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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Access to Care and Ongoing Battles Over Scope of Practice

More than 7 million Americans have signed up for private health insurance under The Affordable Care Act (ACA), and millions more gained coverage under the ACA’s expansion of Medicaid. This is a great achievement, but will they have access to care?

Diana Mason, PhD, RN

Joanne McLaughlin, FNP-C, provides primary care to more than 2000 people in a rural, medically underserved area, the Catskill Mountains in New York. About 40% of her patients are on Medicaid, 30% on Medicare, 10% with private insurance, and 20% uninsured. Some are now getting coverage through the state’s insurance exchange.

But even if they have coverage, her patients could lose access to her overnight. McLaughlin is a family nurse practitioner (FNP) who, by state law, must have an agreement with a “collaborating physician” in her specialty addressing issues such as patient referrals, consultations, and periodic reviews of select cases (until earlier this week, the agreement had to be in writing; a law passed on Monday removed that requirement). She pays the physician a fee for these services. If the physician withdraws from the agreement, moves, or dies, she cannot see patients until she enlists another physician.

After 8 years as a registered nurse (RN) and certified surgical first assistant, McLaughlin began her career as an NP in a hospital primary care clinic. She says she was laid off when the hospital decided to use an all-physician staff, hiring physicians from abroad who were here on H1B visas. Because there were few alternatives and the need for primary care services in her county was so great, she opened her own practice under a collaborative agreement with a physician colleague. Since then, she has changed collaborating physicians several times, for such reasons as retirement and relocation. For McLaughlin to get reimbursed by an insurance plan, her collaborating physician must be enrolled in the plans her patients use, and she has been unable to find one affiliated with all of her patients’ insurers. As a result, she now has 2 collaborating physicians, who are both 60 miles away. No other family physicians practice nearby, and area hospitals will not permit their physicians to be her formal collaborating physician.

What do her collaborating physicians do? They meet with her once every 3 months to review 12 patients’ charts, are available for phone consultation, and accept her referrals. McLaughlin told me she refers patients to specialists more often than to her collaborating physicians because of the distance.

This map, from the American Association of Nurse Practitioners, shows state practice regulations for nurse practitioners (NPs). Green states permit full practice authority for NPs. Red states require physician supervision—including, in some, restrictions on distance from the NP. Yellow states, like New York, require some physician collaboration. If McLaughlin worked in nearby Vermont (or the District of Columbia or 16 other states), she could practice to the full extent of her training without physician oversight.

Why aren’t all states green, especially since the shortage of primary care physicians is likely to persist, with estimates of an additional 52 000 or more needed by 2025?

Controversy Steeped in History

Regulations governing the scope of practice for NPs, physician assistants, and other professionals—both licensed and unlicensed—are highly controversial. Such issues exist not only between NPs and physicians, but also between obstetricians and family physicians, registered nurses and licensed practical nurses, dentists and dental health aide therapists, psychiatrists and psychologists, physicians and pharmacists, and others.

These controversies originated in medical practice acts, says Barbara Safriet, JD, LLM, visiting professor of law at Lewis and Clark College and former associate dean at Yale Law School. An expert in health professions regulation, Safriet wrote in 2002 that the turf battles among health care professionals arose from legally defined practice boundaries, a static legal system, and prescribed norms of professional autonomy, gender, social status, power, and other factors. Noting that physicians were the first health professionals to develop a practice act, Safriet argues that they understandably claimed a broad scope and “swept the entire human condition under their purview.” Safriet maintains that all health professions have since been fighting for their sphere of authority and legitimacy, leading to a “turf protection” mentality.

Evidence on Quality

Most arguments against expanding scopes of practice focus on care quality and safety. A large body of evidence—including a 2005 Cochrane systematic review—on the outcomes of care provided by advanced practice nurses (NPs, nurse midwives, nurse anesthetists, and clinical nurse specialists) supports that they are safe and cost-effective. Such evidence led to reports from the Institute of Medicine, the Josiah Macy Jr Foundation, and others calling for removing the scope-of-practice barriers for advanced practice nurses. Physicians argue that safe care requires physician oversight.

Similarly, nursing’s opposition to nonhealth personnel administering insulin and other medications in California schools centered on quality and safety, but, in this case, there was not substantial evidence on either side of the argument. In both cases, however, the argument for expanding scopes of practice centers on access to care—in primary care where there is a shortage of clinicians and in schools where there are too few nurses.

For the past 30 years, California has used a method for temporarily waiving scope-of-practice restrictions under well-designed, properly funded demonstration projects that want to test approaches to increase access to care. But even if the evidence of safety and quality is clear in these demonstrations, permanent changes to scope-of-practice laws can proceed only with substantial political support. That’s why California is one of the restricted states for NPs.

Team-Based Care

In an era of team-based care, Richard Kiovsky, MD, of Indiana University, argues that no clinician should be in solo practice these days. He is one of a handful of physicians who believe that myriad clinicians can lead these teams—including NPs and social workers. The team approach seems right in an age when many patients require more expertise than any one clinician possesses. The team could be on-site or remotely accessible through Telehealth.

But laws governing collaboration do not advance team-based care. As Syracuse physician Devin Coppola, MD, has noted, collaboration is part of professional MD and NP practice and doesn’t need to be mandated: “. . . no matter who the provider is, they need to ask for help when they need it. A collaborative agreement does nothing to assist that process.”

McLaughlin reaches out to colleagues other than her official “collaborating physician.” She misses the daily teamwork of the hospital clinic, but she has few choices in a community where the need for primary care is greater than the services available. The hospital where she began her NP practice has closed its 3 clinics, and the physicians it employed on H1B visas have left the community.

About the author: Diana J. Mason, PhD, RN, is the Rudin Professor of Nursing and Codirector of the Center for Health, Media, and Policy at the Hunter College; Professor at the City University of New York; and President of the American Academy of Nursing.