of the legislative documents currently informing NPs’ scope of practice in Michigan such as the Michigan Public Health Code, Michigan Senate Bill 0279, Michigan Public Act 499, and Michigan Senate Bill 0680. The most relevant and current literature was identified, and, by utilizing the method of “citation chaining,” additional data, reports, and articles were located among their references to better inform this policy analysis. The list of key literature that has informed this policy analysis is summarized in Table 1 (see Table 1) and includes the following: - Michigan Council of Nurse Practitioners (MICNP) Legislative Task Force White Paper (MICNP, 2021), - Michigan Department of Health & Human Services (MDHHS) official report on primary care needs in Michigan (MDHHS, 2020), - American Association of Nurse Practitioners (AANP) fact sheet on decades of NPs high-quality and cost-effective care (AANP, 2023a), - AANP’s position paper on NPs cost-effectiveness (AANP, 2013), - Full practice authority policy brief by AANP (AANP, 2023b), FULL PRACTICE AUTHORITY MICHIGAN 13 - MICNP’s Talking points for SB 279 (MICNP, 2023), - The United States Health Resources and Services Administration’s (HRSA) state- level projections of supply and demand for behavioral health occupations: 2016-2030 (HRSA, 2018), - Article from the Journal of the American Association of Nurse Practitioners on advanced practice registered nurse practice barriers impacting health care access in Michigan (Sheehan et al., 2021), - Article from Nursing Outlook on the impact of state nurse practitioner scope-of- practice regulation on health care delivery (Xue et al., 2016), - Article from the Journal of Nursing Regulation on full scope-of-practice regulation association with higher supply of nurse practitioners in rural and primary care health professional shortage counties (Xue et al., 2018). Environmental Scan To assess other states’ practices and review how practice authority of NPs is regulated across the United States, an environmental scan was conducted. While the educational and certification requirements are mostly unified throughout the country, it is up to each state to regulate the limits to NP’s practice authority. There are three practice environments based on the scope of practice for NPs: full practice, reduced practice, and restricted practice (see Appendix A). As of April 2024, twenty-seven states, the District of Columbia, and two U.S. territories have already recognized FPA and allow NPs to practice to the full scope of their training without the requirement of a collaborative agreement with a supervising physician (NNCC, 2023). In states that have adopted FPA (Washington, Oregon, Nevada, Arizona, New Mexico, Colorado, Utah, Idaho, and many others) it is within the NP’s scope of practice to evaluate, diagnose, order and FULL PRACTICE AUTHORITY MICHIGAN 14 evaluate testing, prescribe, and manage patients’ treatment without physician’s supervision. According to the American Association of Nurse Practitioners (AANP), full practice is the model recommended by the National Academy of Medicine and the National Council of State Boards of Nursing (AANP, 2023c). Reduced practice environment refers to states where practice laws for NPs limit at least one element of NP practice. Either collaborative agreements with supervising physicians are required or limits exist to settings in which NPs can practice independently. Reduced practice states and the U.S. territories include Wisconsin, Illinois, Indiana, Ohio, Pennsylvania, New Jersey, West Virginia, Kentucky, Arkansas, Louisiana, Mississippi, Alabama, Puerto Rico, the Virgin Islands, and American Samoa. For example, in New Jersey, according to the New Jersey Board of Nursing, NPs are still required to practice under the supervision of a physician. However, the content of a collaborative agreement (“joint protocol”) is not defined by law in detail other than the fact that the document must exist and be reviewed annually (New Jersey Board of Nursing, 2022). States with restricted practice environment (Michigan, California, Texas, Oklahoma, Missouri, Tennessee, South Carolina, North Carolina, Georgia, and Florida (see Appendix A) have laws in place that restrict NPs authority even further. Nurse practitioners are legally required to be supervised by a physician throughout their careers, and face restrictions on performing assessments, diagnosing conditions, and prescribing medications. This strict moderation of NPs’ scope of practice does not allow for NPs to contribute as providers to the full extent of their education and training as well as expand access to care for the patients in Michigan. Most of the states have already implemented FPA for NPs allowing them to assess for best practices. The last state to adopt FPA was Utah: in March 2023, the Utah Governor signed FULL PRACTICE AUTHORITY MICHIGAN 15 Senate Bill 36 into law, “capping a strong bipartisan effort to modernize outdated licensure laws for multiple professions, including NPs” (AANP, 2023, March 16). The new law eliminated a state-mandated collaborative contract with a supervising physician, as well as lifted the limits of prescriptive authority, allowing NPs to practice as independent providers. As the CEO of AANP commented in his statement: “Modernizing licensure laws is a no-cost, no-delay solution to strengthening the health of the nation” (AANP, 2023, March 16). Identify Each state has a specific governing body and legislation to which nurse practitioners are held accountable. In Michigan, nursing licensing and legal regulation is overseen by the Department of Licensing and Regulatory Affairs (LARA) on behalf of the Michigan Board of Nursing. Regarding healthcare professionals, LARA is the agency that issues licenses for Registered Nurses (RNs) and certifications for Advanced Practice Nurses (APRN). Unlike other states with FPA, the Michigan Board of Nursing does not have a Nurse Practice Act to regulate the nursing scope of practice. Instead, the Michigan Public Health Code (Act 368 of 1978) “defines the practice of nursing in Michigan and empowers the Board [of Nursing] to establish qualifications for nurse licensure; to establish standards for education and approve nurse education programs; develop and implement criteria for assurance of continued competency” (Michigan Board of Nursing, 2023). Senate Bill 279 (SB 279), introduced by Senator Jeff Irwin in March 2023, is a bipartisan bill that authorizes FPA for NPs in Michigan by proposing amendments to the Public Health Code. Section17210a of the Michigan Public Health Code, SB 279 suggests that for a certified nurse practitioner it is within the scope of practice to provide comprehensive assessments, “diagnosing, treating, and managing patients with acute and chronic illness and diseases”, FULL PRACTICE AUTHORITY MICHIGAN 16 “ordering performing, supervising, and interpreting laboratory and imaging studies”, “prescribing pharmacological and nonpharmacological interventions and treatments” (Michigan Senate Bill 0279, 2023). A proposed amendment for section 17211a states that an NP may prescribe controlled substances (schedules 2 to 5) without a physician’s supervision and that “only the name of the advanced practice registered nurse […] must be used, recorded, or otherwise indicated in connection with the prescription and only advanced practice registered nurse’s DEA registration number must be used, recorded, or otherwise indicated in connection with the prescription” (SB 0279, 2023). Section 17212 of the Public Health Code notes restrictions for NPs to order complimentary starter doses of controlled substances (schedules 2 to 5), which SB 279 similarly to section 17211a proposes to amend by allowing NPs to order, receive, and dispense without delegation from a physician. For these proposed amendments to take effect, SB 279 must be approved by both the Senate and the House and then signed into law. This policy analysis proposes the comparison of two policy options relevant to NPs’ scope of practice in Michigan: enactment of SB 279 versus maintaining the “status quo”, or no policy change. The evidence from the literature review and environmental scan has informed the analysis and is used to describe the impact of each policy option on public health, feasibility, and economic and budgetary criteria. Describe Enactment of SB 279 Public Health Impact. Voting SB 279 into law would have a significant positive impact on public health. This policy suggests expanding practice authority for NPs allowing them to provide care to patients without physicians’ supervision leading to improved access to care across the state, particularly in underserved areas. Michigan is currently facing several major FULL PRACTICE AUTHORITY MICHIGAN 17 issues in healthcare and population health outcomes, including provider shortage, limited access to care, healthcare disparities, as well as morbidity and mortality that are above the national average. The proposed policy addresses these problems by lifting current practice restrictions on NPs and allowing them to provide care to the full scope of their education and qualifications while increasing the healthcare workforce and enhancing healthcare access for thousands of Michiganders, particularly in medically underserved areas where NPs can positively affect health disparities. Research demonstrates strong evidence in favor of full practice authority implementation, mainly as it increases access to care and addresses healthcare disparities. Evidence indicates that states that have implemented FPA demonstrate the greatest increases in NP primary care provision, including rural and underserved areas (Xue et al., 2016). The United Health Foundation (UHF) has published the 2022 Annual Report - America’s Health Rankings, including state rankings based on social and economic factors, physical environment, behaviors, clinical care, and health outcomes (UHF, 2022). The top five healthiest states include New Hampshire, Massachusetts, Vermont, Connecticut, and Hawaii – all states with either full or reduced practice authority for NPs. Michigan is ranked 29 among those key indicators revealing areas of significant opportunities where NPs can help fill the gaps. According to the literature, FPA for NPs would ensure improved healthcare access for the most vulnerable populations as NPs tend to practice in health professional shortage areas while delivering high-quality and cost- effective care (MICNP, 2023). Evidence suggests that FPA correlates with improved provision of care by NPs in medically underserved areas while restricted practice ties NPs to geographically close supervising physicians thus limiting practice locations (Xue et al., 2016). FULL PRACTICE AUTHORITY MICHIGAN 18 While national healthcare standards are evolving, Michigan remains one of the 10 most restrictive states for NPs to practice with legislation in place that does not fully recognize NP’s education and training. Michigan Council of Nurse Practitioners (MICNP) advocates for practice restrictions to be lifted as FPA would facilitate access to care and expand workforce capacity leading to improved health outcomes for the Michigan population. According to the MICNP Legislative Task Force Paper, stakeholders such as the Federal Trade Commission (FTC), the Robert Wood Johnson Foundation, the Institute of Medicine (now the National Academy of Medicine), the American Association of Retired Persons (AARP), and the National Governors Association (NGA), recommend FPA for NPs (MICNP, 2021). Modernizing the legislation and making NP practice current would reflect key healthcare priorities to expand access to high- quality care, make healthcare more affordable, and invest in public health (MICNP, 2021). Feasibility. The likelihood that the policy can be successfully adopted and implemented is moderate this time around. In 2021 policymakers attempted to expand healthcare access in Michigan by removing the practice restrictions for NPs, but the conservative Republican majority comprising the Health Policy Committee at the time overturned SB 680 (2021). As the composition changes every two years, the Senate majority is currently Democratic (from January 2023 until December 2024), and there is hope that SB 279 (2023) will pass this time even though its language is identical to SB 680 (2021). SB 279 was referred to the Health Policy Committee in April 2023, and the Health Policy Committee hearing was just held on March 20, 2024. However, there is still time until the end of 2024 to get the bill through the legislature. Even though most of the states have already adopted FPA and are experiencing significant improvement based on the key health indicators, there is still significant resistance to lifting restrictions for NPs in Michigan. Conservative political representatives and physicians in FULL PRACTICE AUTHORITY MICHIGAN 19 the state of Michigan are advocating for further limiting NP’s scope of practice. House Bill 4472 (2023) introduced by Representatives Farhat and Mueller proposes to amend the Michigan Public Health Code by placing more barriers to NP’s prescribing authority and limiting their ability to practice through a very strict practice agreement with physicians. This bill is being currently reviewed by the Committee on Health Policy and represents the opposing political forces aiming to counteract the potential strengthening of APRN’s authority in Michigan. Michigan Department of Licensing and Regulatory Affairs (LARA) does not appear to be a proponent of FPA implementation even though it would be financially beneficial, as NPs would have to obtain their controlled substance license (LARA, 2023b). Additional information on the feasibility of SB 279 implementation is limited to news articles that do not provide considerable evidence or deeper insight. Economic and Budgetary Impacts. The economic and budgetary impacts of this policy implementation are minimal as there is very little cost required to enact, implement, and enforce this policy. According to the chief executive officer of AANP, modernizing the scope of practice legislature for NPs is a “no-cost, no-delay solution” to address current healthcare issues and to improve the delivery of high-quality care (AANP, 2023, March 16). Literature also suggests that FPA leads to reduced healthcare expenditures while NP practice restrictions contribute to healthcare costs and generate administrative barriers to care (MICNP, 2021). Studies on the economic impact of NP scope of practice regulations estimate that implementing FPA in one state would save over $700 million over 10 years due to decreased cost of primary care visits. The additional economic impact of implementing the legislation could potentially increase tax revenue and the state’s economic output (Xue et al., 2016). The evidence findings have been FULL PRACTICE AUTHORITY MICHIGAN 20 consistently in favor of implementing an independent NP practice environment leading to cost reduction and improving healthcare access. Cost-saving benefits from allowing NPs to practice independently are significantly greater than the costs associated with policy implementation. For some of the stakeholders such as LARA, allowing FPA would generate an additional $260 per NP every 2-3 years for a controlled substance individual license (LARA, 2023b). For example, in New York where NPs are not required to have a collaborative agreement with a supervising physician, NP’s must obtain authorization to prescribe controlled substances from the New York State Department of Health (a separate form from a Federal Drug Enforcement Administration (DEA) Number) (NYSED, 2023). The enactment of the SB 279 policy option in Michigan would contribute to the local government budget while requiring no costs to implement. Adopting FPA would be financially more beneficial for healthcare organizations and patients as well compared to restricted NP practice. According to research on NP practice outcomes, NPs are providing equivalent or improved medical care at lower cost compared to medical doctors, while academic preparation costs of NPs as well as NP compensation compared to physicians comprise significant cost savings (AANP, 2013). Based on measures of productivity, salaries, and education costs, patient visits cost is reduced when NPs can provide care independently. Findings also point to additional cost savings due to NP cost-effectiveness that is associated with decreased length of hospital stay, hospital readmissions, prescription costs, illness prevention, and health promotion (AANP, 2013; AANP, 2023a). “Status Quo” / No policy change Public Health Impact. Based on the reviewed evidence, the “status quo” policy option will not be able to address current healthcare problems. On the contrary, it will continue to FULL PRACTICE AUTHORITY MICHIGAN 21 negatively affect public health in Michigan along with quality of life, healthcare disparities, morbidity, and mortality. The “status quo” will not improve access to care as NPs would not be able to practice independently while working under physician supervision (thus workforce will not be expanded). With the worsening provider shortage trend in Michigan, the appointment wait time would only increase and some remote areas’ populations would become even more underserved. According to research, health professional shortages and unequal distribution of providers in urban vs. rural areas are expected to worsen, and the projected need for primary care providers in Michigan by 2025 is estimated at 1,000 physicians (HRSA, 2016). A delay in expanding FPA negatively affects healthcare resources due to provider shortages, an aging population, and an increased need for primary care (Chattopadhyay & Zangaro, 2019). No policy change will exacerbate the existing issues and block the opportunity for improvement. Feasibility. The feasibility of no policy change option being implemented is rated as “high” because maintaining the “status quo” is less challenging than any policy implementation. In addition, there is a strong presence of conservative political forces in Michigan who impede SB 279 implementation by advocating against it on the Michigan State Medical Society website claiming that it would undermine the quality of care “by removing physicians from patient care teams” (MSMS, 2023). Furthermore, there is an opposing HB 4472 (“physicians’ bill opposing NPs prescribing authority) that was introduced in April 2023. Its goal is to further restrict NP’s scope of practice and reinforce physicians’ authority in the state through detailed and strict collaborative agreement requirements. Considering that both SB 279 and HB 4472 were introduced in spring 2023 and referred to the Health Policy Committee, no policy change appears to be the most feasible option in the short term. The composition of the Health Policy Committee will change after December 2024 and most likely will become more conservative which would FULL PRACTICE AUTHORITY MICHIGAN 22 significantly decrease the chances of FPA implementation if SB is not approved before that date. With the “status quo” remaining in place for at least 6 more months, current issues in Michigan healthcare will continue to deepen and further negatively impact the population’s health outcomes. Economic and Budgetary Impacts. The economic and budgetary impacts of the “status quo” option, on the one hand, have no implementation costs (since there is no change), but, on the other hand, will most certainly entail the healthcare costs to increase long term. One example of the costs associated with maintaining the “status quo” stems from the provider shortage in Michigan as underserved areas (particularly rural regions) show higher rates of chronic diseases along with higher costs of care associated with them (MICNP, 2023). Physicians’ compensation, high readmission rates, longer hospital stays, lack of prevention care, and other current issues will persist if nothing is done to amend the legislation. FPA policy advocates have been referring to the “status quo” as an “outdated” and “outlived” practice, which requires modernization and urgent change in practice. Domain 2B: Assess Policy Options The assessment of the two policy options is adapted from the CDC’s Policy Analytical Framework (see Table 2). Each option is evaluated based on its effects on public health, feasibility of implementation, and economic and budgetary impacts and is assigned low, medium, or high ratings. Both options, the enactment of SB 279 and the “status quo”, scored high in public health impact indicating large reach, size effect, and impact on populations. Adopting FPA has proven potential to improve the key health indicators and most importantly access to care, while no change option will continue to facilitate currently existing negative trends in Michigan healthcare. Nevertheless, the “status quo” option appears to be more a FULL PRACTICE AUTHORITY MICHIGAN 23 feasible choice as there has not yet been any significant progress in the adoption of SB 279. The likelihood of SB 279 enactment is moderate to low: on one hand, there is strong evidence and stakeholder support for FPA implementation, but on the other hand, the process is extremely slow (it takes months to review a bill) and there is push back from conservative leaders favoring physicians’ vs NPs’ dominance in the field. Finally, the economic and budgetary impact of either policy option presents more evidence in support of SB 279 enactment. In terms of budget impact, while the information on the exact implementation of SB 279 is lacking, there is no reason to assume high costs if it is implemented. And even though it costs less to maintain the “status quo”, no change option is still less favorable about the economic impact since the state would miss out on FPA long-term benefits and end up spending more towards worsening healthcare issues and trends. Domain 2C: Prioritize Policy Options Based on this policy assessment between two possible courses of action regarding FPA in Michigan (see the ratings assigned in Table 2), it appears that implementing SB 279 is the most beneficial option for improving current healthcare trends in Michigan. Despite the “status quo” option being more feasible and requiring no immediate costs to implement, it is the public health impact and the economic impact that carry more weight in the overall analysis. When comparing the enactment of SB 279 with the “status quo”, the public health impact in both cases is very significant. However, based on the literature, available data, and encouraging experience in the states that have already adopted FPA, public health is much more likely to be positively affected by SB 279 implementation, whereas no change would have a negative effect. Access to care, provider shortage, cost of healthcare, healthcare disparities, preventative care, morbidity, and mortality trends – all these issues can be addressed and FULL PRACTICE AUTHORITY MICHIGAN 24 improved by implementing SB 279 and allowing NPs to independently provide care to patients in Michigan. The “status quo” option does not address state-wide urgent and emerging healthcare concerns. No change in current legislation would facilitate and deepen the existing issues and negative trends as well as allow for the continuous deterioration of the state population’s healthcare outcomes. The implementation of the SB 279 policy option is also prioritized in this paper based on its economic impact, which is more favorable compared to the “status quo” option. Looking at the costs to implement relative to the benefits of implementing, it is more likely the adoption of FPA would be more advantageous. It is recommended that SB 279 be implemented to address the current issues in healthcare and to improve health outcomes for the Michigan population. Domain 3: Strategy and Policy Development According to the CDC’s Policy Analysis Framework, once the policy solution has been prioritized, the next step is to define a strategy for getting the policy enacted and implemented (CDC, 2013). This would include clarifying operational issues, identifying stakeholders, and sharing relevant information, as well as conducting additional analysis to support the process of adoption, implementation, and evaluation. SB 279 was introduced in early 2023 and it has until the end of December 2024 to get approved by the Senate Health Policy Committee, the full Senate, the House Policy Committee, the full House, and the Governor to become a law (see Appendix C). The Senate Health Policy Committee hearing occurred on March 20, 2014, and the vote is expected to happen this month. Per the interview with Karla Ruest, the lobbyist for SB 279, the plan is to hold individual in- person meetings with each Senator on the Committee to see if the bill has enough support for a vote. The Senators have just returned from a two-week break, so the meetings are expected to FULL PRACTICE AUTHORITY MICHIGAN 25 happen in mid-April. This Committee is comprised of 6 Democrats and 4 Republicans, and unlike the same Committee in 2021 (which was mostly Republican), it is more likely to approve SB 279 with the majority of the votes. If approved by the Senate Health Policy Committee, SB 279 would need to get at least 19 votes in the full Senate to move on to the House Committee. According to the lobbyist, they are planning to meet with the House Health Policy Committee Chair to discuss if she “would give the bill a fair shot” as she might be strongly opposed to SB 279 and expanding the scope of practice. In case she is opposed, the bill can be sent to another House Committee (Regulatory Affairs or Labor) with the approval of the Speaker of the House. To get SB 279 through the Senate and the House, some additional stakeholders’ support is needed. One of the current goals is to get the unions on board to exert “pressure” on the Democrats in the House to support the bill. The American Federation of Labor and Congress of Industrial Organizations (AFL-CIO) is the largest federation of unions in the United States and would solidify the Democrats even more to vote in favor of FPA. The lobbyist has already reached out to the AFL-CIO, and, with help from the Nurses Union, they are currently gathering members’ votes to support SB 279. Gaining the favor of this powerful union would provide a solid foundation to secure a win in the house. Another important stakeholder - Mackinac Center for Public Policy – is already supporting SB 279 and, according to the lobbyist, able “to put pressure” on Republicans. Finally, the Michigan Catholic Conference might step in as well to support SB 279 (pro-life and Republican legislators will then be informed), which would put to rest the concerns regarding the risk of an abortion rate increase with FPA. To enact SB 279 by having it approved in both the Senate and the House, it is crucial to have all issues addressed and all agendas looked at. Relevant information must be shared to alleviate concerns, disprove opponents, and gain allies. The lobbyist will meet with the FULL PRACTICE AUTHORITY MICHIGAN 26 legislators and present more studies to counteract physicians’ arguments and overcome existing misconceptions regarding FPA (for example, opioid overprescribing). Conclusion As Michigan continues to hold on to the outdated healthcare practice regulations set in the 1970s that do not meet current needs and challenges, the population as well continues to endure the consequences of provider restrictions as nurse practitioners are not allowed to fill the gaps that states with full practice authority have filled. FPA for NPs in Michigan is essential for enhancing access and ensuring high-quality care, protecting patient safety, reducing healthcare costs, and offering patients a choice. Senate Bill 279 presents an opportunity to benefit the Michigan population and improve provider access, cost per visit, and overall health outcomes across the state by allowing NPs to practice to the full scope of their education and training. Most of the states have already implemented FPA for NPs, and research confirms that FPA has a significant positive impact on public health. With the current Michigan health statistics that are below the national average as well as poor projections going forward, SB 279 has a chance to change the course: to have NPs provide independent care therefore increasing the healthcare workforce and improving provider access (instead of NPs leaving Michigan and move to the states with FPA), to address healthcare disparities and reach underserved areas (instead of NPs staying where the physicians are due to the supervision requirement), and offer cost-effective and high-quality care. The policy analysis of SB 279 in the context of the current healthcare landscape in Michigan has pointed out multiple advantages of enacting this bill into law as opposed to the status quo. While there are only eight months left to get the votes in for FPA approval in both the Senate and the House, it is still feasible. As the process is still ongoing, the policy analysis will FULL PRACTICE AUTHORITY MICHIGAN 27 continue as the hearings occur. In December 2024 it will be clear if Michigan legislators are ready to move forward with FPA or if the state remains restricted for NPs to practice. FULL PRACTICE AUTHORITY MICHIGAN 28 References American Association of Nurse Practitioners (AANP). (2023a). Nurse Practitioners: decades of high-quality, cost-effective care. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cdn.ymaws.com/micnp.org/resour ce/resmgr/full_practice_authority/Cost_Effectiveness_1_pager_u.pdf American Association of Nurse Practitioners (AANP). (2013). Nurse Practitioner cost effectiveness. https://www.aanp.org/advocacy/advocacy-resource/position- statements/nurse-practitioner-cost-effectiveness American Association of Nurse Practitioners (AANP). (2023b). Issues at a glance: full practice authority. https://www.aanp.org/advocacy/advocacy-resource/policy-briefs/issues-full- practice-brief American Association of Nurse Practitioners (AANP). (2023c). State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment American Association of Nurse Practitioners (AANP). (2023, March 16). Utah’s New Law Will Improve Patients’ Health Care Access. https://www.aanp.org/news-feed/utahs-new-law- will-improve-patients-health-care-access Bischof, A., Greenberg, S.A. (2021). Post COVID-19 Reimbursement Parity for Nurse Practitioners. OJIN: The Online Journal of Issues in Nursing 26(2). https://doi.org/10.3912/OJIN.Vol26No02Man03 Centers for Disease Control. (2013). CDC’s policy analytical framework. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/policy/paeo/process/ docs/CDCPolicyAnalyticalFramework.pdf Chattopadhyay, S., & Zangaro, G. (2019). The Economic Cost and Impacts of Scope of Practice FULL PRACTICE AUTHORITY MICHIGAN 29 Restrictions on Nurse Practitioners. Nursing Economic$, 37(6), 273–283. Citron-Fink, R. (2022). How bills become laws in your state. Moms clean air force. https://www.momscleanairforce.org/how-bills-become-laws-in-your-state/ Leach, B., Gradison, M., Morgan, P., Everett, C., Dill, M. J. & Strand de Oliveira, J. (2018). Patient preference in primary care provider type, Healthcare 6(1), 13-16. https://doi.org/10.1016/j.hjdsi.2017.01.001 Michigan Board of Nursing. (2023). Governor Gretchen Whitmer. https://www.michigan.gov/whitmer/appointments/oma/all/2/michigan-board-of- nursing#:~:text=The%20Michigan%20Public%20Health%20Code,continued%20compet ency%3B%20and%20take%20disciplinary Michigan Council of Nurse Practitioners (MICNP). (2021). Legislative task force white paper. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cdn.ymaws.com/micnp.org/resour ce/resmgr/full_practice_authority/micnp_legislative_white_pape.pdf Michigan Council of Nurse Practitioners (MICNP). (2023). Talking points for SB 279. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cdn.ymaws.com/micnp.org/resour ce/resmgr/full_practice_authority/2023/Talking_Points_SB279_for_att.pdf Michigan Department of Health & Human Services (MDHHS). (2020). Michigan primary care needs assessment. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.michigan.gov/- /media/Project/Websites/mdhhs/Folder4/Folder27/Folder3/Folder127/Folder2/Folder227/ Folder1/Folder327/Michigan_Primary_Care_Needs_Assessment.pdf?rev=98f8bb196744 456191267b6f4583b5b6 FULL PRACTICE AUTHORITY MICHIGAN 30 Michigan Department of Licensing and Regulatory Affairs (LARA). (2023a). https://www.michigan.gov/lara/about Michigan Department of Licensing and Regulatory Affairs (LARA). (2023b). Michigan Controlled Substance Individual Licensing Guide. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.michigan.gov/- /media/Project/Websites/lara/bpl/Pharmacy/Licensing-Info-and-Forms/Info/Controlled- Substance-Individual-Licensing-Guide.pdf?rev=c6ef0fd21700464b88564b6bad216255 Michigan Public Act 499. (2016). Act No. 499: Public Acts 2016. https://www.legislature.mi.gov/documents/2015-2016/publicact/pdf/2016-PA-0499.pdf Michigan Public Health Code (MPHC). (1978). http://www.legislature.mi.gov/(S(pyxcs3cxblje1be2oqcoej2s))/mileg.aspx?page=getObje ct&objectName=mcl-333-17048 Michigan Senate Bill 0279. (2023). Michigan legislature. http://legislature.mi.gov/doc.aspx?2023-SB-0279 Michigan Senate Bill 0680. (2021). Michigan legislature. http://legislature.mi.gov/doc.aspx?2021-SB-0680 Michigan State Medical Society (MSMS). (2023). Engage. https://www.msms.org/Advocacy/Engage National Council of State Boards of Nursing (NCSBN). (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf National Nurse-Led Care Consortium (NNCC). (2023). Full practice authority. https://nurseledcare.phmc.org/advocacy/full-practice-authority.html FULL PRACTICE AUTHORITY MICHIGAN 31 New Jersey Board of Nursing. (2022). New Jersey Administrative Code, Title 13, Law and Public Safety Chapter 37. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.njconsumeraffairs.gov/regul ations/Chapter-37-New-Jersey-Board-of-Nursing.pdf New York State Education Department Office of the Professions (NYSED). (2023). Prescription Privileges. https://www.op.nysed.gov/professions/nurse-practitioners/practice- issues/prescription-privileges Sheehan, A., Jones, A., McNerlin, C., Iseler, J. & Dove-Medows, E. (2021). How advanced practice registered nurse practice barriers impact health care access in Michigan. Journal of the American Association of Nurse Practitioners, 33(9), 739-745. doi:10.1097/JXX.0000000000000443 United Health Foundation. (2022). Annual report: America’s health ranking report. https://www.americashealthrankings.org/learn/reports/2022-annual-report United States Bureau of Labor Statistics (BLS). (2022). Occupational employment and wage statistics: 29-1171 Nurse Practitioners. https://www.bls.gov/oes/current/oes291171.htm United States Health Resources and Services Administration (HRSA). (2018). State-level projections of supply and demand for behavioral health occupations: 2016-2030. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://bhw.hrsa.gov/sites/default/files/bu reau-health-workforce/data-research/state-level-estimates-report-2018.pdf United States Health Resources and Services Administration (HRSA). (2016). State-level projections of supply and demand for primary care practitioners: 2013-2025. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/primary- FULL PRACTICE AUTHORITY MICHIGAN 32 care-stateprojections2013-2025.pdf Xue, Y., Kannan, V., Greener, E., Smith, J. A., Brasch, J., Johnson, B. A., & Spetz, J. (2018). Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties. Journal of Nursing Regulation, 8(4), 5–13. https://doi-org.proxy2.cl.msu.edu/10.1016/S2155-8256(17)30176-X Xue, Y., Ye, Z., Brewer, C., & Spetz, J. (2016). Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review. Nursing Outlook, 64(1), 71-85. http://dx.doi.org/10.1016/j.outlook.2015.08.005 FULL PRACTICE AUTHORITY MICHIGAN 33 Table 1 Literature Review Table Title / Author(s) Journal / Organization Design Data Source Results related to FPA Improving Access to Health Care in Michigan through Full Practice Authority for Nurse Practitioners (2021) Grace A. Jacek, Barbara C. Jaquith, Ann P. Sheehan, Denise Soltow Hershey Michigan primary care needs assessment (2020) Michigan Council of Nurse Practitioners (MICNP) Legislative Task Force White Paper American Association of Nurse Practitioners’ data and reports; publication in The Journal of Nurse Practitioners, Nursing Economics, Nursing Outlook; government reports (U.S. Department of Health and Human Services, United Health Foundation, U.S. Health Resources and Services Administration) Policy and Planning Administration Michigan Department of Health & Human Services (MDHHS) Government report Official government reports and data (U.S. Census Bureau, CDC, MDHHS, etc.) and other data reports MICNP calls for Michigan legislators to modernize statutes to adopt and authorize FPA for NPs in all healthcare settings, permanently. MICNP is offering clear guidance in this policy initiative to aid policymakers with meeting the healthcare needs of Michigan residents. FPA will improve patient health outcomes and strengthen Michigan’s economic recovery by increasing our healthcare workforce availability, efficiency, effectiveness, and flexibility to address health care disparities. A comprehensive and informative view of Michigan’s vulnerable populations, unmet health care needs, health disparities, and health workforce issues in the state. This report provides a statewide overview of Michigan as well as highlighting certain areas, counties, and cities with areas of concern, workforce shortages, and barriers to access health care. Nurse Practitioners: decades of high-quality, cost-effective care (2023) American Association of Nurse Practitioners (AANP) Fact sheet Research articles from Journal of the American Association of Nurse Practitioners, Health Services Research, Medical Care, Nursing Outlook, Journal of Health Economics, and Journal of Nursing Regulation States that NPs are a proven solution to our nation’s increasing need for accessible, person- centered health care. Over the last 50 years, NPs have been one of the most frequently studied health care providers. Those research outcomes show a solid track record of NPs providing high- quality, cost-effective care to patients. Policy Implications Evidence in support of full practice authority implementation in Michigan Evidence in support of FPA implementation in Michigan as NPs can address highlighted issues Evidence in support of FPA implementation in Michigan FULL PRACTICE AUTHORITY MICHIGAN Nurse Practitioner cost effectiveness (2013) American Association of Nurse Practitioners (AANP) Position paper Research articles from Journal of the American Association of Nurse Practitioners, Journal of the American Geriatrics Society, Nursing Economics, Journal of Occupational and Environmental Medicine, Journal of Nursing Administration, Journal of Rural Health, Nursing Management Highlights that NPs are a proven response to the evolving trend towards wellness and preventive health care driven by consumer demand. A solid body of evidence demonstrates that NPs have consistently proven to be cost-effective providers of high-quality care for almost 50 years. NP cost effectiveness is not dependent on actual practice setting and is demonstrated in primary care, acute care and long-term care settings. Issues at a glance: full practice authority (2023) American Association of Nurse Practitioners (AANP) Policy brief References not listed Describes FPA impact, including improved access to care, more efficient care delivery, lower costs, patient choice protection. Talking points for SB 279 (2023) Michigan Council of Nurse Practitioners (MICNP) Talking points References not listed States that full scope of NPs in Michigan prioritizes patient care needs, helping to relieve the shortage of heath care providers and benefitting all Michigan residents. Highlights that: - Michigan has a shortage of physicians - Michigan is one of the most restrictive states for NP practice - Nurse Practitioners will help fill the gap - Significant support exists for full practice authority 34 Evidence in support of FPA implementation in Michigan Evidence in support of FPA implementation in Michigan Evidence in support of FPA implementation in Michigan State-level projections of supply and demand for behavioral health occupations: 2016-2030 (2018) U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Workforce National Center for Health Workforce Analysis (HRSA) Government report Substance Abuse and Mental Health Services Administration’s (SAMHSA) Behavioral Health report, U.S. Bureau of Labor Statistics data, Bureau of Health Workforce data, and article from American Psychiatric Nurses Association Points to a shortage of primary care providers in both rural and urban areas: the projected need for primary care providers in Michigan by 2025 is estimated at 1,000 physicians Evidence in support of FPA implementation in Michigan FULL PRACTICE AUTHORITY MICHIGAN Journal of the American Association of Nurse Practitioners Literature review Nursing Outlook Systematic review Journal of Nursing Regulation Longitudinal data analyses How advanced practice registered nurse practice barriers impact health care access in Michigan. (2021) Sheehan, A., Jones, A., McNerlin, C., Iseler, J. & Dove-Medows, E. Impact of state nurse practitioner scope-of- practice regulation on health care delivery (2016) Xue, Y., Ye, Z., Brewer, C., & Spetz, J. Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties (2018) Xue, Y., Kannan, V., Greener, E., Smith, J. A., Brasch, J., Johnson, B. A., & Spetz, J. AANP articles, MICNP, Bipartisan Policy Center, Institute of Medicine, Michigan Public Health Code, National Council of State Boards of Nursing (NCSBN), Nursing Outlook Journal, Health Economics Review, Journal of Nursing Regulation States that APRNs could help reduce the state’s health care shortage, as the care they provide is safe, cost effective, and high quality. Michigan’s APRN practice restrictions limit these professionals from autonomously providing care to the underserved and rural populations that need them the most. Eliminating the restrictive practice environment in Michigan will give citizens better access to primary care. 35 Evidence in support of FPA implementation in Michigan AANP articles, Harvard Heath Policy Review, National Academy for State Health Policy, National Council of State Boards of Nursing, Journal of Regulatory Economics, Nursing Outlook, Health Affairs, U.S. Department of Health and Human Services Confirms that states granting NPs greater scope of practice (SOP) authority tend to exhibit greater care provision by NPs and expanded healthcare utilization, especially among rural and vulnerable populations. Review findings show promise that removing restrictions on NP SOP regulations could be a viable and effective strategy to increase primary care capacity. Evidence in support of FPA implementation in Michigan AANP articles, Harvard Heath Policy Review, Journal of the American Medical Association, Health Services Research, National Association of Community Health Centers, National Council of State Boards of Nursing, CDC, U.S. Department of Health and Human Services Confirms that state full SOP regulation was associated with higher NP supply in rural and primary care HPSA counties. Regulation plays a role in maximizing capacity of the NP workforce in these underserved areas, which are most in need for improvement in access to care. Evidence in support of FPA implementation in Michigan FULL PRACTICE AUTHORITY MICHIGAN 36 Table 2 Policy Options Assessment Table CRITERIA PUBLIC HEALTH IMPACT FEASIBILITY ECONOMIC AND BUDGETARY IMPACT Scoring Definitions Low: small reach, effect size, and impact on disparate populations Low: No/small likelihood of being enacted Less favorable: High costs to implement. Less favorable: costs are high relative to benefits. Medium: small reach with large effect size or large reach with small effect size High: large reach, effect size, and impact on disparate populations Medium: Moderate likelihood of being enacted Favorable: Moderate costs to implement High: High likelihood of being enacted More favorable: Low costs to implement Favorable: costs are moderate relative to benefits (benefits justify costs) More favorable: costs are low relative to benefits BUDGET ECONOMIC Enactment of SB 279 □ Low □ Medium X □ High □ Low X □ Medium □ High □ Less favorable □ Less favorable X □ Neutral □ Neutral □ More favorable X □ More favorable Concerns about the amount or quality of data? (Yes / No) Concerns about the amount or quality of data? (Yes / No) Concerns about the amount or quality of data? (Yes / No) Concerns about the amount or quality of data? (Yes / No) “Status Quo” No policy change □ Low □ Medium X □ High □ Low □ Medium X □ High □ Less favorable X □ Less favorable □ Neutral □ Neutral X □ More favorable □ More favorable Concerns about the amount or quality of data? (Yes / No) Concerns about the amount or quality of data? (Yes / No) Concerns about the amount or quality of data? (Yes / No) Concerns about the amount or quality of data? (Yes / No) Note. Adapted from Centers for Disease Control. (2013). CDC’s policy analytical framework. chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/policy/paeo/process/docs/CDCPolicyAnalyticalFramework.pdf FULL PRACTICE AUTHORITY MICHIGAN 37 State Practice Environment Appendix A Note. Adapted from American Association of Nurse Practitioners. (2023c). State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment FULL PRACTICE AUTHORITY MICHIGAN 38 Timeline of Full Practice efforts in Michigan Appendix B 2016 2021 2023 Public Act 499 (Introduced as House Bill 5400) Passed both the House and the Senate Senate Bill 680 Senate Bill 279 Blocked by the Health Policy Committee Currently being reviewed by the Health Policy Committee FULL PRACTICE AUTHORITY MICHIGAN 39 How a bill becomes a law Appendix C Note. Adapted from Citron-Fink, R. (2022). How bills become laws in your state. Moms clean air force. https://www.momscleanairforce.org/how-bills-become-laws-in-your-state/