This story was originally published by Stateline, an initiative of The Pew Charitable Trusts.
When COVID-19 hit the United States in 2020, state policymakers across the country set out to expand access to health care. They’ve temporarily allowed more telehealth, for example, and made it easier for healthcare professionals to practice across state lines.
Many states have also re-authorized nurses, physician assistants and pharmacists, often lowering or easing requirements for medical oversight during emergencies. Some states have expanded the types of services non-physicians could provide — or their “scope of practice” — to allow more of them to administer vaccines or dispense narcotics for substance use treatment.
Many in those professions, who have long fought in state legislatures for greater authority, said the pandemic has proved their case. A handful of states, including Delaware, Kansas, Massachusetts, New York, Utah and Wyoming have made some changes permanent. Supporters say more states should follow.
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“You can’t be comfortable saying in the midst of a crisis, ‘Because you are highly skilled in your profession, we will remove the barriers to care, but now that we are out of the crisis, we’ll put the barriers back because you are now dangerous.'” said Jennifer M. Orozco, president of the American Academy of Physician Associates and director of Advanced Practice Providers at Rush University Medical Center in Chicago.(AAPA recently changed its terminology for the profession from “physician assistants” to “associate doctors” to emphasize his independence.)
But to make some of the changes permanent requires crossing swords with the powerful American Medical Association and its affiliated state chapters. Physician groups have traditionally guarded against what they see as inroads into the care they believe only physicians should provide. And they have fiercely resisted what they perceive as attempts to undermine the authority of doctors.
“Removing doctors from the care team results in higher costs and lower quality of care,” the organization said in an emailed statement to Stateline. Rather than granting more independence to non-doctors, the organization said it supports efforts to broaden the pipeline of doctors and more evenly distribute doctors across the country.
There is a shortage of doctors, including primary care physicians, in the United States. The Bureau of Labor Statistics expects the growth rate of primary care physicians between 2021 and 2031 to be just 3% compared with the nearly 46% growth expected for nurse practitioners and 28% for physician assistants, both listed by the office as among the fastest growing occupations in the country.
On its website, the American Medical Association trumpets its success in opposing state legislation it describes as allowing “scope creep,” which it says threatens patient safety. As of late 2021, the organization boasted that it had achieved 100 state legislative victories in “stopping inappropriate non-physician scope expansions.”
But nonmedical organizations, such as the American Academy of Nurse Practitioners, and some scholars cite peer-reviewed research that questions the notion that giving more responsibility to nondoctors costs more or threatens the health of patients, many of whom live in areas with few doctors.
“The evidence is pretty clear that access improves,” said Matthew McHugh, a Penn Nursing professor at the University of Pennsylvania and a senior fellow at its Leonard Davis Institute of Health Economics. “There isn’t a negative impact on quality and a lot of the regulations or constraints put in place by the scope of practice restrictions aren’t really doing anything positive in the public interest.”
Susanne Phillips, associate dean of clinical affairs at the University of California, Davis, School of Nursing, made a similar point. “We have 50 years of research showing that patient outcomes and satisfaction are the same,” she said. “There’s no difference between states that don’t have physician oversight and states with oversight.”
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A 2021 report from the National Academies of Sciences, Engineering and Medicine recommended states remove barriers that prevent nurses from practicing “to the fullest extent of their education and training.” Such restrictions, the report said, reduce “the types and amounts of health services that can be provided to people in need of care,” especially in rural areas with few doctors.
The AMA counters this with its own research listing, which it says demonstrates that nurses in some settings use more resources, have worse patient outcomes in emergency rooms, order unnecessary imaging tests in emergency rooms, and make fewer quality referrals.
The two sides disagree on how much oversight physicians should have over treatment plans, prescriptions and referrals. Many states require physicians to review a certain percentage of medical records completed by the nurses they supervise. States often limit the number of nurses that any physician can supervise at any one time, and in many states, nurses must pay fees related to supervision.
The AMA argues that such oversight protects patients. But nurses say they don’t need doctors’ supervision when they do what they’ve been trained to do. “All we ask is that you practice to the fullest of our training and education,” said April Kapu, president of the American Association of Nurse Practitioners.
The Nurses Group says there are more than 355,000 licensed nurses in the United States. Professional nurses, such as nurse midwives, clinical nurse specialists, and nurse anesthetists, have higher educational qualifications than are required for registered nurses. They also passed a national certification exam and received a state license to practice.
Kapu, a nurse in Tennessee, said the oversight requirements are inefficient and prevent doctors from doing their clinical work. During COVID-19, the state temporarily lifted the requirement for doctors to review medical records prepared by nurses. “We literally would have had to pull doctors off the front lines to do full-time record review,” he said.
According to the National Conference of State Legislatures, prior to COVID-19, 22 states plus Washington, DC, had granted nurses full practice authority, waiving the oversight requirement. But many other states have given nurses more authority during the pandemic, usually through an executive order from the governor.
Many of these provisions expired when states lifted their emergency health orders. But Delaware, Kansas, Massachusetts and New York have permanently relaxed supervisory requirements. Kapu said other state lawmakers are considering similar actions this year, adding he was very optimistic about the outlook in Indiana, New Jersey and North Carolina.
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The 159,000 physician assistants in the United States face similar problems, according to the American Academy of Physician Associates. The organization said that during COVID-19, more than 20 states have expanded the independence of physician assistants. The changes included granting greater prescribing authority, waiving the relationship between associate physician and requested physician, and eliminating requirements for physicians to co-sign medical records. Some have also allowed health care systems, rather than state authorities, to make decisions about the scope of practice.
As with nurses, many of these measures were temporary. Utah and Wyoming made them permanent in 2021, following North Dakota, which in 2019 became the first state to grant full practice autonomy to physician assistants.
Other medical disciplines are also clamoring for more independence or authority. For example, while the American Pharmacists Association states that pharmacists are licensed to administer vaccines in all states, many limit the types of vaccines pharmacists can provide, the age of the recipient, and whether a prescription is needed. Some authorizations are linked to the existence of a health emergency.
In Colorado, a bipartisan group of lawmakers introduced a bill that would allow psychologists, who don’t have medical degrees, to prescribe drugs to treat mental illness, a measure that psychiatrists, who are doctors, have strongly opposed elsewhere. . Lawmakers say the measure would help address shortages of psychiatrists in many areas, particularly in rural regions.
Idaho, Illinois, Iowa, Louisiana and New Mexico already grant psychologists, who have received additional training in pharmacology, prescribing authority.
The debate between doctors and non-doctors will continue as COVID-19 recedes. But Orozco, of the Association of Associate Doctors, said the argument should be about what’s best for the patient, not the medical providers.
“The question should be how can we help deliver in a way that makes sense and isn’t about arguing on the turf,” he said.
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