Scope of Practice a Hot Topic Across Nation

by David Gorn

A panel of health care experts, outlining proposed and pending changes in scope-of-practice laws across the country yesterday, said California's advancement of four bills in the current session is just the tip of the national legislative iceberg.

"There could never be more state activity at this level, because every single state is under pressure in terms of needing to solve workforce issues," said Kavita Patel, an internist at Johns Hopkins and the managing director for clinical transformation and delivery at the Engelberg Center for Health Care Reform at the Brookings Institution.

Patel was part of a web-accessible panel discussion sponsored by the Alliance for Health Reform and the Robert Wood Johnson Foundation. She said the pending and burgeoning need for physicians -- particularly primary care physicians and those practicing in rural or underserved areas -- has led state legislatures across the country to pursue laws to expand scope of practice, primarily for nurse practitioners and physician assistants.

"In our country, when we think about increasing access, we look to different laws around scope of practice," Patel said.

Patel said 827 bills were proposed nationwide to change scope of practice last year. She said 124 of them were enacted in 29 states.

In California, there are four bills pending in the Legislature: SB 491SB 492 and SB 493 were all authored by Sen. Ed Hernandez (D-West Covina) and were passed by the Senate and now are in the Assembly Committee for Business and Professions; SB 352, by Sen. Fran Pavley (D-Agoura Hills), also passed the Senate, as well as Assembly B & P.  

States have varying degrees of restriction on so-called mid-level providers, with 26 states requiring physician involvement in nurse practitioner decisions. In 11 states, including California, the laws require a collaborative agreement between physician and nurse practitioner, Patel said.

"Sometimes that can be onerous, and sometimes it can limit whether people are practicing in underserved areas," Patel said.

It's not just the scope of skills of NPs and PAs the laws hope to better utilize, Patel said. "Optometry, pharmacy and chiropractory all are doing more intense medical management across the country," she said. In California, two of the bills would expand optometrists' and pharmacists' scopes of practice.

"This scope-of-practice conversation isn't recent," said panelist Polly Bednash, executive director of the American Association of Colleges of Nursing.

Nurse practitioners "have been shown to dramatically improve access to care and maintain quality," she said. "Patient outcomes are comparable. This has created a growing consensus among policy makers and legislators that we need to make these changes."

But, according to Reed Blackwelder, president-elect of the American Academy of Family Physicians, all of the attention focused on expanding scope of practice is a little misplaced.

"Scope of practice is distracting. States that have allowed nurse practitioners expansion of scope of practice continue to struggle with the same issues as before," he said. "The independent NP has not solved this issue."

The real focus should be on team-based care, Blackwelder said, with a physician leading that collaborative group. "Team-based care is the answer," he said. "A team-based approach can improve primary care access and control health care costs."

"I have no problem with a team, but when one person has to constantly get permission, you put up barriers and you increase costs," Bednash said. "Constantly having to move through someone else slows down the flow of care."

Patel said there's another scope of practice issue on the horizon among the fastest-growing segment of health care providers -- home health care workers and community health care workers.

"The greatest growth we see is in home care aides and community health care workers," she said. "The industry is growing in leaps and bounds, and this conversation will spread to these other workers, as well."

Teresa Anderson
Please note that SB 352 is not a scope of practice expansion. Senator Pavley (SB 352) has introduced a bill sponsored by CAPA that would remove the archaic barrier that prohibits PAs from supervising MAs across all medical office settings. The task of supervising MAs is currently delegated to PAs, NPs, and CNMs in community clinic settings.

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