Some states may allow nurses to do more without doctors

When COVID-19 hit the United States in 2020, state policymakers across the country jumped to expand access to health care. They temporarily allowed more telehealth, for example, and made it easier for medical providers to practice across state lines.

Many states also gave new authority to nurses, physician assistants and pharmacists, often dropping or loosening requirements for physician supervision during the emergency. Some states expanded the types of services non-physicians could provide — or their “scope of practice” — to allow more of them to administer vaccines or dispense narcotics for the treatment of substance use.

Many in those professions, who have long battled in state legislatures for more authority, said the pandemic proved their case. A handful of states, including Delaware, Kansas, Massachusetts, New York, Utah and Wyoming, have made some changes permanent. Supporters say more states should follow.

“You can’t be OK saying in the midst of a crisis, ‘Because you’re highly skilled in your profession, we’re going to remove the barriers of care, but now that we’re out of the crisis, we’re going to put the barriers back in place because now you’re dangerous,’” said Jennifer M. Orozco, president of the American Academy of Physician Associates and director of Advanced Practice Providers at Rush University Medical Center in Chicago. (AAPA recently changed its terminology for the profession from “physician assistants” to “physician associates” to underline its independence.)

But making some of the changes permanent requires crossing swords with the powerful American Medical Association and its affiliate state chapters. Physician groups have traditionally guarded against what they regard as incursions into care they believe only physicians should provide. And they have fiercely resisted what they perceive as attempts to diminish the authority of doctors.

“Removing physicians from the care team results in higher costs and lower quality of care,” the organization said in an emailed statement to Stateline. Rather than grant more independence to non-physicians, the organization said it supports efforts to broaden the pipeline of doctors and more evenly distribute physicians around the country.

There is a shortage of doctors, including primary care doctors, in the United States. The Bureau of Labor Statistics projects the growth rate of primary care doctors between 2021 and 2031 to be just 3% compared with nearly 46% growth projected for nurse practitioners and 28% for physician assistants, both of which are listed by the bureau as among the fastest growing occupations in the country.

Dueling studies

On its website, the American Medical Association trumpets its success in opposing state legislation that it describes as allowing “scope creep,” which it says threatens patient safety. In late 2021, the organization boasted of having 100 state legislative victories in “stopping inappropriate scope expansions of non-physicians.”

But non-physician organizations, such as the American Academy of Nurse Practitioners, and some scholars cite peer-reviewed research that casts doubt on the idea that giving more responsibility to non-doctors costs more or threatens the health of patients, many of whom live in areas with few physicians.

“The evidence is pretty clear that it does improve access,” said Matthew McHugh, professor at Penn Nursing at the University of Pennsylvania and senior fellow at its Leonard Davis Institute of Health Economics. “There is not a negative impact on quality, and a lot of regulations or constraints put in place by scope of practice restrictions are really not doing anything positive in the public’s interest.”

Susanne Phillips, associate dean of clinical affairs at the University of California, Davis School of Nursing, made a similar point. “We have 50 years of research that shows patient outcomes and satisfaction is the same,” she said. “There is no difference with states that have no physician supervision and states with supervision.”

A 2021 report by the National Academies of Sciences, Engineering and Medicine recommended that states remove barriers that prevent nurse practitioners from practicing “to the full extent of their education and training.” Those restrictions, the report said, decrease “the types and amounts of health care services that can be provided for people who need care,” especially in rural areas with few doctors.

The AMA counters with its own list of research, which it says demonstrates that nurse practitioners in some settings use more resources, have worse patient outcomes in emergency rooms, order unnecessary imaging tests in emergency rooms, and make fewer quality referrals.

Nurse practitioners

The two sides disagree about how much supervision physicians should have over treatment plans, prescriptions and referrals. Many states require doctors to review a certain percentage of medical charts completed by the nurse practitioners they supervise. States often limit the number of nurse practitioners each physician is permitted to supervise at one time and in many states, nurse practitioners must pay the expenses related to the supervision.

The AMA argues that such oversight protects patients. But nurse practitioners say they don’t need to be supervised by doctors when they are doing what they were trained to do. “All we are asking for is to practice to the full extent of our training and education,” said April Kapu, president of the American Association of Nurse Practitioners.

The nurse practitioner group says there are more than 355,000 licensed nurse practitioners in the United States. Nurse practitioners, like nurse midwives, clinical nurse specialists and nurse anesthetists, have graduate degrees beyond those required for registered nurses. They also have passed a national certification exam and received a state license to practice.

Kapu, a nurse practitioner in Tennessee, said supervision requirements are inefficient and prevent doctors from doing their own clinical work. During COVID-19, her state temporarily lifted its requirement that doctors review the medical charts prepared by nurse practitioners. “We would literally have had to pull physicians off the front lines to do records review full time,” she said.

According to the National Conference of State Legislatures, prior to COVID-19, 22 states plus Washington, D.C., had granted nurse practitioners full practice authority, waiving the supervision requirement. But many other states gave nurse practitioners more authority during the pandemic, usually by way of a governor’s executive order.

Many of those provisions expired when states lifted their emergency health orders. But Delaware, Kansas, Massachusetts and New York have permanently relaxed supervisory requirements. Kapu said other state legislatures are considering similar actions this year, adding that she was most optimistic about prospects in Indiana, New Jersey and North Carolina.

Other personnel

The 159,000 physician assistants in the United States face similar issues, according to the American Academy of Physician Associates. The organization said that during COVID-19, more than 20 states broadened the independence of physician assistants. The changes included giving more prescribing authority, waiving required physician associate to physician ratios, and eliminating requirements that doctors co-sign medical charts. Some also allowed health systems, rather than state authorities, to make scope of practice decisions.

As with nurse practitioners, many of these measures were temporary. In 2021, however, Utah and Wyoming made them permanent, following North Dakota, which in 2019 had become the first state to grant full practice autonomy to physician assistants.

Other medical disciplines also clamor for more independence or authority. For instance, while the American Pharmacists Association says that pharmacists are permitted to administer vaccines in all states, many restrict the types of vaccines pharmacists can give, the age of the recipient and whether a prescription is required. Some authorizations are tied to the existence of a health emergency.

In Colorado, a bipartisan group of legislators has introduced a bill that would allow psychologists, who do not have medical degrees, to prescribe drugs for the treatment of mental illness, a measure that psychiatrists, who are medical doctors, have strongly opposed elsewhere. The legislators say the measure would help address the shortage of psychiatrists in many areas, particularly rural regions.

Idaho, Illinois, Iowa, Louisiana and New Mexico already grant psychologists, who have received additional training in pharmacology, prescription authority.

The debate between physicians and non-physicians will continue as COVID-19 recedes. But Orozco, of the physician associates association, said the argument should be about what is best for the patient, not the medical providers.

“The question should be how can we help deliver in a way that makes sense and isn’t about us arguing about turf,” she said.