Better Healthcare Through Legislation

by Kelley Kaufmann, APRN-CNP, PMHNP-BC, Psychiatric Nurse Practitioner, Center for Health Equity Engagement Education and Research

Two days ago, I met for the first time with my State House Representative in District 70, Rep. Darrel Kick (R) to advocate on behalf of the Ohio Association of Advanced Practice Nursing (OAAPN).   OAAPN is currently working to get Ohio House Bill 177, the Better Access, Better Care Act passed in the 133rd General Assembly.  HB 177 on the outside appears to be just about removing mandatory collaborative agreements between physicians and Advanced Practice Nurses (APNs) as a requirement for APNs to practice in the state of Ohio.  However, the Better Access, Better Care Act has the potential to expand care to millions of Ohioans in rural and underserved areas.

Standard Care arrangements (SCAs) require an APN to be in a collaborative agreement with a physician with processes for obtaining consultation and semiannual chart and prescription reviews.   It is important to note, the SCA does not require that a physician and APN ever meet in person and does not require supervision of the APN by the physician.   In addition, entering into a collaborative agreement may cost some Ohio APNs tens of thousands of dollars each year which can be cost prohibitive for those APNs who wish to open practices in rural or underserved areas.

Ohio currently ranks 35th in the nation in health care access and quality according to the 2018 Best State Ranking by U.S. New and World Report.   This may be partially attributable to only 55% of patient demand in Ohio being met by the current provider workforce.  Already, nearly 1.5 million Ohioans lack access to primary care and this care gap is only expected to rise as baby boomers age.

In the last decade, rural Ohio has lost 12% of physicians practicing there while the physician workforce growth rate only grew by 2% statewide.  Over the same time, the APN workforce in Ohio grew by nearly 227% with 85% of APNs providing primary care—the hardest hit practice workforce shortage area.  A University of Michigan study, showed that physicians tend to practice in affluent areas while APNs gravitate to areas with higher socioeconomic need.

Unfortunately, Ohio is at risk for losing APNs to states with less restrictive requirements for practice.  Over half of states have granted full practice authority or removed the requirement of a mandatory contract with physicians as a condition of APRN practice.  Most of these states experienced immediate increases in the APN workforce working in rural and underserved areas.  Furthermore, 8 out of the 10 best states in the nation for health care access and quality in the 2018 U.S. News and World Report Rankings have granted full practice authority to APNs.

Decades of research have found that APNs provide excellent care, and, in many cases, patient outcomes are equal to or better than those of their physician counterparts.  However, Ohio is in danger of falling further behind in regard to health care access and quality due to outdated laws requiring mandatory paperwork and semiannual, after-the-fact (even 6 months later) chart reviews.  Removal of the SCA would remove a barrier to APNs moving their practice into areas with the most need and is necessary to improving the health of millions of Ohioans.

While reflecting on my meeting with my state Representative, I am optimistic that, although we may not agree on all issues, we have been able to come to a common understanding of the benefits for the Better Access, Better Care Act to the health of all Ohioans.  It was clear to both of us that the everyday voluntary consultations I make about difficult or complex patients with members of the healthcare team including physicians, nurse practitioners, nurses, social workers, etc., has a greater positive impact on patient outcomes than does the semi-annual after-the-fact chart and prescription reviews.  Removal of the SCA with the passage of HB 177 would not end collaboration and consultation, nor would it reduce healthcare quality or outcomes; The Better Access, Better Care Act would just remove barriers to Ohioans accessing necessary healthcare services and that is something I think we can all agree needs to happen.


Davis, M.A., Anthopolos, R., Tootoo, J. et al. Supply of Healthcare Providers in Relation to County Socioeconomic and Health Status. J Gen Intern Med (2018) 33: 412.

Ohioans for Healthcare Access. (2019) Retrieved from