The training and certification that nurse practitioners receive qualify them to administer a wide range of patient care, including the diagnosis and treatment of a variety of medical conditions. The range of care that NPs are legally allowed to provide without a physician's supervision, however, depends on the state. More than half of states limit the care that NPs can provide, even if the restricted activities are within the scope of their qualifications.
In September, California Gov. Gavin Newsom signed legislation that will allow nurse practitioners to practice independently starting in 2023. This is a step forward for California NPs who have been struggling to provide comprehensive care for their patients while navigating practice restrictions. This change also provides a good opportunity for other states that impose restrictions to reconsider following in California's footsteps.
Although all NPs receive the same amount of graduate-level training, nurse practitioner scope of practice is determined by three different status levels that vary by state: full practice, reduced practice and restricted practice. Currently, only 22 states allow NPs full practice. "Full practice" does not allow NPs to perform duties they are not qualified for but does allow them to perform the full range of care they are trained to provide without a physician's supervision. Twenty states allow "reduced practice" and nine only allow "restricted practice," the most limiting of the three statuses.
On top of these state restrictions, there are also federal limitations. Medicare and Medicaid, for example, do not cover many diagnostic tests and procedures if an NP is listed as being the supervising provider.
The impact on healthcare access
A significant body of research shows that nurse practitioners provide effective, quality care for common medical needs with no difference in health outcomes from care provided by physicians and with patient satisfaction levels equaling or surpassing those of physician-provided care.
Allowing NPs to independently provide a full range of care is also cost-effective and reduces overall health spending. Conversely, there may be undesirable consequences to not fully utilizing NPs' full range of skills. For instance, many states still rely on physicians to provide primary care, even though NPs are qualified to be independent primary-care providers. This results in inflexible healthcare models that are not efficient or cost-effective, particularly when we are on the brink of a critical shortage of primary-care physicians.
Addressing the physician shortage
Industry professionals began warning about the physician shortage long before COVID-19, but the pandemic has exacerbated the problem. In response, the American Medical Association in March asked the Department of Homeland Security to expedite the processing of visas for doctors looking to enter the U.S. so they can be trained and transitioned into the American healthcare system. While this could be one among numerous measures to alleviate the crisis, a quicker solution could be to simply let nurse practitioners step in and provide the care they have already been trained for.
For a short period of time, that's what some states did. In May, five states temporarily lifted all restrictions, allowing NPs the full scope of practice their licenses qualify them for without physician supervision. Fourteen states temporarily waived some but not all restrictions as well. In some of these states, however, these waivers expired after just a few months, once again imposing limits on NPs and causing potential disruptions in NP-patient relationships.
These restrictions can delay urgently needed care in a time of national crisis, particularly in areas with underserved populations where many of the new COVID-19 cases are occurring. Nurse practitioners play a critical role for these underserved populations, many of whom would not otherwise be able to receive adequate care. For instance, nearly 90% of NPs are trained in primary care specialties—the specialties with the greatest shortages in rural areas. NPs are also more likely to work in rural areas than physicians, who generally tend to settle in urban locations.
These considerations make it worth looking at this issue beyond the scope of COVID-19 and taking a long-term perspective. That many states were able to lift restrictions, even if temporarily, on nurse practitioner scope of practice virtually overnight shows that it can be done when there is a perceived need.
There is indeed a need. Allowing NPs to practice autonomously within the scope of their licenses would not only help fight against COVID, it would also help underserved populations get the care they need as well as mitigate the looming physician shortage.
