Use of Non-Physician Care Providers

As health reform moves along, concern has been expressed about whether there is adequate capacity in the medical community to meet the needs of the newly insured, whether commercial or Medicaid members.  Particularly in regard to primary care, physicians are not the only method for meeting health care needs, physician assistants and nurse practitioners have the training and skill to provide many of the same services.  But historically physicians have advocated for and largely obtained scope of practice laws that protect their turf and limit the activities of these alternative providers, unless they are supervised by a physician.  Some states have relaxed restrictions in recent years, many other states have not.  A brief from the National Institute for Health Care Reform examines the effect of scope of practice restrictions.   (NIHCR Brief)   About 18 states now allow nurse practitioners full freedom to practice without physician supervision.  Another 7 require doctor supervision only for prescribing, while the remaining 25 continue to require full supervision.  The brief looked at 6 states with a range of laws to ascertain the practical effects.  These effects tend to interact with payer policies, which may independently cause issues because if you can’t get paid for providing a service you are unlikely to want to deliver it.  Both Medicare and Medicaid may require physician involvement for billing of some services, and private payers may also have restrictions.  Many of these payer restrictions may derive back to the era when these alternative providers could rarely practice alone and they are likely undated.  The brief demonstrates that there are problems caused in the states with supervisory requirements.  These laws exacerbate access difficulties in rural and other underserved areas because a nurse practitioner can’t be far from a doctor and there aren’t many physicians in these areas.  They also affect the efficiency and productivity of these practitioners, because of the interaction required.  Although not extensively dealt with in the brief, nurse practitioners are far more cost-effective on a unit-of-service basis and the research does not indicate any more quality concerns in regard to their work than the work of doctors.  If we are concerned about costs, and if increasing unit prices is a major driver of costs, then all scope of practice restrictions should be removed as soon as possible and the use of nurse practitioners should be strongly encouraged.