Relaxing Scope of Practice Laws for APRNs, PAs to Boost Efficiency

June 26, 2018 - Loosening scope of practice laws for advanced practice registered nurses and physician assistants and shifting spending away from physicians can boost provider productivity, driving down costs, the economic policy center The Hamilton Project recently asserted.

“Achieving productivity gains is one way to reduce cost pressures throughout the healthcare system and, ultimately, in government budgets. Productivity can be increased by using different combinations of labor and capital, as well as by using lower-cost sources of labor to achieve the same or better outcomes. Indeed, relatively high payment rates for physicians in the United States versus other developed countries make this a particularly appealing opportunity,” the group wrote.

“The lack of normal competitive forces in the healthcare sector, however, serves as a key barrier to achieving these efficiency gains. Currently, there are strong anticompetitive barriers to making more use of advanced practice providers in the healthcare sector.”

Scope of practice laws vary by state and dictate the degree of independent practice permitted for advanced practice registered nurses, physician assistants, and other advanced practice providers. The laws range from no requirements to collaborative or consultative arrangements with physicians to physician supervisory requirements.

While researchers found scope of practice laws are trending to more advanced practice provider independence, advanced practice registered nurses and physician assistants still face restrictive practice across the country.

READ MORE: Addressing Productivity, Labor to Bend the Healthcare Cost Curve

Opponents of fully authorized scope of practice laws argue that care quality may diminish under non-physician providers because they undergo shorter training and clinical experience requirements.

The American Medical Association (AMA) is a staunch opponent of comprehensive expansions of scope of practice for non-physician providers. Last year, the industry group adopted a resolution that opposed legislative efforts to permit independent practice to non-physician providers, such as the National Council of State Boards of Nursing’s Advanced Practice Registered Nurse Compact.

However, a literature review performed by The Hamilton Project presented no evidence that expanding scope of practice laws harms patients or care quality. Instead, the analysis showed that giving advanced practice providers more autotomy would actually lower healthcare costs.

Medicare reimburses physician assistants, clinical nurse specialists, and nurse practitioners each at 85 percent of the Medicare Physician Fee Schedule (PFS). Meanwhile, certified registered nurse anesthetists receive 80 percent of a physician’s reimbursement.

Lower reimbursement rates for advanced practice providers would reduce healthcare spending on common services.

READ MORE: How Adding Physician Assistants Improves Hospital Revenue Cycle

Researchers also found that the price of a child well-care visit covered by private insurance was 3 to 16 percent lower in offices where nurse practitioners have independent scope of practice. Another recent study also showed that expanded scope of practice for physician assistants resulted in a 12 to 14 percent reduction in the dollar amount of outpatient claims among Medicaid patients.

Allowing advanced practice providers to complete more clinical tasks on their own could significantly reduce healthcare spending and free up physician time, Hamilton Project researchers contended.

Physicians, as well as the healthcare industry at large, would see productivity spike under relaxed scope of practice laws. Introducing more independent nurse practitioners and physician assistants into the industry would expand patient access by supplying more clinicians to meet consumer demands.

“This increased access can take the form of an expanded supply of primary care providers or the opening of new healthcare facilities,” the report stated. “This can also mean reduced waiting times or increased face time with providers as reduced administrative burdens free up their time. In addition, government programs can more readily serve growing patient populations.”

Adding additional clinicians to complement a physician’s work is key at this time. The Association of American Medical Colleges (AAMC) recently projected the physician shortage to reach 120,000 doctors by 2030, up from its previous estimated shortfall of 104,000 physicians by the same time.*

READ MORE: Greater Non-Physician Staffing Helps Healthcare Revenue Cycle

The introduction of independent advanced practice providers would also decrease administrative burdens on providers by decreasing duplicative processes under supervisory and collaborative agreements.

“When no harm is present, the restrictions serve only to generate artificial barriers to care that ultimately provide physicians with protection from competition, prevent the attainment of system-wide efficiencies, and constrain overall provider capacity,” researchers concluded.

Therefore, The Hamilton Project advised state policymakers to allow advanced practice registered nurses and physician assistants to be fully authorized to practice in accordance with their education, training, and experience.

Specifically, the recommendation entails eliminating supervisory practice arrangements, formal collaborative practice agreements and processes, and advanced practice registered nurse to physician ratios, as well as allowing advanced practice registered nurses to prescription drugs

Physician assistant supervisory requirements should also be set at the practice, rather than state, level.

“When a physician and a nonphysician practitioner are both qualified to perform certain procedures, each should specialize in the service in which they are most productive—that is, the service in which they have a comparative advantage,” the report stated. “By doing so, the overall efficiency in the system can be improved and costs lowered.”

*CORRECTION: Previous version of this article stated that the AAMC projected a physician shortage of 102,000 doctors by 2030.