Examining Scope of Practice for Health Care Workers  

By Sydne Enlund  | Vol . 26, No. 13 / April 2018

LegisBrief logoDid you know?

  • Twenty-eight states have enacted scope of practice legislation since 2015.
  • Nearly 80 percent of nurse practitioners deliver primary care.
  • In rural and underserved areas, physician assistants may be the primary care providers at clinics where a physician is present only a few days a week.

By 2030, the demand for primary health care services is predicted to outpace the supply of primary care physicians, partly due to an aging population and higher rates of chronic diseases. One strategy states are employing to address physician shortages—particularly for rural and underserved areas—involves using a broader range of health professionals to meet an area’s health care needs. This can be accomplished by expanding certain health care workers’ “scope of practice”—or range of services they are allowed to perform.

Nurse practitioners (NPs) and physician assistants (PAs) increasingly address workforce shortages by providing care independently or with physician oversight. Incorporating these providers into primary care can help alleviate the pressures of physician shortages. For example, nurse practitioners spend fewer years in education and training than physicians, so they can enter the workforce more quickly. Studies have shown that PAs are more likely to practice in a rural setting than doctors, provide high-quality care, and free up physicians’ time for more complicated health conditions. Since each state has its own specific laws and regulations defining the responsibilities of these providers, the range of services they can perform varies from state to state.

NCSL’s new Scope of Practice Policy website provides state policymakers with resources about scope of practice issues for nurse practitioners and physician assistants, as well as dental hygienists and dental therapists. The website features 11 interactive state policy maps and a legislation database that has tracked 214 bills related to nurse practitioners and physician assistants since the 2015 legislative sessions. This easily accessible resource helps state leaders as they consider ways to meet the health care needs of their constituents.

State Action

State scope of practice laws and regulations define the roles and responsibilities for health professionals’ licenses. For decades, states have taken steps to increase the types of procedures and treatments that are permitted by law, regulation and licensure for non-physician primary care providers to address the needs of an evolving health care landscape. Proponents of these laws say providers such as nurse practitioners and physician assistants can provide needed services in areas with physician shortages, and can provide effective care without compromising quality. Some physician groups disagree, arguing that physicians’ longer, more intensive training equips them to diagnose more accurately and treat patients more safely.

According to the American Association of Nurse Practitioners, 22 states and the District of Columbia allow nurse practitioners to diagnose, treat and prescribe medications without physician supervision. Twenty-eight states either require collaborative agreements that outline an NP’s practice authority, or direct physician supervision of nurse practitioners to diagnose, treat and prescribe.

Physician assistants collaborate with physicians as required by law, often relying on a collaborative agreement that outlines the specific activities permitted and defines the relationship between the physician and the physician assistant. Thirty states permit PAs to practice with adaptable collaboration requirements, allowing them to practice off-site from the physician and removing limitations that require physicians to be within a certain distance of PAs.

Legislators have considered dozens of bills over the past several years assessing their existing state policies related to scope of practice. The three most recent states to pass legislation changing scope of practice for nurse practitioners were Maryland and Nebraska in 2015 and South Dakota in 2017.  Nurse practitioners in those states are now allowed to practice without physician oversight. Supervision requirements for physician assistants are determined either at the practice level with a physician or outlined in state statute or administrative rule.

New Mexico recently passed legislation to allow physician assistants to have a collaborative relationship with a physician instead of a direct supervisory relationship. In 2015, New Jersey lawmakers voted to allow greater flexibility in the way physician assistants provide care. The requirement that a physician must always be present was removed and a physician assistant may now work with a physician to define his or her personal scope of practice.

Federal Action

The Department of Veterans Affairs (VA) allows nurse practitioners to practice independently without physician supervision, and to the full extent of their training at VA facilities across the country. This is clarified under a new federal rule made final in January 2017. VA officials believe the new rule makes it easier for patients to be seen in a more timely manner by a health care professional since it increases the number of primary care providers available to examine and treat patients.

At least 5,000 nurse practitioners work in the VA system, according to the American Association of Nurse Practitioners. They provide many of the primary care services that have traditionally been provided by physicians.

The new federal rule applies only to nurse practitioners working in federal facilities that are part of the VA system. Outside VA facilities, NPs must follow state laws regarding their practice authority. For example, in many states, nurse practitioners in non-VA facilities must practice under the supervision of a physician.