As state lawmakers consider giving advanced practice practitioners more autonomy, some physicians are digging in to defend their turf.
Legislatures in Ohio, Kansas and other states are reviewing bills that would remove the requirement that doctors must sign off on prescriptions before advanced practice registered nurses prescribe them to patients. The American Medical Association has continued to oppose expanding APPs' scope of practice, claiming that APPs cannot match physicians' education, training and expertise.
The AMA lauded New Jersey lawmakers' recent decision to table a similar bill, building on more than 50 victories on scope-of-practice issues across 35 states last year, the physician lobbying group said.
"This win protects patients and preserves physician oversight and leadership," AMA President Dr. Patrice Harris said in prepared remarks. "The AMA will continue the fight—at the state and federal levels and in the courts—as your powerful ally to protect patient safety."
The debate underscores a longstanding disagreement pinned on patient safety. Nurses point to a number of studies that found, at worst, no significant difference in care quality between APPs and physicians. The Federal Trade Commission recently supported the Ohio and Kansas bills, claiming that excessive scope-of-practice restrictions can hurt competition, exacerbate physician shortages, inflate costs and impede team-based care.
This leaves health systems in a precarious position. Providers aim to boost primary-care access as they work around labor shortages and high turnover rates, and deploying non-physician providers can boost bottom lines and productivity, research shows. But they must balance delicate relationships with physicians as roles shift.
More than 40 states introduced 177 scope-of-practice bills during the 2019 legislative sessions, according to a National Conference of State Legislatures-backed website. Fifty-four bills from 30 states were enacted into law related to behavioral health providers, physician assistants, oral health providers and nurse practitioners.
On the behavioral health front, Minnesota, North Dakota and Washington streamlined the application process for addiction counselors. Physician assistants in California can now work in collaboration with a physician instead of under delegation. Five states passed legislation last year aimed at boosting access to dental care for those who live in rural and underserved areas. Nurse practitioners in Arkansas can now prescribe five-day supplies of Schedule II controlled substances as long as their practice agreement with a physician allows it.
Cleveland-based University Hospitals said it has not taken a position on the Ohio bill. Several other Ohio and Kansas providers did not respond by deadline.
"You don't need a PhD to figure out that if you don't train more physicians, we are going to be in a bad spot," said Travis Singleton, executive vice president at Merritt Hawkins, a division of the staffing firm AMN Healthcare. "No matter what scope you give APPs, we saw more physicians leave the system than enter it last year for the first time."
More nurse practitioners are joining the ranks as more medical school graduates opt for specialist roles over primary care.
The number of NPs grew at an unprecedented rate from 2010 to 2017, a new analysis shows. Meanwhile, only about 42% of medical school graduates filled 8,116 primary-care positions last year, marking the lowest percentage on record, according to the 2019 Match report.
"The relative low growth in the physician workforce is creating a gap in primary-care access and these folks are filling that gap," said David Auerbach, adjunct faculty member at Montana State University who penned a recent study on the nurse practitioner workforce.
The rise of non-physician providers aligns with modern care models, Singleton said. Hospitals' prominence as the care hub will wane in lieu of virtual and urgent care, patients will have access to their medical records on their phone, and younger generations likely won't turn to a traditional family physician.
"Anytime you have market shifts this large, it is going to be uncomfortable," Singleton said.
The differences in training should not be overlooked, some doctors warn. Family doctors spend seven years in medical school and residency while NPs go through a two-year master's program, although some universities are shifting to doctorates.
"The amount of negative studies on NPs is so small compared to the mountain of other evidence," said Peter Buerhaus, a nurse and Montana State University professor.
The AMA's argument is reminiscent of concerns raised by states that have not joined the nursing compact, where nurses can practice freely between compact states and avoid individual state licensing. Non-compact states and unions claim the compact licensing process isn't as rigorous and it can jeopardize patient care. But it may also be a means to stifle competition, said Bill Horton, a partner at the law firm Jones Walker.
"There is always resistance from those in the system to those that are coming in," he said.
Still, the vast majority of NPs want to collaborate with doctors, not oppose them, Buerhaus said. That sentiment is reflected by more physicians who understand and accept working with APPs, Singleton said.
"Doctors need them to expand practices, see the patients they should be seeing and to make money," he said.
Some industry observers claim that expanding APPs' scope of practice offers an opportunity for more team-based care, freeing up physicians to operate at the top of their license.
"You have to have APPs to support doctors in a team-based environment," said Jason Tackett, a principal at consulting firm SullivanCotter.
Health systems should ensure doctors are involved in training and reviewing APPs and should establish clearly defined roles, said Trish Anen, a principal at SullivanCotter.
"They may be initially perceived as a threat, but as we work with organizations to redesign or clarify their care model, having a dialogue about the best use of each person's skills can allow surgeons to focus on more complex patients," she said. "There is some competition, but there is also a need to feel comfortable in the provision of safe care."