Nurse practitioners (NPs) and physician assistants (PAs) have become essential components of the healthcare workforce, particularly in addressing primary care shortages and expanding access to medical services. Both professions were developed in the 1960s to meet the growing healthcare demands following the establishment of Medicare and Medicaid. NPs, who are advanced practice registered nurses, receive specialized graduate-level education that enables them to assess, diagnose, manage, and treat various medical conditions, often serving as primary care providers, especially in rural and underserved areas. PAs, trained in a medical school curriculum modeled after physician education, collaborate with doctors to diagnose illnesses, develop treatment plans, and prescribe medications. NPs and PAs have evolved into critical healthcare providers, with advocates claiming they improve access to care, ease physician workloads, and enhance patient outcomes. However, some medical associations and physician groups argue that reducing supervision requirements could compromise care quality and patient safety.
With physician shortages looming and access to care for millions of Americans hanging in the balance, scope of practice expansion has reemerged as a hot-button issue within medical communities as federal agencies and state legislatures seek solutions for care access and quality of care concerns. What is scope of practice? Often based on laws, regulations, and professional standards established by state legislatures, scope of practice can be defined as the activities that a person licensed to practice as a health professional is permitted to perform.(1) Scope of practice laws vary significantly across states, ranging from full practice authority (allowing NPs and PAs to practice independently) to restrictive laws requiring physician collaboration and oversight.(2) In Georgia, NPs must have collaborative agreements with physicians for key elements of their practice and are not allowed to prescribe Schedule II controlled substances or sign disabled person placard forms. Medical staff reviews are required for new credentialing, and NPs can sign death certificates with physician oversight. The state does not define NPs as primary care providers and lacks clear laws on their ability to refer patients for physical therapy.(3) In New York, NPs have full practice authority, allowing them to independently diagnose, treat patients, and prescribe medications, including Schedule II drugs, without physician involvement. NPs can join medical staff, are recognized as primary care providers, and can refer patients for physical therapy. They are also authorized to sign death certificates and disabled person placard forms, and complete the state’s MOLST form, giving them wide-ranging autonomy in patient care.(3) The stark contrast in SOP laws between states such as Georgia and New York highlights the significant impact state regulations can have on NPs’ autonomy and ability to provide care. While restrictive laws in Georgia limit NP practice and necessitate physician collaboration, New York’s full practice authority grants NPs greater independence. These variations raise important questions about how expanding scope of practice laws can affect healthcare access and physician workload, a topic explored in the next section.
Expanding scope of practice laws for NPs and PAs may improve access to healthcare by allowing these professionals to serve as primary care providers, particularly in areas with physician shortages. According to the Bureau of Health Workforce’s 2023 report, NPs and PAs are increasingly filling primary care roles in underserved communities, helping to address gaps in healthcare availability.(4) By easing scope of practice restrictions, these practitioners can help reduce physician burnout by distributing the patient load more evenly. Research indicates that states with less restrictive scope of practice laws have experienced improved care accessibility and reduced patient wait times. However, data from the American Medical Association suggest that while expanding practice authority contributes positively, it may not fully resolve physician shortages, highlighting the need for comprehensive solutions that include but are not limited to scope of practice reforms.(5)
Ongoing policy debates at the state and federal levels continue to shape discussions on expanding scope of practice for NPs and PAs. Proponents, such as the American Association of Nurse Practitioners, advocate for full practice authority, emphasizing its potential to improve access to care in underserved areas.(6) Recent legislative efforts in states such as California and Florida reflect these efforts. However, the American Medical Association (AMA) has voiced strong opposition, citing concerns about patient safety and care quality, successfully challenging scope expansions in several states.(7) For example, in California, the California Medical Association opposed full practice authority for NPs, citing safety concerns, while in Florida, physician groups have pushed for maintaining oversight. In Texas and Mississippi, the AMA successfully fought against granting full independence to NPs and PAs, citing risks to care quality.(2) While research supports improved access in states with more autonomy, ongoing debates continue about the impact on long-term care quality and safety.
Expanding scope of practice for NPs and PAs presents a prospective opportunity to improve healthcare access and alleviate physician workloads, especially in underserved areas. By granting these professionals greater autonomy, states can reduce wait times, expand primary care capacity, and address physician shortages. However, ongoing debates underscore the need for balanced policy decisions considering accessibility and quality of care. Continued research is essential to ensure that scope expansions benefit patients without compromising safety or the overall standard of healthcare delivery.
References
What is scope of practice? American Medical Association. https://www.ama-assn.org/practice-management/scope-practice/what-scope-practice . Accessed October 18, 2024.
Kraus EJ, Thompson TE. Debate continues around scope of practice expansion for APPs. National Law Review. https://natlawreview.com/article/debate-continues-around-scope-practice-expansion-apps . Accessed October 18, 2024.
Nurse practitioner scope of practice laws. Barton Associates. https://www.bartonassociates.com/locum-tenens-resources/nurse-practitioner -scope-of-practice-laws/. Accessed October 18, 2024.
State of the Primary Care Workforce, 2023. HRSA. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/state-of-primary-care-workforce-2023.pdf . Accessed October 18, 2024.
Robeznieks A. Amid doctor shortage, NPs and PAs seemed like a fix. Data’s in: nope. American Medical Association. https://www.ama-assn.org/practice-management/scope-practice/amid-doctor-shortage-nps-and-pas-seemed-fix-data-s-nope . Accessed October 18, 2024.
Kidd VD, Amin A, Bhatia N, et al. Optimal use of advanced practice providers at an academic medical center: a first-year retrospective review. Cureus. 2023;15(1):e34475. https://pmc.ncbi.nlm.nih.gov/articles/PMC9889205/pdf/cureus-0015-00000034475.pdf .
AMA successfully fights scope-of-practice expansions that threaten patient safety. American Medical Association. https://www.ama-assn.org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threaten . Accessed October 18, 2024.