FTC Staff Letter to the Honorable Theresa W. Conroy, Connecticut House of Representatives, Concerning the Likely Competitive Impact of Connecticut House Bill 6391 on Advance Practice Registered Nurses

Office of Policy Planning
Bureau of Competition
Bureau of Economics
March 19, 2013
The Honorable Theresa W. Conroy
Connecticut State Representative
105th Assembly District
Legislative Office Building, Rooom 4113
Hartford, CT 06106-1591
Dear Representative Conroy:
The staffs of the Federal Trade Commission’s Office of Policy Planning, Bureau
of Competition, and Bureau of Economics1 appreciate the opportunity to respond to your
invitation for comments on the likely competitive impact of Connecticut House Bill 6391
(“the Bill” or “HB6391”).2 Current Connecticut law requires that an Advanced Practice
Registered Nurse (“APRN”) have a collaborative practice arrangement with a physician
before the APRN may offer health care services within his or her established scope of
practice. No written agreement is required, unless the APRN will be prescribing
medications. The Bill would remove the collaborative practice requirement and allow
APRNs to diagnose, treat, and prescribe medications for their patients in accordance with
their licensed scope of practice without a collaboration arrangement or agreement with a
physician.
Recent reports by the Institute of Medicine (“IOM”) have identified a key role for
advanced practice nurses in improving the delivery of health care.3 The IOM, established
in 1970 as the health arm of the National Academy of Sciences, provides expert advice to
policy makers and the public and has conducted an intensive examination of issues
surrounding advanced nursing practice. Among other things, the IOM found that
advanced practice nurses play a key role in improving access to health care and that
“[r]estrictions on scope of practice . . . have undermined [nurses’] ability to provide and
improve both general and advanced care.”4
Similarly, in December 2012, the National Governors Association (NGA) issued a
paper exploring the potential role of APRNs in addressing increased demand for primary
care services, particularly in historically underserved areas.5 The report noted, among its
findings and conclusions, that APRNs “may be able to mitigate projected shortages of
primary care services [and that e]xisting research suggests that NPs can perform a subset
of primary care services as well as or better than physicians.”6
UNITED STATES OF AMERICA
FEDERAL TRADE COMMISSION
WASHINGTON, D.C. 20580

It is our understanding that the current collaborative practice requirements can be
costly to APRNs, assuming they can even find a physician willing to collaborate.7 As a
result, the requirement is likely to increase the price and limit the availability of APRN
care. Although overall Connecticut appears to have adequate numbers of primary care
providers for current needs,8 there are shortages in specific areas and for specific
populations (e.g., rural and low income patients in urban areas), and shortages are
expected to develop or worsen as more Connecticut consumers gain health coverage and
seek access to primary health care services.9 By eliminating the APRN collaboration
requirement, the Bill may improve access and consumer choice for primary care services,
especially for rural and other underserved populations, and may also encourage beneficial
price competition that could help contain health care costs. Of course, FTC staff
understand that collaboration between APRNS and other healthcare providers are often
beneficial to patients, and are not suggesting that such collaboration should be limited.
Rather, staff are suggesting that collaboration does not necessarily require direct
supervision by or accountability to another licensed health care provider.10
Given the potential benefits of eliminating unwarranted impediments to APRN
practice, we recommend that the Connecticut legislature seek to ensure that statutory
limits on APRNs are no stricter than patient protection requires. FTC staff do not offer
advice on appropriate standards for patient care and safety, but we encourage the
legislature to carefully consider available safety evidence on APRN practice in
Connecticut and elsewhere. Absent a finding there are countervailing safety concerns
regarding APRN practice, HB6391 appears to be a procompetitive improvement in the
law that would benefit Connecticut health care consumers.
I. 	INTEREST AND EXPERIENCE OF THE FTC
The FTC is charged under the FTC Act with preventing unfair methods of
competition and unfair or deceptive acts or practices in or affecting commerce. 11
Competition is at the core of America's economy, 12 and vigorous competition among
sellers in an open marketplace gives consumers the benefits of lower prices, higher
quality products and services, more choices, and greater innovation. Because of the
importance of health care competition to the overall economy and consumer welfare,
anticompetitive conduct in health care markets has long been a key focus of FTC law
enforcement,13 research,14 and advocacy.15 Recently, FTC staff have analyzed the likely
competitive effects of proposed APRN regulations in other states.16
II. 	BACKGROUND: APRN PRACTICE IN CONNECTICUT AND HB6391
APRNs are licensed by the Connecticut Department of Public Health. According
to Connecticut law:
Advanced nursing practice is defined as the performance of advanced
level nursing practice activities that, by virtue of post basic specialized
education and experience, are appropriate to and may be performed by an
advanced practice registered nurse. The advanced practice registered

nurse performs acts of diagnosis and treatment of alterations in health
status, as described in subsection (a) of this section, and shall collaborate
with a physician licensed to practice medicine in this state. In all settings,
the advanced practice registered nurse may, in collaboration with a
physician licensed to practice medicine in this state, prescribe, dispense
and administer medical therapeutics and corrective measures and may
request, sign for, receive and dispense drugs in the form of professional
samples in accordance with sections 20-14c to 20-14e.17
Connecticut law defines “collaboration” as:
a mutually agreed upon relationship between an advanced practice
registered nurse and a physician who is educated, trained or has relevant
experience that is related to the work of such advanced practice registered
nurse. The collaboration shall address a reasonable and appropriate level
of consultation and referral, coverage for the patient in the absence of the
advanced practice registered nurse, a method to review patient outcomes
and a method of disclosure of the relationship to the patient. Relative to
the exercise of prescriptive authority, the collaboration between an
advanced practice registered nurse and a physician shall be in writing and
shall address the level of schedule II and III controlled substances that the
advanced practice registered nurse may prescribe and provide a method to
review patient outcomes, including, but not limited to, the review of
medical therapeutics, corrective measures, laboratory tests and other
diagnostic procedures that the advanced practice registered nurse may
prescribe, dispense and administer.18
Thus, current law does not require an APRN to have a formal written
collaborative practice agreement unless the APRN wishes to prescribe medications.
Nonetheless, even APRNs who do not choose to prescribe medications must have a
physician willing to be identified by name and practice as a collaborator in order to
practice to the full extent of their training, education, and abilities. Although
collaborative agreements could, in theory, encompass varying arrangements, the IOM
Report observes that Connecticut law imposes no requirements for on-site supervision of
APRNs, the frequency or extent to which physicians must review the charts of APRN
patients, or the maximum number of APRNs with whom a physician may have
collaborative arrangements.19
III. 	LIKELY COMPETITIVE BENEFITS OF HB6391
FTC staff recognize that certain professional licensure requirements are necessary
to protect patients. Consistent with patient safety, however, we urge legislators to also
consider the potential benefits of competition, including improved access to care, lower
costs, and increased options, that the passage of HB6391 would likely promote by
removing restrictions on APRNs’ ability to practice to the full extent of their training,
education, and abilities.

a. 	HB6391 Would Likely Improve Access to Primary Care Services
The United States faces substantial and growing shortages of physicians.20
While these shortages will exacerbate health care access problems for many American
consumers, the impact of reduced access is likely to be most acute among Medicaid
beneficiaries, due not only to geographic misalignment between low-income
communities and physician practice locations, but also to low physician participation in
state Medicaid programs.21
Given that APRNs play a key role in filling the gap between demand and supply
for health care services, any unnecessary restrictions on APRNs are likely to exacerbate
access problems and thereby harm patients. According to one report, the Massachusetts
health reform legislation, which mandated health insurance coverage, resulted in “an
increase in the wait times for appointments with primary care physicians and an increase
in emergency department visits by persons with insurance.” 22 Thus, eliminating
unnecessary restrictions on APRNs’ ability to practice may be beneficial for all patients,
and especially for those medically underserved areas or populations where there are
shortages of primary care providers.
The recent NGA report noted there were 39 federally-designated Health
Professional Shortage Areas (“HPSA”) in Connecticut.23 An estimated 434,885 people in
Connecticut live in a Primary Care HSPA. 24 Federal health care reform will expand the
number of people with insurance in Connecticut, including approximately 150,000
additional Medicaid enrollees, which is likely to further increase the demand for primary
care services, and potentially exacerbate the imbalance between demand for and supply
of primary care physicians.25 Optimizing use of APRNs can mitigate the consequences
of current and future shortages of primary care physicians.
APRNs are seen by many as crucial to addressing access problems. As a general
matter, APRNs make up 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.
APRNs also are more likely than primary care physicians to care for large numbers of
minority patients, Medicaid beneficiaries, and uninsured patients.26 It is also important to
note that APRNs are the fastest-growing segment of the primary care professional
workforce in the United States. Between the mid-1990s and the mid-2000s, the number
of APRNs per capita grew an average of more than nine percent annually, compared with
just one percent for primary care physicians.27 Given that APRNs play a key role in
filling the gap between demand and supply for health care services, any unnecessary
restrictions on APRNs are likely to exacerbate access problems and thereby harm some
of the most vulnerable patients.28 In Connecticut there are approximately 2,526 licensed
APRNs, and it is estimated that approximately 1,667 practice in primary care settings.29
Some reports suggest more APRNs practice in states that allow independent practice (i.e.,
practice without immediate supervision or collaborative agreement requirements).30
Thus, if Connecticut eliminates the requirement for a collaborative agreement for full

practice authority for APRNs, Connecticut may benefit from a growth in the number of
APRNs.
In sum, the Bill’s elimination of the collaborative practice agreement requirement
for APRNs may improve access and consumer choice for primary care services,
especially for rural and other underserved populations.
b. 	HB6391 Would Likely Lower Costs and Increase Consumer Options
HB6391, which would remove the requirement that APRNs have a collaborative
agreement with a physician, also is likely to reduce the cost of basic health care services
and could spur innovation in health care delivery and broaden the range of choices
available to consumers. APRN care is generally less expensive to patients and payers
than physician care, and is often provided in a variety of health care delivery settings.31
Similar to the situation in other states, there is anecdotal evidence suggesting some
Connecticut APRNs who wish to set up a practice that is separate from a physician or
other health care entity (e.g., they are not employees) must pay physicians to enter a
collaborative agreement.32 Unless these arrangements involve true and beneficial
supervision,33 they raise the possibility that APRNs are not compensating physicians for
their time, but rather for the potential loss of income some physicians believe may occur
as a result of APRNs’ entry into the primary care marketplace. Such payments raise the
costs of practice, likely resulting in fewer independently practicing APRNs and higher
prices, without any improvement in the quality of care provided.
The Connecticut Coalition of Nurse Practitioners, in a formal request for review
and expansion of APRNs’ scope of practice made to the Department of Public Health,
provided five specific case examples of APRNs’ difficulties in identifying physicians
willing to collaborate.34 These case examples illustrate several issues of concern. First,
securing a collaborative practice agreement may be a difficult process for some APRNs.
Some APRNs who attempted to use the Connecticut State Medical Society’s “APRN
Assist” link to find a physician collaborator did not receive any response or were told
there were no physicians “hiring” at that time, even though the APRN explained she was
not looking for a job, but for a collaborator.35 Second, APRNs may find it difficult and
costly to develop a sustainable business with this requirement in place. Even if they find
a physician who is able and willing to agree to collaborative practice, the APRN may not
be able to find a substitute if a collaborating physician retires, relocates, passes away, or
just decides to revoke or refuse to renew the collaborative practice agreement.36 Finally,
the case examples suggested one APRN had to pay a collaborating physician 70 percent
of her reimbursement and another APRN had to pay $30,000 per year to the collaborating
physician.37
APRNs have also played an important role in the development of alternative
settings for care delivery, such as retail clinics. Retail clinics typically are located within
larger retail stores, staffed by APRNs, and offer consumers a convenient way to obtain
basic medical care at competitive prices.38 Retail clinics generally offer weekend and
evening hours, which provide greater flexibility for patients,39 and appear to provide

competitive incentives for other types of physician practices to offer extended hours as
well.40 Elimination by the Connecticut legislature of the requirement that APRNs
collaborate with a physician might increase both the number and types of care settings
available to Connecticut consumers.41
c. 	Legislative Consideration of Health and Safety Issues
As previously noted, certain professional licensure requirements are necessary to
protect patients. It is unclear, however, whether the current Connecticut collaboration
requirement provides any additional patient protection.42 Moreover, the IOM, based on
an extensive review of the studies and literature on the safety of APRNs as primary care
providers, has recommended that nurses be permitted by state licensing laws to practice
to the full extent of their education and training.43 The IOM noted some “states have kept
pace with the evolution of the health care system by changing their scope-of-practice
regulations to allow NPs to see patients and prescribe medications without a physician’s
supervision or collaboration,” and that sixteen states and the District of Columbia allow
APRNs to practice and prescribe independently.44 The IOM further stated 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.”45
Similarly, the National Governors Association stated that it “performed an up-to-
date review of peer-reviewed literature relevant to NP scope of practice policy [and]
focused primarily on research that compares health care offered by NPs (working either
solo or in teams with physicians) to health care offered exclusively by physicians.”46 The
NGA’s review concluded: “None of the studies in NGA’s literature review raise concerns
about the quality of care offered by NPs. Most studies showed that NP-provided care is
comparable to physician-provided care on several process and outcome measures.
Moreover, the studies suggest that NPs may provide improved access to care.”47 The
report also noted that in order to “better meet the nation’s current and growing need for
primary care providers, states may want to consider easing their scope of practice
restrictions and modifying their reimbursement policies to encourage greater NP
involvement in the provision of primary care.”48
We further note that HB6391 does not otherwise change either the scope of
APRN practice or established regulatory oversight of APRNs in Connecticut, nor does it
limit institutional credentialing, or other aspects of collaboration or oversight established
by hospitals, ambulatory care facilities, or other clinics in the state.
IV. 	CONCLUSION
HB6391 would remove the requirement that APRNs enter into collaborative
practice agreements with physicians, permitting them to fully employ their education and
experience in serving Connecticut health care consumers in accordance with state
licensure standards. Removing this requirement has the potential to benefit consumers by
expanding choices for patients, containing costs, and improving access. Accordingly, we
encourage legislators to consider whether the existing requirement is necessary to assure
patient safety in light of your own regulatory experience and the expert findings of the

IOM, as well as the literature review and conclusions of the National Governors
Association. Maintaining an unnecessary and burdensome requirement is likely to
deprive consumers of the benefits that increased competition can provide. Therefore, the
Connecticut legislature should carefully consider the safety record of APRNs in
Connecticut. Absent countervailing safety concerns regarding APRN practice, HB6391
appears to be a procompetitive improvement in the law that would benefit Connecticut
health care consumers.
Respectfully submitted,
Andrew I. Gavil, Director
Office of Policy Planning
Richard A. Feinstein, Director
Bureau of Competition
Howard Shelanski, Director
Bureau of Economics
1 This staff letter expresses the views of the Federal Trade Commission’s Office of Policy Planning, Bureau
of Competition, and Bureau of Economics. The letter does not necessarily represent the views of the
Federal Trade Commission or of any individual Commissioner. The Commission, however, has voted to
authorize staff to submit these comments.
2 Letter from the Hon. Theresa W. Conroy, Connecticut House of Representatives, to Andrew I. Gavil,
Director, Office of Policy Planning, Federal Trade Commission (rec’d Feb. 7, 2013) [hereinafter Letter
from Rep. Conroy].
3 See generally I NSTITUTE OF MEDICINE, THE F UTURE OF N URSING : LEADING CHANGE, A DVANCING
H EALTH (2011) [hereinafter IOM N URSING REPORT ] (especially Summary, 1-15).
4 Id. at 4. See also id. at 85-161, 98-99 (discussing nursing scope-of-practice issues and quality of care,
including numerous quality of care studies); About the Institute of Medicine, available at
http://www.iom.edu/About-IOM.aspx.
5 National Governors Association, The Role of Nurse Practitioners in Meeting Increasing Demand for
Primary Care (Dec. 20, 2012), at: http://www.nga.org/cms/home/nga-center-for-best-practices/center-

divisions/page-health-division/col2-content/list---health-left/list-health-highlight/content-reference-2@/the-
role-of-nurse-practitioners.html [hereinafter NGA, Role of Nurse Practitioners].
6 Id. at 11.
7 See Request from the Connecticut APRN Coalition for Consideration of Scope of Practice Change
Submitted to the Connecticut Department of Public Health (Aug. 10, 2012), at:
http://www.ct.gov/dph/lib/dph/practitioner_licensing_and_investigations/_2013_scope_of_practice/ct_aprn
_coalition_scope_of_practice_request.pdf (providing specific examples of APRNs who have had difficulty
finding physicians with whom to collaborate or finding one willing to collaborate for a reasonable fee)
[hereinafter, “CT APRN Coalition’s Request for Scope of Practice Change”]. According to the
Department of Public Health’s website, at:
http://www.ct.gov/dph/cwp/view.asp?a=3121&q=486562&PM=1&dphNav=|&dphNav_GID=1821:
Connecticut Public Act 11-209, An Act Concerning the Department of Public
Health's Oversight Responsibilities Relating to Scope of Practice Determinations for
Healthcare Professions, establishes a process for the submission and review of requests
from health care professions seeking to revise or establish a scope of practice prior to
consideration by the General Assembly. Under the provisions of this act, scope of
practice review committees may review and evaluate these requests and provide findings
to the joint standing committee of the General Assembly having cognizance of matters
relating to public health. The Department of Public Health (DPH) is responsible for
receiving requests and for establishing and providing support to the review committees,
within available appropriations.
8 See, e.g., Univ. of CT, Center for Public Health and Health Policy Report, Assessment of Primary Care
Capacity in Connecticut (Dec. 2008), at:
http://publichealth.uconn.edu/images/reports/PrimaryCare_Report_02_17_09.pdf (indicating that although
overall capacity appears adequate for current needs, there are shortage areas, especially in rural areas and
for low income patients in large cities) [hereinafter Univ. of CT, Assessment of Primary Care Capacity];
U.S. Dep’t Health & Human Servs., Health Resources & Servs. Admin., Find Shortage Areas: MUA/P by
State and County, available at http://muafind.hrsa.gov/index.aspx (last checked Mar. 1, 2013) (indicating
shortage areas in Connecticut, especially in rural areas and for low income patients in large cities by HRSA
criteria).
9 See, e.g., Univ. of CT, Assessment of Primary Care Capacity, supra note 8 at ii (noting “while
Connecticut may be able to absorb near term increases in primary care services demand without any
improvements in primary care capacity and workforce policy, this may not be the case in the future”); id. at
3 (discussing increased wait times for appointments with primary care providers after Massachusetts’
enacted health care reform).
10 See P. Mitchell, et al., DISCUSSION P APER , I NSTITUTE OF M EDICINE, Core Principles & Values of
Effective Team-Based Health Care (Oct. 2012) at http://www.iom.edu/tbc. [Hereinafter IOM, Team-Based
Health Care].
11 Federal Trade Commission Act, 15 U.S.C. § 45.
12 Standard Oil Co. v. Fed. Tr. Comm’n, 340 U.S. 231, 248 (1951) (“The heart of our national economic
policy long has been faith in the value of competition.”).
13 See FTC, An Overview of FTC Antitrust Actions in Health Care Services and Products (Mar. 2013),
available at http://www.ftc.gov/bc/healthcare/antitrust/hcupdate.pdf; FTC, Competition in the Health Care
Marketplace: Formal Commission Actions (1996 – 2008), available at
http://www.ftc.gov/bc/healthcare/antitrust/commissionactions.htm.
14 See FTC & U.S. D EP ’ T OF J USTICE (“DOJ”), I MPROVING H EALTH C ARE: A D OSE OF COMPETITION (2004),
available at http://www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf [hereinafter FTC & DOJ,
I MPROVING H EALTH CARE].

15 FTC and staff advocacy may comprise letters or comments addressing specific policy issues,
Commission or staff testimony before legislative or regulatory bodies, amicus briefs, or reports. See, e.g.,
Letter from FTC Staff to Hon. Timothy Burns, Connecticut Legislature, (May 1, 2009) (regarding proposed
restrictions on mobile dentistry), available at
http://www.ftc.gov/os/2009/05/V090009Connecticutdentistry.pdf; FTC and DOJ Written Testimony before
the Illinois Task Force on Health Planning Reform Concerning Illinois Certificate of Need Laws (Sept.
2008), available at http://www.ftc.gov/os/2008/09/V080018illconlaws.pdf; FTC Amicus Curiae Brief in In
re Ciprofloxacin Hydrochloride Antitrust Litigation Concerning Drug Patent Settlements Before the Court
of Appeals for the Federal Circuit (Case No. 2008-1097) (Jan. 2008), available at
http://www.ftc.gov/os/2008/01/080129cipro.pdf; FTC & DOJ, I MPROVING H EALTH C ARE supra note 14.
16 FTC Staff Testimony Before Subcommittee A of the Joint Committee on Health of the State of West
Virginia Legislature on The Review of West Virginia Laws Governing the Scope of Practice for Advanced
Practice Registered Nurses and Consideration of Possible Revisions to Remove Practice Restrictions (Sept.
2012), available at http://www.ftc.gov/os/2012/09/120907wvatestimony.pdf; FTC Staff Letter to The Hon.
Thomas P. Willmott and The Hon. Patrick C. Williams, Louisiana House of Representatives, Concerning
the Likely Competitive Impact of Louisiana House Bill 951 Concerning Advanced Practice Registered
Nurses (Apr. 2012), available at http://www.ftc.gov/os/2012/04/120425louisianastaffcomment.pdf; FTC
Staff Letter to The Hon. Paul Hornback, Senator, Commonwealth of Kentucky State Senate Concerning
Kentucky Senate Bill 187 and the Regulation of Advanced Practice Registered Nurses (Mar. 2012),
available at http://www.ftc.gov/os/2012/03/120326ky_staffletter.pdf; FTC Staff Letter to The Hon. Rodney
Ellis and The Hon. Royce West, the Senate of the State of Texas, Concerning Texas Senate Bills 1260 and
1339 and the Regulation of Advanced Practice Registered Nurses (May 2011), available at
http://www.ftc.gov/os/2011/05/V110007texasaprn.pdf; FTC Staff Letter to The Hon. Daphne Campbell,
Florida House of Representatives, Concerning Florida House Bill 4103 and the Regulation of Advanced
Registered Nurse Practitioners (Mar. 2011), available at http://www.ftc.gov/os/2011/03/V110004campbell-
florida.pdf.
17 CONN . G EN. S TAT. § 20-87a (2012). The Connecticut Department of Public Health is responsible for
issuing licenses to nurses, CONN . G EN. S TAT . § 20-92 (2012) and to APRNs, CONN . G EN. S TAT. § 20-94
(2012). The Connecticut State Board of Examiners for Nursing consults with the Department of Health
concerning licensure examinations for licensed practical nurses and registered nurses. CONN . G EN. S TAT . §
20-90a (2012). In addition, “the [nursing] board shall (1) hear and decide matters concerning suspension
or revocation of licensure, (2) adjudicate complaints filed against practitioners licensed under this chapter
and impose sanctions where appropriate.” C ONN . G EN. S TAT. § 20-90b (2012). CONN . G EN. S TAT. § 20-94a
(2012) states:
The Department of Public Health may issue an advanced practice registered nurse license
to a person seeking to perform the activities described in subsection (b) of section 20-87a,
upon receipt of a fee of two hundred dollars, to an applicant who: (1) Maintains a license
as a registered nurse in this state, as provided by section 20-93 or 20-94; (2) holds and
maintains current certification as a nurse practitioner, a clinical nurse specialist or a nurse
anesthetist from one of the following national certifying bodies that certify nurses in
advanced practice: The American Nurses' Association, the Nurses' Association of the
American College of Obstetricians and Gynecologists Certification Corporation, the
National Board of Pediatric Nurse Practitioners and Associates or the American
Association of Nurse Anesthetists, their successors or other appropriate national
certifying bodies approved by the Board of Examiners for Nursing; (3) has completed
thirty hours of education in pharmacology for advanced nursing practice; and (4) if first
certified by one of the foregoing certifying bodies after December 31, 1994, holds a
master's degree in nursing or in a related field recognized for certification as either a
nurse practitioner, a clinical nurse specialist, or a nurse anesthetist by one of the
foregoing certifying bodies.
18 CONN . G EN. S TAT. § 20-87a (2012). It is our understanding under current law that although an APRN
must have a collaboration agreement with a physician in order to practice independently, the agreement
must only be in writing if the APRN will be prescribing medications.

19 IOM F UTURE OF N URSING R EPORT, supra note 3, at 157, Table 3-A1. See also IOM, Team-Based Health
Care, supra note 10 at 11-12 (discussing the elements of effective team-based health care and noting issues
concerning scope-of-practice and independent practice appear much less problematic in the field than in the
political arena).
20 See Kaiser Commission on Medicaid and the Uninsured, Improving Access to Adult Primary Care in
Medicaid: Exploring the Potential Role of Nurse Practitioners and Physician Assistants, at 1 (Mar. 2011),
available at http://www.kff.org/medicaid/upload/8167.pdf [hereinafter “Kaiser Commission, Improving
Access”]; the Association of American Medical Colleges (AAMC) Physician Shortages Factsheet,
available at https://www.aamc.org/download/150584/data/physician_shortages_factsheet.pdf (in its
projections of physician supply and demand, the AAMC assumes that each additional two NPs (or
Physicians Assistants) reduce physician demand by one) [hereinafter “AAMC, Physician Shortages”]; U.S.
D EPARTMENT OF H EALTH AND H UMAN S ERVICES , H EALTH RESOURCES AND S ERVICES A DMINISTRATION
BUREAU OF H EALTH P ROFESSIONS , THE P HYSICIAN W ORKFORCE: P ROJECTIONS AND R ESEARCH INTO
CURRENT I SSUES A FFECTING S UPPLY AND D EMAND , 70-72, exhibits 51-52 (2008), available at
http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. [Hereinafter HRSA P HYSICIAN
W ORKFORCE REPORT ].
21 See Kaiser Commission, Improving Access, supra note 20, at 1.
22 Univ. of CT, Assessment of Primary Care Capacity, supra note 8, at 3. See also discussion concerning
APRNs and retail clinics, infra at Section III.b.
23 NGA, Role of Nurse Practitioners, supra note 5. See also Kaiser Family Foundation,
statehealthfacts.org, Primary Care Health Professional Shortage Areas (HPSAs), available at
http://www.statehealthfacts.org/comparemapreport.jsp?rep=112&cat=8&utm_source=shfonl&utm_mediu
m=email&utm_campaign=040512short (indicating 12.2% of Connecticut population living in HPSA) (last
checked Mar. 4, 2013). For a general description of HPSAs, see U.S. Dep’t Health and Human Servs.,
HRSA, Guidelines for Primary Medical Care/Dental HPSA Designation,
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/medicaldentalhpsaguidelines.html (last checked
Mar. 4, 2013).
24 Kaiser Family Foundation, statehealthfacts.org, Primary Care Health Professional Shortage Areas
(HPSAs), available at
http://www.statehealthfacts.org/comparemapreport.jsp?rep=112&cat=8&utm_source=shfonl&utm_mediu
m=email&utm_campaign=040512short (last checked Mar. 4, 2013).
25 See Kaiser Commission on Medicaid and the Uninsured, The Cost and Coverage Implications of the
ACA Medicaid Expansion: National and State-by-State Analysis, at 48, Table 9, (Nov. 2012), available at:
http://www.kff.org/medicaid/upload/8384.pdf.
26 Kaiser Commission, Improving Access, supra note 20, at 3.
27 See Kaiser Commission, Improving Access, supra note 20, at 3; AAMC, Physician Shortages, supra note
20.
28 See generally AARP & Robert Wood Johnson Foundation, Center to Champion Nursing in America,
Access to Care and Advanced Practice Nurses: A Review of Southern U.S. Practice Laws (2010), available
at http://championnursing.org/resources/access-care-and-advanced-practice-nurses-review-southern-us-
practice-laws (policy paper discussing restrictions on APRN practice in 11 southern states, including the
impact on access and consumers and advocating the removal of state restrictions on APRNs’ practice,
including the removal of restrictions on prescriptive authority). See also discussion supra at note 19 and
accompanying text.
29 Univ. of CT, Assessment of Primary Care Capacity, supra note 8 at 7.

30 See, e.g., TEXAS LEGISLATIVE BUDGET BOARD S TAFF , TEXAS S TATE G OVERNMENT EFFECTIVENESS AND
EFFICIENCY: S ELECTED I SSUES AND RECOMMENDATIONS 297, 300 (Jan. 2011) (submitted to the 82nd Texas
Legislature) (indicating that the number of advanced practice nurses is lower in states with restrictive
regulatory environments, and these restrictions may “limit the expansion of retail clinics, which generally
employ APRNs to provide a limited range [of] primary healthcare”) [hereinafter TEXAS BUDGET B OARD
S TAFF R EPORT ]; Julie A. Fairman et al., Perspective: Broadening the Scope of Nursing Practice, 364 N.
ENGL. J. MED. 193, 194 (2011) (noting “nurses tend to move from more restrictive to less restrictive states .
. . with a resulting loss of access to care for patients”).
31 See Joanne M. Pohl et al., Unleashing Nurse Practitioners’ Potential to Deliver Primary Care and Lead
Teams, 29 H EALTH A FFAIRS 900, 901 (2010), available at
http://content.healthaffairs.org/content/29/5/900.full.pdf+html (noting APRNs and physicians assistants are
underutilized “despite being qualified to provide primary care at a lower cost than other providers”).
32 See CT APRN Coalition’s Request for Scope of Practice Change, supra note 7 at 8. Anecdotal evidence
from other states suggests APRNs pay significant fees to collaborating physicians. See, e.g., Letter from
The Hon. Paul Hornback, Commonwealth of Kentucky State Senate, to Susan DeSanti, Director, Office of
Policy Planning, Federal Trade Commission (Jan. 18, 2012) (noting in “some cases, the physicians are
charging a considerable amount of money monthly or annually to sign a CAPA [the collaborative
prescribing agreement], although they essentially perform no services for the fee”); Letter from The Hon.
Thomas P. Willmott and The Hon. Patrick C. Williams, Louisiana House of Representatives, to Susan S.
DeSanti, Director, Office of Policy Planning, Federal Trade Commission (Jan. 18, 2012), (noting that
APRNs in Louisiana often must pay 10-45% of their collected fees to physicians for entering into
collaborative practice agreements).
33 See discussion in Section II supra at note 19 and accompanying text.
34 CT APRN Coalition’s Request for Scope of Practice Change, supra note 7 at 8.
35 Id. at 8 (Case #1 and Case #2).
36 See Id. (Case #1).
37 Id. (Case #4 and Case #5); see also supra note 32 and citations therein.
38 See Robin Weinick, et al., Policy Implications of the Use of Retail Clinics at 12 (2010) (Rand Health
Technical Report prepared for the U.S. Dept. of Health and Human Serv.), at
http://www.rand.org/content/dam/rand/pubs/technical_reports/2010/RAND_TR810.pdf [hereinafter Rand,
Policy Implications of the Use of Retail Clinics] (also noting the services offered at retail clinics are
generally narrower in scope than those provided by urgent care centers and emergency rooms); Ateev
Mehrotra et al., Retail Clinics, Primary Care Physicians, and Emergency Departments: A Comparison of
Patients Visits, 27 H EALTH A FFAIRS 1272, 1279 (2008). See generally William M. Sage, Might the Fact
that 90% of Americans Live Within 15 Miles of a Wal-Mart Help Achieve Universal Health Care?, 55 U.
Kan. L. Rev. 1233, 1238 (2007) (describing the size and scope of retail clinics); Mary Kay Scott, Scott &
Company, Health Care in the Express Lane: Retail Clinics Go Mainstream, at 22 (Sept. 2007) (report
prepared for the California HealthCare Foundation), available at http://www.chcf.org/publications.
Evidence indicates that the quality of care provided by APRNs in retail clinics is “similar to that
provided in physician offices and urgent care centers and slightly superior to that of emergency
departments.” Ateev Mehrotra et al., Comparing Costs and Quality of Care at Retail Clinics with that of
Other Medical Settings for 3 Common Illnesses, 151 A NNALS I NTERNAL MED. 321, 326 (2009) (analyzing
14 quality metrics for commonly treated ailments, including ear, strep, and urinary tract infections, and
finding “[f]or most measures, quality scores of retail clinics were equal to or higher than those of other care
settings”).
39 Cf. Rena Rudavsky, Craig Evan Pollack, & Ateev Mehrotra, The Geographic Distribution, Ownership,
Prices, and Scope of Practice at Retail Clinics, 151 A NNALS I NTERNAL M ED. 315, 317 (2009) (“In a

random sample of 98 [limited service] clinics, all had weekday and weekend hours and 95 (97%) had
evening hours (after 6 p.m.) on weekdays.”).
40 See Robin Weinick, et al., Policy Implications of the Use of Retail Clinics at 12 (2010) (Rand Health
Technical Report prepared for the U.S. Dept. of Health and Human Serv.), at
http://www.rand.org/content/dam/rand/pubs/technical_reports/2010/RAND_TR810.pdf (according to
many medical community representatives interviewed for this report, including a representative of the
American Medical Association, “retail clinics have stimulated physicians to adopt evening and weekend
hours”).
41 See, e.g., TEXAS BUDGET BOARD S TAFF REPORT, supra note 30, at 300 (noting restrictions on APRNs’
scope of practice may limit both the number and types of retail clinics available to Texas consumers);
MARY TAKACH & K ATHY W ITGERT, N ATIONAL A CADEMY FOR S TATE H EALTH P OLICY , A NALYSIS OF
S TATE REGULATIONS AND P OLICIES G OVERNING THE O PERATION AND LICENSURE OF RETAIL CLINICS 6
(Feb. 2009) (noting “the most powerful state regulatory tools affecting [retail clinics’] operations are the
scope of practice regulations that govern nurse practitioners and other non-physician medical personnel”).
42 See discussion in Section II supra at note 19 and accompanying text.
43 IOM N URSING REPORT, supra note 5 at 85-161; see especially id. at 98 (with respect to many primary
care services, “the contention that APRNs are less able than physicians to deliver care that is safe, effective,
and efficient is not supported by the decades of research that has examined this question”) (internal
citations omitted).
44 Id. at 98.
45 Id. at 99. See also Julie A. Fairman et al., Perspective: Broadening the Scope of Nursing Practice, 364
N. ENGL. J. MED. 193, 194 (2011) (stating “[t]here are no data to suggest that nurse practitioners in states
that impose greater restrictions on their practice provide safer and better care than those in less restrictive
states or that the role of the physician has changed or deteriorated”).
46 NGA, Role of Nurse Practitioners, supra note 5 at 5.
47 Id. at 7-8; see also id. at 1 (noting “[r]esearch suggests that NPs can perform many primary care services
as well as physicians do and achieve equal or higher patient satisfaction rates among their patients”).
48 Id. at 1; see also id. at 11.