- Overhauls to scope of practice (SOP) laws for advance practice registered nurses (APRNs) and physician assistants (PAs) could improve practice efficiency and increase patient care access, according to a recent report from the Brookings Institute’s economic policy project, The Hamilton Project.
SOP laws seek to regulate the practice authority for various clinicians, including APRNs, PAs, and even physicians. These medical professionals obtain licenses to practice medicine, and SOP laws offer state-by-state definitions for what that license allows clinicians to do.
“SOP laws vary depending on the practitioner group being considered, but all laws specify the degree of independent practice that is permitted, ranging from no specific requirements, to collaborative or consultative arrangements with physicians, to supervisory relationships with physicians,” The Hamilton Project explained.
But these laws are in many cases restrictive, the report authors explained. This can have consequences on practice efficiency and patient access to care. Notably, restrictive SOP could reduce employment for APRNs and PAs, which decreases the supply that healthcare organizations use to meet patient demand.
As the healthcare industry faces a growing physician shortage, some industry experts have recommended the relaxing of SOP regulations. This policy change could have two implications, experts have posited. First, it could incent more aspiring medical professionals to enter the field. Second, it could free up existing APRNs and PAs to deliver higher-level care.
Critics of the proposal have stated that expanding practice authority for APRNs and PAs could have negative consequences, the report pointed out. Care delivery from a non-physician clinician could water down care quality. Critics have also said there is little evidence indicating that expanding APRN and PA practice authority could improve care and costs.
However, a literature review completed by The Hamilton Project found benefits to expanding SOP for non-physician clinicians. For one, it modestly improves patient access to care.
When a patient replaces her physician with an APRN or PA, care access does not usually improve. However, when those clinicians are hired in addition to physicians, it has a positive impact on patient care access because there are more clinician to meet consumer demand.
APRNs and PAs may also be more cost-efficient for patients who previously neglected care because treatment as unaffordable.
Additionally, care quality does not typically deteriorate when SOP laws relax.
Because of these benefits, The Hamilton Project recommended states revisit their SOP laws and expand practice authority for APRNs and PAs.
“Consistent with the recommendations of the Federal Trade Commission (FTC; 2014), we propose that state policymakers enable APRNs and PAs to be fully authorized to practice in accordance with their education, training, and experience,” the organization wrote. “This would enhance competition in the healthcare sector by mitigating the anticompetitive consequences of administratively burdensome SOP laws.”
In addition to improving practice efficiency, leaders from The Hamilton Project expect a policy change to improve patient access to care, a social determinant of health plaguing patients across the country.
“The overriding goal of this proposal is to enable labor markets for health-care providers to work uninhibited by unnecessary state-based SOP restrictions,” the group said. “This would encourage competition among providers as they respond to the demand of patients and payers to increase patient access to care at more affordable prices.”
In theory, restructuring SOP laws should allow APRNs, PAs, and physicians to specialize in their areas of expertise. This could increase competition in the medical market which could enable patient access to care at a more affordable price.
Allowing APRNs and PAs to practice at the top of their licenses would also increase the number of providers available to deliver some medical services to meet the demands of a growing patient population. As the healthcare industry emphasizes value-based care, patient wellness, and preventive care, APRNs and PAs can deliver this type of care.
Specifically, the recommended policy changes call for a reduction in supervising protocol for APRNs and PAs. This could free APRNs to accomplish tasks such as prescribing medications. It could also facilitate fluidity in practice ratios for PAs and physicians, making a practice more agile and able to meet patient demands.
It could also allow PAs and physicians to determine the parameters of their own unique relationships. There may be some situations in which a PA should have rigid oversight from a physician, but in others that relationship should be relaxed to facilitate more fluid care delivery and access.
“This is especially important given that supply and demand forces vary markedly across urban and rural market areas, as well as across the changing organizational structures (e.g., large group practices, ACOs, multihospital systems) within which these professionals work,” The Hamilton Project explained.
Project leaders advised states to maintain some standards calling for APRN and PA collaboration with physicians. This could facilitate more team-based care within an organization, which is one of the underlying principles of value-based care.
Of course, states need to make some considerations. For example, granting greater practice authority to NPs and PAs could increase the malpractice liability for physicians. New laws should ensure more liability is placed on the non-physician clinician.
“As states move to eliminate supervisory relationships and APRNs or PAs are able to purchase their own malpractice insurance, the physician will eventually be insulated from this liability burden,” the report authors asserted.
Additionally, federal and state governments must assess the billing implications of granting more practice authority for APRNs and PAs.
This proposal is for state SOP regulations, not nationwide regulations, the authors concluded. However, federal policymaker support will be necessary to create buy-in for expanded practice authority for APRNs and PAs.