Healthcare Scope of Practice Debates Continue

November 25, 2014
Aubrey Westgate

Scope of practice for nurse practitioners and physician assistants is changing. Here's what physicians should know.

The physician shortage coupled with higher patient demand for healthcare services is opening several doors for nurse practitioners and physician assistants. But the debate, regarding which doors should be opened, continues.

New "turf  battles" over the appropriate scope of practice of advanced practitioners seem to ignite on an almost monthly basis, and it can be difficult to keep track of what changes are taking place, where, and when. In the first seven months of 2014 alone, 44 states and the District of Columbia "modernized" their PA practice laws and regulations, according to the American Academy of Physician Assistants (AAPA). On the NP front, Minnesota recently became the 19th state (in addition to Washington, D.C.) to allow NPs to practice without physician supervision.

Physician organizations are quite vocal regarding scope of practice issues, particularly when it comes to the independent practice of NPs. Both the AMA and the American Academy of Family Physicians (AAFP) have repeatedly stressed that healthcare teams should be "physician-led."

Regardless of where you stand on this issue - and many others related to scope - it's likely you will begin working more closely with advanced practitioners, as more enter the healthcare system each year. Since 1999, the number of NPs practicing in the United States has jumped from 60,000 to more than 192,000, according to the American Association of Nurse Practitioners (AANP). By 2025, that number is expected to reach 244,000. On the PA front, the number of PAs practicing has nearly doubled every decade since the first PAs graduated in 1967, according to the AAPA. Today, more than 100,000 certified PAs practice in the United States, and more than 7,000 matriculate into the workforce each year.

To ensure that you are utilizing this growing workforce of advanced practitioners in smart ways, we asked the AMA, the AAFP, the AAPA, and the AANP to weigh in. Here's a closer look at some of the most recent scope-of-practice changes; and how these four organizations say physicians and advanced practitioners can learn to work better - together - to improve patient care.

Physician assistants

Many of the recent changes to PA legislation have been due to the need to update "outdated" state laws, says AAPA President John G. McGinnity. "For us, being a new profession, we weren't around when a lot of these laws were created, so we weren't specifically named," he says.

One recent example of this type of change in legislation occurred in March, when Oregon Gov. John Kitzhaber signed Oregon Senate Bill 1548 into law. The bill clarified and updated 75 statutes that reference "physician" to also include references to "physician assistant."

Also propelling PA legislation changes, McGinnity says, is a growing awareness of the benefits PAs bring to patient care, as team-based care concepts like Patient-Centered Medical Homes gain momentum. "You're seeing people rethink team medicine, and PAs, we were team [oriented] before team was cool," says McGinnity. "We've been doing team-based medicine since the 1960s, so we're very comfortable in that environment."

In January, the Indiana Office of the Secretary of Family and Social Services adopted a regulation that allows adult mental health habilitation services to be covered by Medicaid. PAs are included within the new rule as "authorized healthcare professionals" and "qualified behavioral health professionals," which allows them to administer drugs and order medical services for adult mental health patients. In July, Missouri Gov. Jay Nixon signed a bill authorizing PA enrollment in the state's Medicaid program. Enrollment authorizes PA services to be billed under the PA's National Provider Identifier or a unique modifier.

When it comes to the issue of PA independence, the AAPA believes PAs should practice under physician supervision, but that the extent of that supervision should be determined at the practice level. It's about partnering and communicating with the physicians in the practice to determine "what works best for the two of us," says McGinnity.

The recommendation that scope should be determined at the practice level is one of the AAPA's "six key elements" that it says should be included in every state's PA practice act. The other elements are:

• Using "licensure" as the regulatory term to describe the process by which states authorize PAs to practice;

• Enabling supervising physicians to delegate prescriptive authority to PAs;

• Enabling practices and physicians to determine PA on-site requirements;

• Enabling practices and physicians to determine chart co-signature requirements; and

Eliminating restrictions on the number of PAs with whom physicians can practice.

States vary widely when it comes to adopting these elements. At press time, four states, (Massachusetts, North Dakota, Rhode Island, and Vermont), have adopted all six; five states, (Alabama, Iowa, Kentucky, Oklahoma, and West Virginia), have adopted only one.

For more information on the six key elements, visit bit.ly/six-elements.

Nurse practitioners

The most hotly debated issue when it comes to NP scope of practice, of course, is whether they should be able to practice without physician supervision or a collaborative relationship with a physician. In May, Minnesota became the 19th state to allow this, just after Connecticut did so in April.

The AANP advocates for "full scope of practice" for NPs, which it defines as the ability to evaluate patients, diagnose conditions, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing. According to the AANP, Alaska, Arizona, Colorado, Connecticut, Hawaii, Idaho, Iowa, Maine, Minnesota, Montana, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, Vermont, Washington, and Wyoming have adopted full scope of practice for NPs.

Taynin Kopanos, vice president of state government affairs at the AANP, says that many states have "modernized" their NP licensure laws in the past few years due to factors such as increased workforce needs, the aging patient population, and increasing patient demand as a result of the Affordable Care Act. "When we're talking about modernizing licensing law, we're talking about retiring that conditional requirement that says for a nurse practitioner to provide the services they're educated and prepared to provide, they have to have that external relationship [with a physician]," says Kopanos. "What [they're] asking for would be the equivalent of a family physician having to have authorization from a surgeon before [the family physician] could provide a certain service to that patient, even if that family physician is educated and ready to provide it. It's that linking of one profession's ability to provide care to a patient that really is handicapping the ability of our healthcare system to meet patient care needs, and is really restricting how clinicians can practice together."

For eight key facts to share with patients about NPs, view "Eight Facts about Nurse Practitioners for Patients."

As more states face higher patient demand, more could continue to expand NP scope of practice. Already in the works for instance, New York's NPs with more than 3,600 hours of experience will be able to practice without a written practice agreement with a supervising physician starting in January 2015.

"I think there's a perception that we are seeing major shifts in NP scope of practice over the last few years, when truthfully the scope of care and scope of services NPs have been educated in and certified to provide for nearly 50 years hasn't changed," says Kopanos. "Patients' ability to directly access them because of state law has been changing."

For more on NP scope of practice regulations in your state, visit bit.ly/NP-by-state.

Patient access concerns

Clearly, patient access to care is a key player in scope of practice debates. But many physician organizations, such as the AAFP and the AMA, say the solution lies in team-based care, not NP independence.

"We really believe that every patient in this country deserves a physician and a nurse as basically a team," says AAFP President Reid Blackwelder. "Independence of practice and siloing of care just continues to fragment our healthcare system. The issue really isn't independence so much as really creating effective teams. That is the only thing that has been shown to improve patient outcomes, improve access, and decrease costs." For more on the AAFP's scope-of-practice recommendations, visit bit.ly/AAFP-recs.

The AMA takes a similar stance, agreeing that physician-led teams are the best approach. These teams should "utilize the unique knowledge and valuable contributions of physician assistants, nurse practitioners, and other healthcare providers to enhance patient outcomes," says AMA President Robert M. Wah, adding that innovative physician-led teams are already improving care quality while reducing care costs at top healthcare systems across the country. "The AMA looks to these systems as evidence that physician-led, team-based models of care are the future of American healthcare," he says.

Working better together

While scope of practice remains a contentious issue, it's clear that advanced practitioners are playing, and will continue to play, a growing role in the healthcare system. Here are strategies to ensure your practice is working with them in smart ways:

Find the right fit. If you are considering hiring an advanced practitioner, make sure the candidate's background and skills match up to your practice's needs. For instance, if your practice offers hospital medicine, make sure the potential new hire has experience in a hospital setting, says Blackwelder. This is especially critical, he adds, if you are considering hiring an NP. "In many ways the PA's training is going to be more standard [as] nationally, there's a standardized educational process," he says. "The NP's exposure is different and so it really will require more of that clarity of their comfort zone."

Form a strong partnership. If you are a physician and your practice is adding an advanced practitioner, work closely with that individual at the outset, says Blackwelder. "There likely needs to be some more time of working together, probably more closely than you would with a physician, to make sure that their approach and their style reflects yours and that you're comfortable with that [advanced practitioner]," he says. In addition, make sure that you are adhering to your state's scope-of-practice requirements.

Take special considerations if the advanced practitioner is a recent graduate. Carolyn Montoya, an NP with more than three decades of experience and a teacher at the College of Nursing at the University of New Mexico, says practices should allot 20 minutes to 30 minutes for a new NP's patient visits. "It doesn't mean that they're going to stay at that level; it means that if you are hiring a new grad, you've got to give them time," says Montoya. In addition, she says, physicians should prepare to be consulted by the new grad more frequently.

Have a healthy dialogue. If you are adding an advanced practitioner or you are currently working with one, spend some time getting to know that individual on a more personal and professional level. For instance, Montoya says physicians should ask NPs about their area of expertise and their strengths. Also, discuss your work style and expectations. For instance, will you be on-site with the NP? And, how will the NP be able to consult with you, if needed?

McGinnity, who also teaches at Wayne State University in Detroit, agrees that communication is critical. PAs are trained with a teamwork approach, so they are going to expect to be provided with that sense of teamwork and "back up" when necessary, he says. "I think your new, fresh PA comes out [of training] understanding that it's perfectly acceptable and expected to call a physician if there are questions ..."

Foster respect. Cultivate a healthy workplace by ensuring that all members of your healthcare team value each others' unique strengths. For instance, a physician's relationship with his advanced practitioner should be "collegial and supportive," says Ken Miller, president of the AANP. "All of us have the same goal in mind, which is to improve patient outcomes, so a physician should not treat me any differently than he treats a physician colleague, and I should not treat him any differently than I would treat a nurse practitioner colleague."

Build on strengths. Identify the benefits advanced practitioners bring to your practice, and cultivate them. NPs, for instance, focus closely on prevention, have a strong background in patient education and motivational interviewing, and have the ability to manage complex patients with comorbidities, says Kopanos. In addition, she says, NPs bring advanced expertise in key areas to practices, such as pediatrics or women's health, because much of their training and education focuses on a specific patient population.

PAs, McGinnity says, also bring several benefits, such as increasing patient satisfaction, practice efficiency, and potentially, physicians' incomes. They are also trained in the medical model with a strong focus on teamwork, which helps them meld quickly with new practices and new physicians. "We're educated really similarly to the physicians that we work side-by-side with," says McGinnity.

Find what works for your community. Of course, improving patient access to care is one of the key benefits advanced practitioners can bring to practices. To ensure you are working with NPs and PAs to form a smart healthcare team for your community, ask yourself what its needs are. For instance, does your patient population benefit from evening or weekend hours, and would it be helpful to offer a satellite clinic in a rural area? "Those kinds of questions can help direct what the ideal team situation might be," says Blackwelder.

In Summary

The ongoing physician shortage, increasing patient demand, and growing acceptance of team-based care models are shedding new light on the benefits advanced practitioners can bring to practices and communities. Here's how physicians can ensure they are working with this growing healthcare workforce in smart ways:

• Make sure you are complying with your state's scope-of-practice regulations

• Work with advanced practitioners whose skills and backgrounds match up to your needs

• Give new advanced practitioners extra time to spend with patients

• Identify how advanced practitioners can help you improve patient care

Aubrey Westgate is senior editor for Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the November/December 2014 issue of Physicians Practice.