Scope of practice, the set of services a health care practitioner is licensed to provide, is a growing topic of interest in health care, particularly as it relates to the Affordable Care Act and advanced care practitioners, such as nurse practitioners (NPs) and physician assistants (PAs). CVS Health and POLITICO recently hosted a forum that brought together a number of experts who participated in a panel discussion and working group to discuss recent developments and changes related to scope of practice, a follow-up to a similar discussion we hosted in 2013.
Participating experts included Tammi L. Damas, PhD, MBA, WHNP-BC, RN, Associate Dean, Division of Nursing, College of Nursing and Allied Health Sciences, Howard University. Dr. Damas set the scene for the discussion by noting that 21 states now allow nurse practitioners (NP) to practice with full authority. And since the original forum in 2013, seven states have taken action to give NPs wider authority. The discussions revealed three themes that will continue to impact scope of practice: provider supply, policy developments and payment issues.
The Physician Supply Shortage Creates Strain and Presents Opportunities
According to panelists, physician supply issues present opportunities for the broader health care team. Patricia Pittman, PhD, Associate Professor, Department of Health Policy and Management; Co-Director, Health Workforce Institute, George Washington University, underscored the severity of the physician shortage and noted the increasing demand for services. She pointed to NPs and PAs as resources that can help fill those gaps.
Jeffrey Katz, PA-C, DFAAPA, President and Chair of the Board, American Academy of Physician Assistants, echoed concerns about unmet mental health needs, highlighting a severe shortage of mental health care providers and a gap in continuity of care, especially in rural areas.
Scope of Practice Policies Vary by State and Impact Care Delivery
Scope of practice is regulated by many different entities, including the federal Medicare program, state legislatures, and state governing boards, creating significant differences across state lines. While developments continue at a steady pace overall, individual states differ in speed of adoption, contributing to varying policy and cultural health care landscapes.
Jeffrey Katz noted that prescriptive ability for PAs has expanded in some states to include controlled substances. However, laws and regulations have not yet fully adapted to the changing standards of practice in some areas, resulting in additional and unnecessary office visits when a physician is not immediately available. As a result, NPs and PAs tend to migrate to states that have less restrictive scope of practice laws. Rural areas, where PAs and NPs are already more likely to practice, may be able to boost access to care by expanding scope of practice, Dr. Pittman noted.
Provider Payment Structures Can Also Affect Access to Care
Provider reimbursement systems can also present challenges to comprehensive care. Panelists discussed several issues, including a lack of reimbursement for care of mental health conditions during a physical exam, and incentives to bill higher rates through physicians’ license numbers, rather those of the NPs and PAs who treat patients directly.
Panelist Eugene Rich, MD, Senior Fellow and Director, Center on Health Care Effectiveness, Mathematica Policy Research, noted we are moving away from fee-for-service models and towards alternative payment systems. Dr. Rich explained that this will give clinicians the potential to earn bonuses by participating in an advanced alternative payment model, encouraging movement towards team-based care.
Jeffrey Katz shared his perspective that MACRA, a Medicare payment reform policy going into effect in 2019, could be a force driving the health care team toward collaboration.
Experts Believe Team-Based Care is Here to Stay
With the strain on physician supply creating more opportunity for other members of the health care team, and payment model reforms in development, experts agreed that the environment increasingly will support team-based care. We echo their sentiments and support the efficient use of all health care professionals on the care team. Our health care model supports connecting patients along the continuum of care, as well as championing broader efforts to support a patient-centered medical home.