The macroeconomic benefits of Tennessee APRNs

The macroeconomic benefits of Tennessee APRNs
having full practice authority
Carole R. Myers, PhD, RN, FAANa,
*, Cyril Chang, PhDb
, David Mirvis, MDc,d
Tracey Stansberry, MSN, APN, AOCNe
College of Nursing and Department of Public Health, University of Tennessee, Knoxville, TN b
Methodist Le Bonheur Center for Healthcare Economics, The University of Memphis, The Fogelman College of Business and Economics,
Memphis, TN c
College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN d
Methodist LeBonheur Center for Healthcare Economics, The Fogelman College of Business and Economics, The University of Memphis,
Memphis, TN e
University of Tennessee, College of Nursing, Knoxville, TN
Background: To-date, advocacy efforts to advance full practice authority for APRNs
have primarily stressed arguments based on evidence on the cost effectiveness
and quality of APRN-provided care, as well as the improved care access and
patient satisfaction these providers offer.
Purpose: The economic impact analysis forecasts the additional job and economic
output associated with granting Tennessee APRNs full practice authority.
Methods: The IMPLAN software and a variety of data inputs were used to estimate
the direct, indirect, and induced economic impact on jobs, labor income, valueadded benefits, total output, and tax revenues.
Findings: From a 2017 baseline, the cumulative impact of granting Tennessee
APRNs full practice authority is a net gain of 25,536 jobs and $3.2 billion in economic impact.
Discussion: Granting Tennessee APRNs full practice authority would confer substantial economic benefits and employment opportunities to the state.
Cite this article: Myers, C.R., Chang, C., Mirvis, D., & Stansberry, T. (2019, xxx). The macroeconomic benefits of Tennessee APRNs having full practice authority. Nurs Outlook, 00(00), 17.
Article history:
Received 21 June 2019
Received in revised form
8 September 2019
Accepted 18 September 2019
Full practice authority (FPA)
Advanced Practice Registered
Nurse (APRN)
Economic impact
Primary care
One of the four key messages of the landmark
Future of Nursing report (Institute of Medicine [IOM],
2011) is that nurses should practice to the full extent
of their education and training (p. 4). State practice
restrictions are barriers to Advanced Practice Registered Nurses (APRNs) achieving this aim. To date,
advocacy efforts primarily have stressed arguments
based on evidence from a robust body of scholarly
research on the cost effectiveness and quality of
APRN-provided care, as well as the improved care
access and patient satisfaction these providers offer.
The purpose of this study is to present a complementary approach that adds a new dimension to the
ongoing dialog on APRN practice authority by
highlighting the macroeconomic consequences of
APRN practice.
* Corresponding author: Carole R. Myers, College of Nursing and Department of Public Health, University of Tennessee, 1200 Volunteer Blvd., Knoxville, TN 37996.
E-mail address: [email protected] (C.R. Myers).
0029-6554/$ -see front matter 2019 Elsevier Inc. All rights reserved.
Available online at
Nurs Outlook 0 0 0 ( 2 0 1 9 ) 1 7
Specifically, this study shows the potential economic
impacts on state and local economies of granting full
practice authority (FPA) to Tennessee APRNs. FPA, as
defined by the American Association of Nurse Practitioners, allows APRNs to evaluate patients; diagnose,
order, and interpret diagnostic tests; and initiate and
manage treatments, including prescribing medications
and controlled substances, under the exclusive licensure
authority of the state board of nursing. (American Association of Nurse Practitioners [AANP], 2018).
This economic impact analysis makes an economic
case for granting APRNs FPA in Tennessee in two analytical steps. First, we describe the economic impact of
APRNs on the state and local economies in Tennessee
based on the current APRN workforce distribution and
the restrictive practice environment. Second, we present estimates of the potential economic benefits of
granting Tennessee APRNs FPA.
APRNs have provided care for patients and populations
since the 1960s (Dellabella, 2015). These professionals
are highly trained registered nurses who have met all
prelicensure educational requirements to become an RN
and then completed either a Masters or Doctoral degree
program. After completing all coursework and supervised clinical hours, each is credentialed by a national
boardsuch as the American Nurses Credentialing Center (ANCC) or the AANPto practice as either a nurse
practitioner (NP), clinical nurse specialist (CNS), certified
nurse midwife (CNM), or certified registered nurse anesthetist (CRNA) (IOM, 2011). These nurses are responsible
for health promotion and can assess, diagnose, and
manage patient problems, which may involve using and
prescribing both pharmacologic and non-pharmacologic
interventions (AANP, 2018; APRN Consensus Work
Group and the National Council of State Boards of Nursing APRN Advisory Committee, 2008).
APRN Practice Authority
State boards of nursing regulate and govern APRN
practice authority. APRNs must meet the practice
requirements of the states in which they practice.
There are three main delineations of practice authority: FPA, reduced practice authority, and restricted
practice authority (AANP, 2018).
Twenty-two states, the District of Columbia, and
three U.S. territories have granted nurses FPA. Sixteen
states and two U.S. territories allow practice under
reduced authority, while 12 states (including Tennessee) have legislated restricted practice authority
(AANP, 2018). In restrictive practice environments,
APRNs must practice under the supervision of another
healthcare professional, with state statute limiting at
least one practice element for which they have been
credentialed (IOM, 2011). The language pertaining to
this supervision varies. In Tennessee, APRNs who
have a certificate of fitness to prescribe must have a
collaborative arrangement with a physician. The collaborating physician is responsible for reviewing a specific percentage of patient charts, as well as approving
the practice protocols and the controlled substance
prescriptions of the APRN. The collaborating physician
also is required to be onsite at least once every 30 days
and available for telephone consultation at all times
while the APRN is seeing patients (Tennessee Nurse
Practice Act, 2010). The scope and intensity of physician collaboration or supervision agreements required
in reduced and restricted practice states varies. Agreements vary based on work expected, including for
example responding to APRN calls, meetings with
APRNs, and level of chart review (Bupert, 2019). Sagi
(2016) reported that the mean annual stipend for physicians was $9,274 in the 2015 report (report was not
directly accessed as it is behind a pay wall). The rules
and regulations related to Tennessee APRNs prescriptive
authority must be approved jointly by the Tennessee
Board of Nursing and Board of Medical Examiners.
Macroeconomic Impact on Local and State Economies
APRNs act as economic engines in several ways including impacting healthcare costs and professional
incomes and jobs. This study examines APRNs macroeconomic impacts on local and regional economies.
Granting APRNs FPA augments communities macroeconomies (rather than individual markets) via several
routes. Historically, many of the economic studies
examining the cost savings of NP practice have been
segmented (i.e., examining specific cost domains using
a limited number of variables). A more modern
approach to forecasting the broad economic impact of
expanded authority of practice is modeling. This
approach involves inputting integrated variables into a
computational analysis to determine NPs projected
economic impact over a specific period (University of
Wisconsin Center for Cooperatives, 2019).
Economic Model
For this study, the term economic impact is defined as
an events effects or consequences, either beneficial or
harmful, on the economic activities of a region, state,
or local area. We estimated Tennessee APRNs economic impact using the IMPLAN economic impact
model initially developed by the U.S. Department of
Interior and currently maintained by the Minnesota
IMPLAN Group. This empirically tested analytical tool
has been used by more than 500 universities, government agencies, and nonprofit organizations to estimate the economic and fiscal impacts of fresh
investments and/or changes in economic activities
2 Nurs Outlook 00 (2019) 1 7
(University of Wisconsin Center for Cooperatives,
2019). Conceptually, the IMPLAN model is an inputoutput regional economic model that uses the dollar
amounts of total purchases of goods and services
made by all households, businesses, and government
entities in a geographic area as input to drive the output or the resulting economic impacts.
In terms of output estimates, the IMPLAN model
reports three types of economic effects of the original
total purchases or expenditures that represent the
level or the expected changes in local economic activities: Direct effects, indirect effects, and induced effects.
Direct effects consist of the initial changes in the
industry in question, in this case the APRN market,
and include total economic output directly created by
the initial total spending associated with the presence
of practicing APRNs in the local healthcare market.
Indirect effects include changes in inter-industry
transactions when supplying industries (e.g., hospitals, nursing homes, and drug stores) respond to
increased demands from directly affected industry
sectors. Induced effects reflect changes in business
and individual incomes in the directly and indirectly
affected industry sectors as dollars continue to change
hands from business to business and person to person.
The net result of these factors is a multiplier effect. The
three economic impact effects suggest that the overall
impact of an increase (e.g., in revenues generated by
an NP) is a multiple of the economic benefit directly
generated by the change in patient care. This overall
benefitwhich ripples throughout the economy to virtually all sectors as indirect and induced effects
occuris referred to in the economic impact literature
as the multiplier effect. For example, the overall multiplier for Tennessee is approximately 2.0. In other
words, for each $1 added to the states economy,
the overall economic gain across all economic sectors
is $2.
In addition to the estimated dollar values of the total
output of the APRN labor market and its three major
components, five additional economic impact measures were used to describe the total economic impact
of APRNs: jobs; labor income; value added; total output; and federal, state, and local tax revenues (Table 1).
The IMPLAN model can be used to either estimate the
impacts separately for each of the 95 Tennessee counties
to create a state sum or estimate impacts for the entire
state and divide the sum total among the 95 counties.
Our results are from the second approach. This approach
recognizes the likelihood that the economic activities
taking place in one county not only will benefit that
county, but also will generate spillover benefits for
neighboring counties and the rest of the state.
Our impact analysis began with an estimate of
APRNs current economic impact on state and local
economies for the baseline year of 2017. We then estimated four separate layers of future economic impacts
of APRNs and added each of these to the baseline estimates to derive the cumulative impacts for an
8-year period (20172025).
The first layer captures the effects of allowing Tennessee to become an FPA state. This estimate assumes
a 2.2% per year increase in the APRN workforce resulting from expanded practice authority, a growth rate
lower than the 3.05% rate assumed by the North Carolina study (Conover & Richards, 2015) and higher than
the 0.92% rate used by the Florida study (Unruh, Rutherford, Schirle, & Brunell, 2018). The second layer estimates the long-term effects of population growth in
Tennessee on the economy through the increases in
the demand for health care and, therefore, the
demand for APRN workforce. The third layer estimates
the effect of inflation, and the fourth layer estimates
the continuing effects of the Affordable Care Act
(ACA). While Tennessee has not expanded Medicaid,
there are other ACA consequences including increased
federal spending for subsidies for Health Insurance
Exchange participants. The total overall economic
impact was calculated by adding each of the four
layers to the baseline 2017 estimates.
Data Sources
The Tennessee Board of Nursings Geographic Information System (GIS) was accessed to secure the numbers of
full-time (FT), part-time (PT), and non-practicing APRNs
in Tennessee for 2015 to 2017.
Realistic estimates of labor costs and initial market
value created in a county by APRNs were derived from
compensation information on salaries and fringe benefits from the U.S. Department of Labor (Bureau of
Labor Statistics, 2017), and the private data provider,
Table 1 Economic Impact Measures
Measure Definition
Jobs The number of original APRN jobs plus additional jobs supported either directly by the
patient care activities or indirectly through downstream benefits
Labor income The labor income dollars generated as a result of APRNs patient care activities and the
downstream benefits of APRNs initial contributions
Value added The additional dollars contributed to a local economy over and beyond the original
dollars generated by the APRNs patient care activities
Total output The value of total contributions created directly by APRNs care activities and the additional value added by downstream economic activities
Federal, state, and local
tax revenues
Taxes collected at the federal, state and local levels
Nurs Outlook 00 (2019) 1 7 3 (n.d.). We followed the examples of estimating office practice expenses from prior studies in
North Carolina (Conover & Richards, 2015) and Florida
(Unruh et al., 2018). Therefore, the initial value of total
output of APRNs in a Tennessee county is the sum of
total annual salaries, total fringe benefits, and estimated office expenses of full-time equivalent (FTE)
APRNs in each of Tennessees 95 counties.
The assignment of Tennessees 95 counties to one of
the Grand Divisions (East, Middle, and West) followed
the recommendations of the Tennessee Office of the
Secretary of State (n.d.). Population density was
defined in accordance with the U.S. Office of Management and Budget (OMB) three levels: metropolitan
(metro) area, micropolitan (micro) area, and nonmetropolitan (rural) area.
Our presentation of results begins with a summary of
workforce data on the current distribution of APRNs in
Tennessee. Next, we present economic impact estimates
of the current APRN workforce based on its existing distribution on the economy of the whole state. Finally, we
provide estimates of the economic impacts of granting
Tennessee APRNs FPA and the projected future benefits
of such a policy change up to 2025.
Distribution of APRNs in Tennessee
The number of Tennessee APRNs rose steadily in the
three-year baseline period from 9,276 in 2015 to 10,886
in 2017 (Tennessee Board of Nursing, 2017). During the
same period, the from
140.7 to 162.3 per 100,000 individuals in the general
population, suggesting that the number of APRNs grew
faster than the general population.
Baseline Economic Impact Estimates for Tennessee
Table 2 shows summary results on the total economic
impacts of the existing supply of APRNs on the state
economy based on estimates calculated for each of the 95
counties and summarized to the state level for the baseline year of 2017. We estimated that practicing APRNs in
Tennessee contributed $5.45 billion of total output and
43,727 jobs in 2017. The greatest impacts come from
direct effects (53.6%), followed by induced impacts
(36.3%) and indirect effects (10.1%).
Cumulative and Layered Economic Impact Estimates
for Tennessee
Table 3 presents the long-term (20172025) effects
expected from granting Tennessee APRNs FPA, with a
breakout of the individual layers of the expected impacts
that comprise the totals. These layered effects as measured by such growth indicators as community employment, labor income, value added to the local economy
and total economic output that result from population
growth, expected changes in the number of insured population induced by the ACA, and inflation for years 2017
through 2025. Table 4 includes the cumulative economic
impacts of APRNs derived from the sums of the baseline
and the layered effects for 2017 through 2025.
With no consideration of the effects of population
growth, inflation, and ACA, FPA by itself is estimated
to generate close to $1.00 billion of total output and
7,696 jobs from 2017 to 2025. The effects of population
growth, inflation, and the ACA are estimated to be
$2.22 billion of total output and 17,840 jobs. Therefore,
the total economic impacts (baseline impacts plus projected impacts) of granting FPA to FT and PT APRNs are
estimated to be about $8.63 billion and 69,263 jobs
between 2017 and 2025.
Our study projections illustrate the macroeconomic benefits of removing APRN practice authority restrictions in
Tennessee. Indeed, granting APRNs FPA would confer
substantial economic benefits and employment opportunities. APRN economic contributions are not limited to
the market value of the direct patient care and other
services they deliver. The eventual magnitude of APRNs
total economic contributions are much larger because of
the spillover multiplier effects, as the initial dollars
APRNs earn and contribute turn over again and again
from business to business and person-to-person.
The economic model used does not account for
increased utilization, associated increases in costs, or
the cost of full practice authority implementation, specifically APRN practice start-up. One study demonstrated an increase in primary care visits based on
availability of new primary care services (Glass, Kanter,
Jacobsen, & Minardi, 2017). Studies examining the result
of increased access to Medicaid Expansion have shown
similar increases in utilization (Antonisse, Garfield,
Rudowitz, & Guth, 2019; Biener, Zuvekas, & Hill, 2017).
Table 2 Baseline Economic Impact of Tennessee APRNs in 2017
Employment Labor Income Value Added Output
Direct 25,503 $2,055,876,632 $2,255,724,897 $2,919,498,778
Indirect 3,814 $187,341,053 $323,147,092 $549,949,344
Induced 14,410 $693,520,052 $1,333,041,018 $1,977,922,069
Total impact 43,727 $2,936,737,737 $3,711,913,006 $5,447,370,191
4 Nurs Outlook 00 (2019) 1 7
A comprehensive review of the literature related to the
effects of Medicaid Expansion showed that increased
utilization and costs occurred more in year two than
year postexpansion (Antonisse, Garfield, Rudowitz, &
Guth, 2019). Another study (OMalley et al., 2019)
showed that increased utilization of primary care led to
reductions in emergency care, hospitalizations, and per
capita expenditures. The modeling used for this study
does not account for costs associated with implementation of full practice authority, including the startup cost
of setting-up an APRN-owned practice. According a
(CDC report 2019), the expenses and apprehension
associated with setting-up an APRN-owned practice
can be daunting. The expenses and the managerial
skills associated with establishing a practice and apprehension are a consideration.
In many local communities, health and healthcare
are economic engines that drive the local economy
(Mirvis, Chang, & Cosby, 2008). Several related factors
contribute to economic growth and development:
Healthier local residents, new jobs, and goods and services purchased by the local healthcare industry. For this
study, we did not examine changes in care access,
health status, or the potential two-way, mutually influential relationship among health, healthcare, and the
economic strength of a local economy.
The macroeconomic effects of FPA have been modeled in three other states: Florida (Unruh et al., 2018),
North Carolina (Conover & Richards, 2015), and Texas
(Perryman Group, 2012). The IMPLAN model was used
for the Florida and North Carolina studies. The Texas
study used a model developed by the Perryman Group
and refined over 30 years of use. A summary of the
effects in other states is shown in Table 5.
Although outside of the scope of our study, our findings complement the noneconomic gains associated
with APRNs attaining FPA. States with FPA have seen
an increased supply of APRNs (Reagan & Salsberry,
2013), particularly in primary care settings (Blewett,
2011; Kuo, Loresto, Rounds, & Goodwin, 2013; Loresto,
Jupiter, & Kuo, et al., 2017). This increase in primary
care providers has been shown to reduce mortality,
lower hospital readmission rates (Starfield, Shi, & Macinko, 2005; Chang, Stukel, Flood, & Goodman, 2011),
and significantly decrease annual per beneficiary
Medicare expenditures (Baicker & Chandra, 2004; Perloff, DesRoches, & Buerhaus, 2015).
Adding providers produces more competition. While
increased competition could lower primary care physicians incomes (Perry, 2009; Kleiner, Marier, Park, &
Wing, 2014), Pittman and Williams (2012) found that
physician incomes were more likely to remain stable.
Table 3 Added Economic Impact of APRNs and Full Practice Authority on State Economy, Baseline to 2025
Impact Employment Labor Income Value Added Output
Added Impact of Full Practice Authority, 20172025
Direct 4,489 $361,834,287 $397,007,582 $513,831,785
Indirect 671 $32,972,025 $56,873,888 $96,791,085
Induced 2,536 $122,059,529 $199,415,219 $348,114,284
Total impact 7,696 $516,865,842 $653,296,689 $958,737,154
Added Impact of Population Growth, ACA, and Inflation 20172025
Direct 10,405 $838,797,666 $920,335,758 $1,191,155,501
Indirect 1,556 $76,435,150 $131,844,014 $224,379,332
Induced 5,879 $282,956,181 $462,280,735 $806,992,204
Total impact 17,840 $1,198,188,997 $1,514,460,507 $2,222,527,038
Table 4 Cumulative and Layered Economic Impacts of APRNs from Baseline to 2025
Impact Employment Labor Income Value Added Output
Direct 40,397 $3,256,508,586 $3,573,068,236 $4,624,486,064
Indirect 6,041 $296,748,227 $511,864,994 $871,119,761
Induced 22,825 $1,098,535,762 $1,794,736,972 $3,133,028,558
Total impact 69,263 $4,651,792,575 $5,879,670,202 $8,628,634,383
Table 5 The Projected Macroeconomic Effects of Expanded APRN Authority in Three States
Effects Florida
(Unruh et al., 2018)
North Carolina
(Conover & Richards, 2015)
(Perryman Group, 2012)
Increase in total
economic output
$542.6 million to $1.24 billion $477 million to $883 million $16 billion
Increase in value added
or gross product
$339.5 million to $780.9 million $314 million to $495 million $8 billion
Increase in wages
and benefits
$238 million to $457 million $244 million to $452 million $5.2 billion
Additional jobs 4,518 to 10,290 3,848 to 7,128 97,205
Nurs Outlook 00 (2019) 1 7 5
Additionally, physicians not being required to spend
their limited time in supervisory activities likely would
lead to opportunities for improved efficiencies for
physicians and healthcare practices, which ultimately
could improve physician incomes (Liu & DAnunno,
2012). APRN incomes generally have improved in the
wake of FPA, as APRNs have been able to expand their
service provision (Kleiner et al., 2014). Granting Tennessee APRNs FPA also could help mitigate the challenges associated with recruitment and retention of
health professionals, particularly in rural areas (Tennessee Department of Economic and Community
Development, 2016). According to a recent study
(Barnes, Richards, McHugh, & Martsolf, 2018), the
number of NPs in rural primary care settings grew
from 17.9% in 2008 to 25.2% in 2016. Similarly, NPs in
urban primary care settings grew from 15.9% to 23%
during the same period. States with FPA had the highest NP presence, while states with reduced practice
authority had the fastest growth in NP primary care
presence (Barnes et al., 2018). States with restricted
scopes of practice had both slower growth and lower
NP presence. The authors theorized that tighter regulatory constraints may lead to productivity ceilings for
practices, resulting in slower growth in demand for
NPs in these states (Barnes et al., 2018).
The policy of granting FPA for Tennessee APRNs
aligns well with current Tennessee Governor Bill Lees
first executive order calling for accelerated development in Tennessees distressed rural counties, which
are those among the 10% most economically challenged in the country (Allison, 2019). The Appalachian
Regional Commission has classified 15 Tennessee
counties as distressed. Enhancing access in rural and
other underserved communities can facilitate economic development. The value of granting Tennessee
APRNs full practice authority can be realized with minimal fiscal impact to the state, while also enhancing
access in rural and other underserved communities,
spurring economic development, and promoting
choice and competition among providers.
The findings from our analysis can be used to broaden
discussions about FPA in Tennessee and other restricted
states and help draw new stakeholders to the conversations. Granting Tennessee APRNs FPA will benefit state
and local economies with substantial increases in economic output and employment opportunities. Future
health policy discussions, decision-making, and policymaking should include attention to the economic impact
of granting FPA to Tennessee APRNs.
The value of FPA should be defined in terms of how it
benefits individuals, populations, communities, and the
state. Our findings demonstrate the macroeconomic benefits of granting Tennessee APRNs FPA. Other economic
benefits, beyond the scope of this analysis, could include
improvements in health and healthcare as well as the
synergistic effects between good citizen health and a
strong economy. These are fertile areas for future study.
This case for the economic benefits of FPA augment
other points supporting this policy, including its potential
to improve the relatively poor health outcomes of many
Tennesseans (United Health Foundation, 2018) and
increase access to primary care services in many areas of
the state, most notably rural areas (Blewett, 2011; Chang,
Zhan, Mirvis, & Fleming, 2015; Hing & Hsiao, 2014).
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