Does Expanding Scope of Practice Improve Access?

When you or a loved one seeks medical care, that care is typically delivered by a healthcare team. The healthcare team includes a variety of clinicians. Each team members serves an important role, but it is important that a healthcare team is led by a physician (either an MD or a DO). Physicians have the most education and training and are best suited to lead the healthcare team.

At both the state and national level, “scope of practice” is regularly challenged through various legislation. When scope of practice is expanded for non-physician practitioners, physicians are often excluded from a patient’s healthcare team. Scope of practice advocacy efforts are to help make sure that patients can continue to be cared for by a healthcare team led by physicians.

In many states, legislation has been passed to allow non-physician practitioners to have full practice authority (FPA). “FPA” allows a practitioner who is not a physician to evaluate patients, diagnose, order and interpret diagnostic tests, prescribe medications, and create treatment plans without the oversight or input from a physician. A common rationale for proposing the expansion of practice authority is that it will expand access to care. However, numerous studies have shown that this argument is not valid. Non-physician practitioners with FPA are no more likely to practice in rural, underserved areas than those who do not have FPA.

In Arizona, nurse practitioners (NPs) were granted FPA under the access rationale. Within five years, Arizona saw an increase in the number of NPs in practice, but there is conflicting data about whether this had a meaningful impact on access to care in rural areas. Studies such as the Arizona Rural Workforce Shortage Study supports the claim that FPA improves access, but several other studies have since refuted those findings. In peeling back the layers of the data results in the Arizona report, researchers have found that the number of NPs in rural areas did not increase significantly – and, in fact, may have decreased. The Arizona report cites a number of studies, but the discrepancies in data collection do not allow for true “apples to apples” comparisons (e.g., use of RCUAs versus Zip codes). There are also inconsistent definitions of what is considered a rural and/or underserved areas. Regardless, the statistics from the report show that at least 75% of graduates went to areas that were neither underserved nor rural.

In Arizona, to improve the ratio of NPs per 100,000 population in rural areas to be proportionally equal to the ratio in urban areas, it would have required 30 NPs to begin practicing in rural areas, which translates to less than three per year since the FPA was granted in Arizona. The actual gain was only five over the course of 12 years.

The experience in Arizona is very similar to other states. Here in Maine, non-physician practitioners are also not any more likely to practice in rural or underserved parts of the state. The map below illustrates that non-physician practitioners generally practice in the same geographic areas as physicians.

Visit the American Medical Association website for more information about the geographical trends of the healthcare workforce or to learn more about scope of practice issues.