Mind the Gap: Emerging Roles for Non-Physician Health Care Providers

As of December 2010, 66 million Americans lived in a primary medical health professional shortage area, while only around 10 percent of physicians practice in those areas. The coverage expansions in the ACA will place additional strain on the existing primary care system, which has led some states to look at creative ways to provide access to health care services.
One tool for improving access to primary care is updating scope of practice regulations for non-physician providers like physician assistants and nurse practitioners. States — which largely regulate scope of practice through licensing boards — can allow non-physician providers to provide an expanded set of services to populations in underserved areas. Some states are already thinking about this issue. After passage of the ACA, 28 states began considering a reexamination of their scope of practice regulations for nurse practitioners.
To determine whether altering scope of practice regulations is necessary to improve access to care, states may want to first develop a plan to examine or assess scope of practice policies. A few states have already done this, and some have gone further by expanding the role of existing non-physician providers or even creating new provider models. For example:

• Because California is one of 23 states that does not require direct physician involvement in services performed by nurse practitioners, Los Angeles county recently increased use of nurse practitioners in medical homes in order to meet the growing health care demands of residents and to comply with the ACA. The new initiative employs nurse practitioners to provide primary care to patients instead of physicians. This is critical for Los Angeles county, which is currently experiencing a shortage of primary care physicians.

• Last year, Minnesota approved the creation of two new oral health providers, Dental Therapists and Advanced Dental Therapists. These providers will practice in low-income settings that cater to under served patients and provide basic oral health services such as dental sealants, x-rays, and restorations.

Some additional states are taking the initial steps to examine the possibility of changing scope of practice regulations:

• Rhode Island’s health reform task force recently recommended that the state expand the role for physician assistants and nurse practitioners.
• Washington’s Joint Select Committee on Health Reform Implementation convened an advisory group on workforce issues. The work group discussed many issues including whether it is necessary to create a new mid-level provider in the state and expanding scopes of practice for existing providers.

Other states are taking a more cautious approach:

• In Oklahoma, Governor Mary Fallin just signed a bill that requires all new scope of practice regulations be approved by the state legislature. This new law limits the ability of the licensing board to make changes to scope of practice regulations.

Is your state examining scope of practice policies? Share or discuss your state’s work on your state’s milestone page on State Refor(u)m. To engage in a cross-state discussion about this milestone visit State Refor(u)m’s national discussion page.