Health Professions Regulation in the US

The Impact of Scope of Practice

A key goal of health reform in the US is to improve population health through expanded access to health insurance. Demand for high-quality, cost-effective, basic health services is anticipated to grow, particularly for underserved populations. However, there is also growing concern about the impact of health professions scope of practice on access, quality, and cost of health services. Since health professions regulation falls under state jurisdiction, the legal scope of practice for a health profession is typically defined in a state-specific scope of practice act. These acts describe the services that professionals can provide and under what conditions they can be provided. Scope of practice acts also define the requirements for education and training, certification and licensure, and supervision. Restrictive legal scopes of practice often serve as a barrier to effective and efficient delivery of health services.

Key Issues and Challenges Related to Scope of Practice Regulation

Legal Scope of Practice vs Professional Scope of Practice or Competence

  • While a health professional may be trained and competent to provide a service, a restrictive legal scope of practice in a state may prohibit him/her from providing a service in that state
  • Legal scope of practice and professional competence overlap, and the amount of overlap varies by state and by profession (eg, state-to-state scope of practice variation for nurse practitioners)

Overly Restrictive Scope of Practice for a Profession Can Limit Patients’ Access to Care

  • When a service can only be provided by a more highly skilled professional, it can increase the cost of that service (eg, a nurse can immunize a patient while a medical assistant cannot)

Lack of Consistency in Scope of Practice Across States

  • Limits professional mobility
  • Challenging for multistate health care provider organizations and providers of telehealth services that cross state lines

Changing Existing Scope of Practice Regulations for a Profession Is Often a Costly, Time-consuming, Adversarial, and Incremental Process Involving Many Stakeholders With Divergent Opinions About the Proposed Change/s

  • Although the primary purpose of scope of practice regulation is to protect public safety, efforts to change scope of practice requirements often include an element of professional self-interest from professions that already perform a task or provide a service

Policy Reforms to Support Improvements in Scope of Practice Decision Making

  • Aligning profession-specific legal scopes of practice with professional competence
  • Increasing participation of consumers in scope of practice decision making
  • Using the best available evidence about what is best for patients in scope of practice decision making
  • Allowing short-term demonstration/pilot programs that are carefully evaluated to test new approaches when evidence is not available
  • Establishing a national clearinghouse on scope of practice information and research with up-to-date and reliable information on scope of practice proposals, modifications, demonstrations, innovations, evaluations, and model practice acts

Relevant Information and Research

2015 - Present

Timmons, E. J., & Mills, A. (2018). Bringing the Effects of Occupational Licensing into Focus: Optician Licensing in the United States. Eastern Economic Journal. http://dx.doi.org/10.1057/eej.2016.4

Frogner, B. K., Fraher, E. P., Spetz, J., Pittman, P., Moore, J., Beck, A. J., … Buerhaus, P. I. (2020). Modernizing scope-of-practice regulations – Time to prioritize patients. New England Journal of Medicine. https://doi.org/10.1056/NEJMp1911077 

Adams, A. J. (2019). Transitioning pharmacy to “standard of care” regulation: Analyzing how pharmacy regulates relative to medicine and nursing. Research in Social and Administrative Pharmacy. https://doi.org/10.1016/j.sapharm.2018.10.008 

Xue, Y., Kannan, V., Greener, E., Smith, J. A., Brasch, J., Johnson, B., & Spetz, J. (2018). Full Scope-of-Practice Regulation Is Associated With Higher Supply of Nurse Practitioners in Rural and Primary Care Health Professional Shortage Counties. Journal of Nursing Regulation, 8(4), 5–13. https://doi.org/10.1016/S2155-8256(17)30176-X 

Liu, C.-F., Hebert, P. L., Douglas, J. H., Neely, E. L., Sulc, C. A., Reddy, A., … Wong, E. S. (2020). Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Services Research, 55(2), 178–189. https://doi.org/10.1111/1475-6773.13246

Squires, A., & Dorsen, C. (2018). Qualitative Research in Nursing and Health Professions Regulation. Journal of Nursing Regulation. https://doi.org/10.1016/S2155-8256(18)30150-9 

Perloff, J., Clarke, S., DesRoches, C. M., O’Reilly-Jacob, M., & Buerhaus, P. (2019). Association of State-Level Restrictions in Nurse Practitioner Scope of Practice With the Quality of Primary Care Provided to Medicare Beneficiaries. Medical Care Research and Review. https://doi.org/10.1177/1077558717732402 

Patel, E. Y., Petermann, V., & Mark, B. A. (2019). Does State-Level Nurse Practitioner Scope-of-Practice Policy Affect Access to Care? Western Journal of Nursing Research. https://doi.org/10.1177/0193945918795168 

Ladd, E., Sweeney, C. F., Guarino, A., & Hoyt, A. (2019). Opioid Prescribing by Nurse Practitioners in Medicare Part D: Impact of State Scope of Practice Legislation. Medical Care Research and Review. https://doi.org/10.1177/1077558717725604 

Spetz, J., Toretsky, C., Chapman, S., Phoenix, B., & Tierney, M. (2019). Nurse Practitioner and Physician Assistant Waivers to Prescribe Buprenorphine and State Scope of Practice Restrictions. JAMA. https://doi.org/10.1001/jama.2019.0834 

Park, J., Han, X., & Pittman, P. (2019). Does expanded state scope of practice for nurse practitioners and physician assistants increase primary care utilization in community health centers? Journal of the American Association of Nurse Practitioners. https://doi.org/10.1097/JXX.0000000000000263

Pittman, P., Leach, B., Everett, C., Han, X., & McElroy, D. (2020). NP and PA Privileging in Acute Care Settings: Do Scope of Practice Laws Matter? Medical Care Research and Review. https://doi.org/10.1177/1077558718760333 

Barnes H, Maier C, Sarik D, Germack H, Aiken L, McHugh M. Effects of regulation and payment policies on nurse practitioners’ clinical practices. Medical Care Research and Review. 2016;0(0):1077558716649109. PMID: 27178092.

Barton Associates. NP Scope of Practice Laws.

Behavioral Health Workforce Scope of Practice Articles.

Gadbois EA, Miller EA, Tyler D, Intrator O. Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010. Medical Care Research and Review : MCRR. 2015;72(2):200-219. doi:10.1177/1077558714563763.

Graves J, Mishra P, Dittus R, Parikh R, Perloff J, Buerhaus P. Role of geography and nurse practitioner scope-of-practice in efforts to expand primary care system capacity: Health reform and the primary care workforce. Med Care. 2016;54(1):81-89. PMID: 26565526.

Koppelman J, Vitzthum K, Simon L. Expanding where dental therapists can practice could increase Americans’ access to cost-efficient care. Health Aff. 2016;35(12):2200-6.

Langelier M, Continelli T, Moore J, Baker B, Surdu S. Expanded scopes of practice for dental hygienists associated with improved oral health outcomes for adults. Health Aff. 2016;35(12):2207-2215. http://dx.doi.org/10.1377/hlthaff.2016.0807

McMichael B, Safriet B, Buerhaus P. The extraregulatory effect of nurse practitioner scope-of-practice laws on physician malpractice rates. Medical Care Research and Review. 2017;0(0):1077558716686889.

Page C, Beck A, Buche J, Singer P, Vazquez C, Perron B. National Assessment of Scopes of Practice for the Behavioral Health Workforce. Behavioral Health Workforce Research Center, School of Public Health, University of Michigan. April 2017

Pittman P, Leach B, Everett C, Han X, McElroy, D. NP and PA privileging in acute care settings: Do scope of practice laws matter? Medical Care Research and Review: MCRR. 2018;1077558718760333. doi:10.1177/1077558718760333.

Poghosyan L, Boyd D, Clarke S. Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nursing Outlook. 2016;64(2):146-155. PMID: 26712385.

ScopeOfPracticePolicy.org

Timmons E. The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care. Health Policy. 2016. PMID: 28041774.

Xue Y, Ye Z, Brewer C, Spetz J. Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review. Nursing Outlook. 2016;64(1):71-85.

2010 - 2015

Bader J, Lee J, Shugars D, Burrus B, Wetterhall S. Clinical technical performance of dental therapists in Alaska. Journal of the American Dental Association. 2011;142(3):322-326. PMID: 21357866. 

Boissonnault WG, Badke MB, Powers JM. Pursuit and implementation of hospital-based outpatient direct access to physical therapy services: An administrative case report. Journal of Physical Therapy Science. 2010;90(1):100-109. PMID: 19892855.

Corazzini K, Anderson R, Mueller C, Thorpe J, McConnell E. Licensed practical nurse scope of practice and quality of nursing home care. Nursing Research. 2013;62(5):315-324. PMID: 23995465. 

Dower C, Moore J, Langelier M. It is time to restructure health professions scope-of-practice regulations to remove barriers to care. Health Aff. 2013; 32(11)1971-6. doi: 10.1377/hlthaff.2013.0537.

Hain D, Fleck L. Barriers to NP practice that impact healthcare redesign. Online Journal of Issues in Nursing. 2014.

Hale J, Murawski M, Ives T. Perceived successes and challenges of clinical pharmacist practitioners in North Carolina. Journal of the American Pharmacists Association. 2013;53(6):640. PMID: 24185431.

Iglehart, J. Expanding the role of advanced nurse practitioners: Risks and rewards. New England Journal of Medicine. 2013;368(20):1935-1941. PMID: 23675663.

Kuo Y, Loresto FL, Rounds LR, Goodwin JS. States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Aff. 2013;32(7):1236–1243. doi:10.1377/hlthaff.2013.0072.

McMullen T, Resnick B, Hansen J, Miller N, Rubinstein R. Certified nurse aides and scope of practice clinical outcomes and patient safety. Journal of Gerontological Nursing. 2015;41(12):32-39. PMID: 26468657.

National Council of State Legislatures, Scope of Practice Legislative Database (Jan 2011 – Dec 2012)

National Council of State Legislatures, Scope of Practice Overview, 2013 Enacted Legislation

Post J, Stoltenberg J. Use of restorative procedures by allied dental health professionals in Minnesota. Journal of the American Dental Association. 2014;145(10):1044-1050. PMID: 25270703.

Safriet B. Federal Options for Maximizing the Value of Advanced Practice Nurses in Providing Quality, Cost-Effective Health Care. (Excerpted from Appendix H of The Future of Nursing: Leading Change, Advancing Health). Institute of Medicine, 2011.

Spetz J, Parente S, Town R, Bazarko D. Scope-of-practice laws for nurse practitioners limit cost savings that can be achieved in retail clinics. Health Aff. 2013;32(11): 1977-1984. doi: 10.1377/hlthaff.2013.0544.

Traczynski J, Udalova V. Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes. [Internet]. Madison, WI: University of Wisconsin; 2013.

Yang Y, Meiners M. Care coordination and the expansion of nursing scopes of practice. Journal of Law, Medicine and Ethics. 2014;42(1):93-103.PMID: 26767480

Yee T, Boukus E, Cross D, Samueal D. Primary care workforce shortages: Nurse practitioner scope of-practice laws and payment policies. Washington, DC: National Institute for Health Care Reform; February 2013. 

2005 - 2010

Dower C, Christian S, O’Neil E. Center for the Health Professions, University of California, San Francisco. Promising Scope of Practice Models for the Health Professions, 2007.

National Council of State Boards of Nursing, Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations

2000 - 2005

Safriet B. Closing the Gap Between Can and May in Health Care Providers’ Scope of Practice: A Primer for Policymakers. Yale Law School, Faculty Scholarship Series, Paper 4422. 2002;301.