One of the interesting stories to watch in the coming months in the states is the fight over “scope of practice.” That means: who gets to do what, and under whose supervision. It basically pits doctors against other health care providers – nurses, nurse practitioners, physician assistants, etc. They are sometimes called “extenders” or “non-physician providers.” (There are also big fights within dentistry.)
These fights would heat up even without the Affordable Care Act – you’ve all heard about the shortage (in some communities at least) of primary care physicians. And you know there is an aging population that is going to need access to primary care. Throw in the health care law – millions of newly insured people entering the system, as well as delivery system reforms and care innovations that encourage more primary care, care coordination and team-based medicine that invites a larger role from those “extenders.” (Can you tell I don’t like that word?)
But state law – some state laws – may limit what these health care workers can do or require so much supervision by a physician that it is tantamount to a limit. The nurses and physician assistants use the phrase “practice to the top of their license” to mean they want to be able to do everything they are trained and licensed to do. There also are questions about how insurance plans address these different kinds of providers, and what options/explanations/information patients are given about who they are going to see at any particular juncture in their care.
In my next Covering Health post, I will share two recent stories I liked a lot about the changing role of nursing (which isn’t the only scope-of-practice fight but it’s the one you hear most about). First I want to provide some resources and thoughts on how to cover this topic more broadly.
Keep in mind that there are national trends but it’s a state-based legal problem. The federal government doesn’t have much leverage to fix it. But there are a lot of ways to tell this story: a policy story, a clash of the interest groups, a health system innovation story, a chronic disease management story, a cost-saving story … you get the idea.
I also wonder whether there’s a generational aspect to these disputes – are younger physicians more accepting than older ones of these other professionals? Or are they more turf-aware because they are paying off their huge medical school loans? Do some specialties work better with nurse practioners than others? (My personal, utterly anecdotal and statistically meaningless experience is that, in my community, physician assistants seem to be relatively common in orthopedic practices. Never run into them anywhere else.)
The Alliance for Health Reform and Robert Wood Johnson Foundation put together a toolkit examining some of these health care workforce issues. It’s a brief (about two pages) snapshot of the nursing workforce and then a few pages of resources and sources and explanations. The Institute of Medicine did a report in 2010 showing that allowing nurses to practice to the top of their licenses is safe.
The National Conference of State Legislatures has an excellent data bank – updated every two weeks – on all 50 states and dozens of aspects of scope of practice. Not just the doctor-nurse fights but the paramedics, physical therapists, podiatrists (and that’s just the letter P!).
Various medical societies have positions on this (Academy of Family Physicians, etc.) and you can contact your state medical association. The American Medical Association website has some information on related litigation. There’s also a group called the Patients Rights Coalition (which I’ve personally never dealt with) that represents about 35 health professions, and the website may be helpful .
Watch for my next post, featuring two stories that looked at the role of nurse practitioners in primary care clinics in underserved areas.