Practice Notes

Are you getting the most out of your nurse practitioners?

Tiffany Chan

As the physician shortage continues to grow, medical groups across the country are hiring more nurse practitioners (NPs) with the hope of expanding patient access to high-quality, lower-cost care.

However, state regulations on NP practice can be an obstacle to effective NP utilization.

In some states, these laws can reinforce physician resistance and impose geographic and scope-of-practice restrictions that needlessly limit groups' ability to deploy NPs. In addition, organizations in restrictive states may struggle to attract NPs in sufficient numbers.

Medical groups in restrictive states can take three initiatives to offset the impact of state laws on NP recruitment and utilization.

Steps to Maximize NP Utilization

NP Utilization

Optimize NP role within the group

Eliminate unnecessary internal restrictions.

Many medical groups have led the charge on updating health system bylaws and organizational policies that lag several years behind state law, imposing added restrictions on NPs.

  • At the University of Mississippi Medical Center, a standing committee regularly reviews hospital bylaws and regulations to ensure that NPs perform to the maximum extent of the law. With many states considering change to NP laws, UM’s choice to monitor the legislative climate will likely pay off.

Relaxing internal restrictions may raise concern among physicians, particularly in states that allow NPs to practice independently. However, such states often require higher standards of NP clinical preparation.

  • In Vermont, NPs with fewer than two years of experience must have a formal collaborative agreement with an NP or physician. Medical groups can emphasize these state policies, as well as invest in internal resources to ensure that NPs are clinically prepared to work more autonomously.

Elevate NPs within the organization to compensate for reduced autonomy.

To counteract the effect of restrictive state laws on local NP practice, medical groups can elevate the status of NPs by:

  • Working with physicians and other practice staff to maximize NP clinical autonomy
  • Designing more competitive NP employment contracts and compensation packages
  • Engaging NPs in medical group governance and leadership

Ease the supervision burden

Use technology to facilitate supervision compliance.

Medical groups using electronic medical records can facilitate physician compliance with review requirements by automating the delivery of NPs’ charts to physicians. Groups can also leverage telemedicine to give NPs quick access to physician consultation.

Counteract external restrictions

Seek exemptions from state law.

Medical groups often have negotiating power in the face of state regulations. For example, although Wisconsin state regulations deny NPs admitting privileges, Ministry Medical Group obtained a waiver allowing NPs to admit, discharge, and manage patients at a rural hospital.

To learn more about Ministry’s model, see our webconference.

Negotiate with payers to remove NP restrictions.

Even when state laws are relatively permissive, payers may restrict NP practice by offering NPs lower rates than physicians, reimbursing them for fewer services, and denying them status as primary providers and direct billers. Groups should work with payers to remove these restrictions, highlighting NPs’ impact on quality improvement and cost reduction.

Learn More

For more information on how state regulations can impact NP utilization, see our related guide.

Has your group effectively worked with the state to facilitate your NP utilization strategy? Tell us your story by writing to