Antitrust Law Daily Wrap Up, ANTITRUST NEWS: FTC Staff Issues Letter Supporting Removal of Connecticut Nurse-Physician Collaboration Requirement, (Mar 19, 2013)

By Tobias J. Gillett, J.D., LLM.

The staffs of the FTC’s Office of Policy Planning, Bureau of Competition, and Bureau of Economics have sent a letter to Connecticut State Representative Theresa W. Conroy, expressing their support for a Connecticut House of Representatives bill that would remove restrictions on the ability of Advanced Practice Registered Nurses (APRNs) to treat patients without a collaboration agreement with a physician, in the absence of evidence that APRN practice presented safety concerns.

Under current Connecticut law, APRNs must “collaborate with a physician licensed to practice medicine in [Connecticut]” before they may diagnose, treat, and provide medications for their patients, although they only require a written collaboration agreement if they intend to prescribe medication. Connecticut House Bill 6391 would rescind this collaborative practice requirement.

Although the letter recognized that professional licensure requirements can help ensure patient safety, the FTC staff noted that HB 6391 could provide benefits stemming from increased competition, “including improved access to care, lower costs, and increased options.” While Connecticut as a whole has adequate numbers of physicians for present needs, Connecticut has 39 federally designated Health Professional Shortage Areas (HPSAs), and increases in insurance coverage could place more strain on the supply of physicians, the FTC staff observed.

Therefore, APRNs could help alleviate access problems, according to the FTC staff. APRNs represent “a greater share of the primary care workforce in less densely populated, less urban, and lower income areas, as well as in federally-designated HPSAs,” and are more likely to care for minority patients, Medicaid beneficiaries, and uninsured patients. Moreover, evidence indicated that APRNs may prefer to practice in areas that permit independent practice, meaning Connecticut could benefit from a growth in the number of APRNs in the state.

Furthermore, the FTC staff noted that removing collaboration requirements from APRNs could lead to lower costs and greater options for healthcare consumers. APRNs typically provide their services at lower cost than physicians, and provide care in a broader variety of health care settings. To the extent that APRNs must pay physicians in exchange for their agreement to collaborate, the APRNs may be compensating the physicians “for the potential loss of income some physicians believe may occur as a result of APRNs’ entry into the primary care marketplace,” a practice that would raise health care costs and reduce the number of APRNs without improving the quality of care. The FTC staff cited examples of the difficulty and costs faced by APRNs in finding a physician willing to collaborate, and APRNs’ significant role in expanding the variety of settings in which consumers could obtain health care, such as retail clinics.

The FTC staff also addressed the potential health and safety consequences of the legislation, stating that it was “unclear” whether the collaboration requirement provided any additional patient protection. The FTC staff cited research from the Institute of Medicine and the National Governors Association finding that “[n]o studies suggest that care is better in states that have more restrictive scope-of-practice regulations for APRNs than in those that do not,” and that “[m]ost studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures.” The FTC staff noted that HB 6391 did not change any other aspects of APRN practice, credentialing, or oversight.

“Maintaining an unnecessary and burdensome requirement is likely to deprive consumers of the benefits that increased competition can provide,” the letter concluded. “Absent countervailing safety concerns regarding APRN practice, HB 6391 appears to be a procompetitive improvement in the law that would benefit Connecticut health care consumers.”

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