Scope of Practice Restrictions

For decades physicians have tried to protect themselves from competition by encourage scope of practice licensing laws which limited the ability of other health professionals to work without the supervision of a doctor and/or put restrictions on what services those health professionals could offer.  The justification was usually quality, but the real reason was economic.  A Journal of Health Economics article explores the impact of scope of practice laws in regard to nurse midwives.   (JHE Article)   Nurse midwives have been able to secure relaxed scope of practice restrictions in a number of states, so there is an opportunity for comparisons among various states.  The authors examined changes in these laws over the period 1994 to 2013 and any related impacts on maternal and child outcomes.  Certified Nurse Midwives are a subset of Advanced Practice Registered Nurses who have taken specialized training in pregnancy and childbirth.  Driven by malpractice cases and insurance costs, there is a real shortage of OB/GYN doctors in many parts of the country, so these nurse midwives can be important in maintaining access.  State laws on scope of practice, however, vary substantially, from complete freedom to practice to very restrictive requirements of physician supervision.

In their analysis the researchers focus on relationships between the nature of scope of practice and maternal prenatal health behaviors, labor and delivery outcomes and infant outcomes.  Overall, there are very few and very small differences in the three studied areas of outcome between states with no practice restrictions and those with high restrictions.  States with no barriers see fewer induced births and fewer C-sections, which aside from the quality implications, implies a large savings on the cost of the birth.  There was no evidence of reduced quality in terms of either maternal prenatal health behaviors or infant health and health outcomes.  So if the justification for restrictions on scope of practice is better quality when physicians are in charge, this research clearly undermines that justification.

Several forces are driving a relaxation in scope of practice laws.  One is enhanced lobbying by these other health professionals.  A second is a growing body of research suggesting that there is little or no quality difference in terms of outcomes.  A third is concerns about health care workforce shortages.  The most important is that since unit prices are the single largest driving force in health spending growth, increasing competition, especially from lower-priced practitioners can really help keep costs under control.  Ideally, there would be a federal law that prevents these scope of practice limitations.  Pregnancy and childbirth is a significant expense to the health system.  Much of this expense relates to other than purely natural childbirth.  This paper suggests that allowing greater scope of practice for certified nurse midwives can not only improve access but can improve outcomes by lowering the use of more complex procedures, without any apparent drop in quality.  In fact, fewer of these procedures may itself be an indication of better quality.