Are Scopes of Practice the Answer to Primary Care Workforce Shortages?

On November 4, the National Health Policy Forum hosted a discussion to examine the roles thathealth practitioner scopes of practice – state regulations that define the activities that a health professional may perform – play in determining patient access to primary care providers. Four speakers provided information about the current situation, the views of various professions, what states have done, and what state and federal policymakers should consider.
David Goodman of Dartmouth College kicked off the conversation by sharing data about the role of nurse practitioners (NPs) in the primary care workforce. Almost 20% of primary care clinicians are NPs. While scope of practice laws for NPs vary widely from state to state, over time the trend has been towards increased autonomy for NPs. While scope of practice expansions may not solve the primary care workforce shortage on their own, broader scopes of practice allow NPs to practice “at the top of their license,” that is, to perform and be reimbursed for all the clinical skills they are trained in.
Linda Cronenwett, Professor at the School of Nursing at the University of North Carolina – Chapel Hill, outlined barriers that advanced practice nurses (APNs) face in realizing a full scope of practice. These include:

• Limitations on scope of practice in state regulations;
• Reimbursement policies that limit or preclude payment for services provided by APNs, (e.g. federal reimbursement policies that require “physician leadership”);
• Policies that prevent consumers from selecting an APN as their primary care provider;
• Regulations that limit the services and referrals that APNs can provide;
• Differing interpretations of “team practice.”

This last point is especially poignant as various provisions of the Affordable Care Act encourage team care. While physicians may interpret “team practice” as a synonym for “physician-directed,” other providers view “team practice” as a group of professionals, each practicing within their scope of practice, to deliver coordinated care.
Ned Calonge, President and CEO of the Colorado Trust, presented the process, findings, and recommendations of the Colorado Scopes of Care Advisory Committee. In 2009, Colorado formed this committee, chaired by Calonge who was with the Colorado Department of Public Health and Environment at the time, to conduct a systematic evidence review and make recommendations about scopes of practice for advanced practice nurses. Based on the Committee’s recommendations, the existing requirement for APNs to collaborate with physicians was removed and replaced with a one-year physician mentorship for new APNs. The state also created an ongoing nurse/physician task force to inform licensing boards on scope of practice issues.
Barbara Safriet, Visiting Faculty at Lewis and Clark Law School, defined scope of practice issues in three words:

• Can: The ability of health care providers to deliver services, based on the education and training that gave them their clinical skills.
• May: The legal authority health care providers are granted by their state practice acts. (Only physicians have unlimited legal authority.)
• Pay: State, federal, and private insurers set reimbursement policies for different kinds of providers.

Each of the speakers echoed the recommendations of the Institute of Medicine in its recent reportThe Future of Nursing, which calls for all providers to be allowed to practice to the full extent of their education and training. The Forum’s speakers had additional recommendations for state and federal policymakers who are interested in updating clinical practice acts and payment policies:

• Look for the least restrictive regulatory mechanism that is consistent with the state’s goals;
• Pay for health care based on value and quality of service, rather than on type of provider;
• Use insurance exchange regulations, such as those defining ‘essential community providers’ and ‘network adequacy’ to include rather than exclude non-physician provider types.

As the Affordable Care Act is implemented and more Americans gain health insurance, the demand on primary care providers will only increase. Scope of practice expansions may be one tool states can employ to help meet that demand. Is your state considering expanding scopes of practice? Tell us on your state’s scope of practice milestone page or in the blog comments below.
[Note: This blog post originally appeared on The SHAP DiaBlog run by the National Academy for State Health Policy, which shares lessons and best practices learned from the 13 states expanding access to coverage through participation in the State Health Access Program sponsored by theHealth Resources and Services Administration.]