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
2020 - Present
.orgFeyereisen S, Puro N. Seventeen states enacted executive orders expanding advanced practice nurses’ scopes of practice during the first 21 days of the COVID-19 pandemic. Rural and Remote Health. 2020;20(4). https://doi.org/10.22605/RRH6068.
Boehringer B, O’Meara P, Wingrove G, Nudell NG. An Emergency Amendment to the National Scope of Practice for Paramedics in the Setting of a Global Pandemic. J Rural Health. 2021 Jan;37(1):191-193. https://doi.org/10.1111/jrh.12441.
Barton Associates. Nurse Practitioner Scope of Practice Laws [Internet]. Peabody (MA): Barton Associates; [last updated 2021 June 16]. Available from: https://www.bartonassociates.com/locum-tenens-resources/nurse-practitioner-scope-of-practice-laws/
Barton Associates. PA Scope of Practice Laws [Internet]. Peabody (MA): Barton Associates; [cited 2021 June 4]. Available from: https://www.bartonassociates.com/locum-tenens-resources/pa-scope-of-practice-laws/
Andino J, Zhu Z, Surapaneni M, Dunn R, Ellimoottil C. Interstate Telehealth Use Meidcare Beneficiaries Before and After COVID-19 Licensure Waivers, 2017-2020. Health Affairs 2022 41:6, 838-845
Faget, K. Y. (2022). Telehealth Practice Standards With Emphasis on the United States: What Telerehabilitation Providers Need to Know. In Telerehabilitation (pp. 405-415). Elsevier. https://doi.org/10.1016/B978-0-323-82486-6.00028-9
Ferris, M., Gill, C., Preston, J., & Browne, M. (2021). Validity Evidence for the Continued Professional Certification Assessment: Professional Practice Analysis of the National Board of Certification and Recertification for Nurse Anesthetists. Journal of Nursing Regulation, 11(4), 51-62. https://doi.org/10.1016/S2155-8256(20)30172-1
Giron, S. E., Dishman, D., McMullan, S. P., Riel, J., Newcomer, T., Spence, D., & Choudhry, S. A. (2021). Longitudinal assessment: A strategy to improve continuing professional certification. Journal of Professional Nursing, 37(6), 1140-1148. https://doi.org/10.1016/j.profnurs.2021.09.002
Lee, N. T., Karsten, J., & Roberts, J. (2020). Removing regulatory barriers to telehealth before and after COVID-19. Brookings Institution. https://www.brookings.edu/research/removing-regulatory-barriers-to-telehealth-before-and-after-covid-19/
Brannock, M. K., & Bradford, N. A. (2021). Barriers to licensure for military spouse registered nurses. Journal of Nursing Regulation, 11(4), 4–14. https://doi.org/10.1016/s2155-8256(20)30170-8
Chappell, K. B., Howard, M. S., Lundmark, V., & Ivory, C. (2021). Credentialing and Certification: Overview, Science, and Impact on Policy, Regulation, and Practice. International Nursing Review. https://doi.org/10.1111/inr.12721
Jefferson, K., Bouchard, M. E., & Summers, L. (2021). The Regulation of Professional Midwifery in the United States. Journal of Nursing Regulation, 11(4), 26–38. https://doi.org/10.1016/s2155-8256(20)30174-5
Maine, L. L. (2020). An Unparalleled Spirit of Collaboration Amid the COVID-19 Pandemic. American Journal of Pharmaceutical Education, 84(6). https://doi.org/10.5688/ajpe8155
Benton, A. D., Ferguson, S. L., Douglas, J. P., & Benton, D. C. (2021). Contrasting Views on Scope of Practice: A Bibliometric Analysis of Allied Health, Nursing, and Medical Literature. Journal of Nursing Regulation, 12(1), 4–18. https://doi.org/10.1016/s2155-8256(21)00016-8
Adams, T. L. (2020). Health Professional Regulation in Historical Context: Canada, the USA and the UK (19th Century to Present). Human Resources for Health, 18(1). https://doi.org/10.1186/s12960-020-00501-y
Svorny, S., & Cannon, M. F. (2020). Health care workforce reform: COVID-19 spotlights need for changes to clinician licensing. Cato Institute, Policy Analysis, (899).
Szalados, J. E. (2021). Regulation of Provider Practice: State Oversight, Licensing, Credentialing, Peer Review, and the National Practitioner Data Bank. The Medical-Legal Aspects of Acute Care Medicine, 137–169. https://doi.org/10.1007/978-3-030-68570-6_6
Leslie, K., Moore, J., Robertson, C., Bilton, D., Hirschkorn, K., Langelier, M. H., & Bourgeault, I. L. (2021). Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK. Human Resources for Health, 19(15). https://doi.org/10.1186/s12960-020-00550-3
Poghosyan, L., Ghaffari, A., Liu, J., Jin, H., & Martsolf, G. (2021). State policy change and organizational response: Expansion of nurse practitioner scope of practice regulations in New York State. Nursing Outlook, 69(1), 74–83. https://doi.org/10.1016/j.outlook.2020.08.007
McMichael, B. (2020). Healthcare licensing and liability. Indiana Law Journal.
Yang, B. K., Johantgen, M. E., Trinkoff, A. M., Idzik, S. R., Wince, J., & Tomlinson, C. (2020). State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review. Medical Care Research and Review. https://doi.org/10.1177/1077558719901216
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
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
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
2015 - 2019
Elliot, A., Bohecker, L., Elliott, G. M., Townsend, B. J., Johnson, V., Lopez, A., … & Roach, K. (2019). Interstate Licensure Portability: Logistics and Barriers for Professional Counselors. Professional Counselor, 9(3), 252-266.
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
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
Benton, D. C., Cleghorn, J., Coghlan, A., Damgaard, G., Doumit, M. A. A., George, J. L., González-Jurado, M. A., Kwek, P.-E., Johansen, C., Msibi, G. S., Nyante, F., Owyer, E., Reed, C. M., Rodriguez, A., & Vogt, T. (2019). Acting in the Public Interest: Learnings and Commentary on the Occupational Licensure Literature. Journal of Nursing Regulation, 10(2). https://doi.org/10.1016/s2155-8256(19)30120-6
Mueller, C., Duan, Y., Vogelsmeier, A., Anderson, R., McConnell, E., & Corazzini, K. (2018). Interchangeability of Licensed Nurses in Nursing Homes: Perspectives of Directors of Nursing. Nursing Outlook, 66(6), 560–569. https://doi.org/10.1016/j.outlook.2018.09.004
Ritter, A. Z., Bowles, K. H., O’Sullivan, A. L., Carthon, M. B., & Fairman, J. A. (2018). A Policy Analysis of Legally Required Supervision of Nurse Practitioners and Other Health Professionals. Nursing Outlook, 66(6), 551–559. https://doi.org/10.1016/j.outlook.2018.05.004
Spetz, J., & Muench, U. (2018). California Nurse Practitioners Are Positioned To Fill The Primary Care Gap, But They Face Barriers To Practice. Health Affairs, 37(9), 1466–1474. https://doi.org/10.1377/hlthaff.2018.0435
Ortiz, J., Hofler, R., Bushy, A., Lin, Y., Khanijahani, A., & Bitney, A. (2018). Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes. Healthcare. https://doi.org/10.3390/healthcare6020065
Park, J., Athey, E., Pericak, A., Pulcini, J., & Greene, J. (2018). To What Extent Are State Scope of Practice Laws Related to Nurse Practitioners’ Day-to-Day Practice Autonomy? Medical Care Research and Review. https://doi.org/10.1177/1077558716677826
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
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
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
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.
Lofgren, M. A., Berends, S. K., Reyes, J., Wycoff, C., Kinnetz, M., Frohling, A., … O’Brien, M. (2017). Scope of Practice Barriers for Advanced Practice Registered Nurses: A State Task Force to Minimize Barriers. Journal of Nursing Administration, 47(9), 465–469. https://doi.org/10.1097/NNA.0000000000000515
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
Spetz, J., Skillman, S. M., & Andrilla, C. H. A. (2017). Nurse Practitioner Autonomy and Satisfaction in Rural Settings. Medical Care Research and Review. https://doi.org/10.1177/1077558716629584
Yang, B. K., Trinkoff, A. M., Zito, J. M., Burcu, M., Safer, D. J., Storr, C. L., … Idzik, S. (2017). Nurse practitioner independent practice authority and mental health service delivery in U.S. Community Health Centers. Psychiatric Services. https://doi.org/10.1176/appi.ps.201600495
Kleiner, M. M., Marier, A., Park, K. W., & Wing, C. (2016). Relaxing occupational licensing requirements: Analyzing wages and prices for a medical service. Journal of Law and Economics. https://doi.org/10.1086/688093
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.
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
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.
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.
Covvey, J. R., Cohron, P. P., & Mullen, A. B. (2015). Examining Pharmacy Workforce Issues in the United States and the United Kingdom. American Journal of Pharmaceutical Education, 79(2), 17. https://doi.org/10.5688/ajpe79217
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.
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.
Shilling, D. L., & Hodnicki, D. (2015). APRN prescribing in Georgia: An evolving environment. Journal of the American Association of Nurse Practitioners, 27(6), 300–307. https://doi.org/10.1002/2327-6924.12203
2010 - 2014
Brannon, J. A., Cohn, E. R., & Cason, J. (2012). Making the case for uniformity in professional state licensure requirements. International Journal of Telerehabilitation, 4(1), 41.
Cason, J., & Brannon, J. A. (2011). Telehealth regulatory and legal considerations: Frequently asked questions. International Journal of Telerehabilitation, 3(2), 15.
Massie, M. L. (2014). The Tipping Point in Health Care: Using the Full Scope of Practice of Certified Registered Nurse Anesthetists as Advanced Practice Registered Nurses. Clinical Scholars Review, 7(1), 4–6. https://doi.org/10.1891/1939-2095.7.1.4
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.
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
Hain D, Fleck L. Barriers to NP practice that impact healthcare redesign. Online Journal of Issues in Nursing. 2014.
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.
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.
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.
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.
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.
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.
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.
Mathews, B. P., Boland, M. G., & Stanton, B. K. (2010). Removing barriers to APRN practice in the state of Hawai’i. Policy, Politics, and Nursing Practice, 11(4), 260–265. https://doi.org/10.1177/1527154410383158
2005 - 2009
Kleinpell, R. M., Hravnak, M., Hinch, B., & Llewellyn, J. (2008). Developing an advanced practice nursing credentialing model for acute care facilities. Nursing Administration Quarterly. https://doi.org/10.1097/01.NAQ.0000336724.95440.fd
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
Carlson D, Thompson JN. (2005). The Role of State Medical Boards. AMA Journal of Ethics Virtual Mentor, 7(4), 311–314. doi: 10.1001/virtualmentor.2005.7.4.pfor1-0504
2000 - 2004
Hilliard, J. W., & Johnson, M. E. (2004). State Practice Acts of Licensed Health Professions: Scope of Practice. DePaul J. Health Care L., 8, 237.
Schlesinger, M. (2002). A Loss of Faith: The Sources of Reduced Political Legitimacy for the American Medical Profession. The Milbank Quarterly, 80(2), 185–235. https://doi.org/10.1111/1468-0009.t01-1-00010
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.
Van Scoder, L. I. (2001). Recredentialing in the allied health professions. Journal of Allied Health, 30(4), 229–231.
Kleiner, M. M. (2000). Occupational licensing. Journal of Economic Perspectives, 14(4), 189–202.
Prior to 2000
Gaumer, G. L. (1984). Regulating Health Professionals: A Review of the Empirical Literature. The Milbank Memorial Fund Quarterly. Health and Society, 62(3), 380–416. https://doi.org/10.2307/3349858
Professional scope of practice or competence is often found in model practice acts developed by a profession and describes the services that its members are trained and competent to perform.
- A Model Act to Regulate the Practice of Medicine across State Lines
- Essentials of a State Medical and Osteopathic Practice Act
- Nurse Practitioners
- Social Workers
- Emergency Medical Personnel
- Physician Assistants
- Occupational Therapists
- Physical Therapists
- Respiratory Therapists
Innovations in Health Professions Regulation