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APRN and PA Scope of Practice Rules Draw Fire

Analysis  |  By Christopher Cheney  
   June 21, 2018

Researchers say reforming state and local rules for advanced practice providers can boost productivity, lower cost of care, and improve access to healthcare services.

Expanding the scope of practice for physician assistants and advanced practice registered nurses is a golden opportunity for U.S. healthcare, Brookings Institution researchers say.

Reducing restrictions on scope of practice (SOP) for physician assistants (PAs) and advanced practice registered nurses (APRNs) generates significant benefits without compromising quality of care, the researchers say.

"To the extent that APRNs and PAs provide healthcare that is equal in quality at a lower cost—as the existing research demonstrates—removing restrictions on their practice can help alleviate shortages and improve efficiency," they wrote in their report, "Removing Anticompetitive Barriers for Advanced Practice Registered Nurses and Physician Assistants."

The study was published this month.

SOPs, which are mainly generated in state legislatures, feature limitations on the tasks and autonomy of advanced practice providers such as APRNs and PAs. Physicians generally are not subject to SOP restrictions.

The researchers say SOPs have three primary negative impacts:

  • Depressed productivity: Finetuning the staffing mix of clinical care teams increases efficiency, but it is often blocked by anticompetitive policy barriers in SOPs
  • Cost of care: Compared to physicians, APRNs and PAs are lower-cost sources of labor who can provide equivalent quality of care
  • Access: SOP restrictions on advanced practice providers are a missed opportunity to ease the country's physician shortage

Physicians and their associations have lobbied against SOP reform based on quality of care concerns. "Opponents contend that quality of care may suffer under the direction of a non-physician practitioner, citing the shorter length of training and clinical experience required," the researchers wrote.

There is no evidence to support the quality of care claim, the researchers wrote. "The academic literature finds no evidence of harm to patients associated with less-restrictive SOP laws."

If there is no quality concern, then there is no justification for restrictive SOP laws, they wrote.

"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."

There are three main SOP rules for PAs:

  • SOP determination: Entities responsible for setting SOP for PAs varies by state, with rules set at practices, state medical boards, and state legislatures
  • Supervision: Oversight requirements for PAs include work plans that specify allowed procedures as well as guidelines for physician consultation and monitoring
  • Prescription authority: Medication rules include the exclusion of some drugs from a PA's allowable prescriptions

SOP rules for APRNs are set in state legislatures, and there are two main rules:

  • Practice authority: The practice independence of APRNs ranges from no restrictions, to collaborative or consultative arrangements, to supervisory relationships
  • Prescription authority: State laws grant prescription authority, set the schedule or types of medications allowed, and determine the level of physician supervision

Policy proposals

The Brookings researchers make six primary recommendations to ease SOP restrictions:

  • States should allow APRNs and PAs to practice in accordance with their education, training, and experience
  • When a physician and an advanced practice provider are both qualified to perform a service, the clinician with the comparative advantage should provide the service to maximize efficiency
  • For APRNs, end supervisory or delegative practice arrangements, stop formal collaborative practice agreements, allow prescription of medications, and scrap APRN-to-physician ratio rules
  • Set the level of interaction between physicians and PAs at the practice level, which would end legislated caps on PA-to-physician supervision ratios and allow the clinicians to set optimal staffing at the local level
  • Until APRNs and PAs can buy their own malpractice insurance, policymakers should be sensitive to the malpractice liability of physicians who supervise advanced practice providers
  • The federal government should encourage best practices at the state level and fund SOP research

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


There is no evidence that APRNs or PAs provide sub-standard care

Easing APRN and PA limits can lower costs, boost efficiency, and relieve physician shortages

Proposed fixes include setting the interaction between physicians and PAs at the practice level

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