In the Name of the Patient

Differing views on ‘scope of practice’

“Scope of practice” is a term describing the services that a health professional is deemed competent to perform and is permitted to undertake in keeping with their professional license. Sounds straightforward. But in fact, as medicine evolves, so too do the discussions around scope of practice. And they can get quite heated.

Nurse practitioners, physician assistants, nurse anesthetists and others believe that expanding scope of practice is in the best interest of the patient. Here’s the rub: Physicians, anesthesiologists, ophthalmologists and others believe that limiting expansion of scope of practice is in patients’ best interest.

It’s not a new debate. The American Medical Association formed the Scope of Practice Partnership back in 2006. To date, the Partnership has awarded more than $2.3 million in grants to members (national, state and specialty medical associations) to fund advocacy tools and campaigns.

In that same year – 2006 – 14 healthcare professional organizations formed the Coalition for Patients’ Rights to “monitor the legislative and regulatory environment to identify efforts to limit the scope of practice of the healthcare professionals it represents,” including critical-care nurses, nurse practitioners, occupational therapists, hospice and palliative nurses,
and pharmacists.

The divisions fester today. For example, in May 2019, the American Association of Nurse Anesthetists launched a campaign – “CRNAs: We are the Answer” – which included these words: “Anesthesia services are provided the same way by nurses and physicians; in other words, when anesthesia is provided by a CRNA [certified registered nurse anesthetist] or by a physician anesthesiologist, it is impossible to tell the difference between them.” The American Society of Anesthesiologists took exception, calling AANA’s campaign “malicious” and “irresponsible.”

Scope-of-practice struggles are playing out in state legislatures and in the courts today. In January, Massachusetts became the 23rd state to allow nurse practitioners to practice independently. In March, Hawaii lawmakers advanced a bill to allow advanced practice registered nurses (APRNs) to perform abortions.

Also in January, however, New Jersey lawmakers rejected legislation that would have allowed APRNs to prescribe without physician oversight, reports the American Medical Association. And in March, a measure in South Dakota that would have allowed physician assistants to diagnose and treat patients and prescribe substances without physician involvement died in committee.

In her testimony before the South Dakota committee, AMA President Susan Bailey, M.D., said the proposed measure would move healthcare in the wrong direction by removing physicians from care teams. “And when you remove the most highly educated and trained health care professional from the care team, you put patients at risk,” she said.

What’s next?

“The removal of unnecessary barriers to CRNA practice is an ongoing effort,” says Anna Polyak, RN, JD, senior director of state government affairs for AANA. “While CRNAs work collegially with physicians and other providers every day to provide optimal patient care, barriers such as unnecessarily restrictive physician involvement in CRNA practice do not improve care or increase patient safety. Studies have consistently shown that CRNAs and other APRNs, when allowed to practice to the full extent of their education and training, provide increased access to safe, cost-effective patient care.

“There is a great shortage of anesthesia providers around the country,” she says. “So, this is not about replacing one provider with another, but rather about improving access to care by allowing all providers to practice to the full extent of their training and education.”

The number of nurse practitioners and advanced practice registered nurses is expected to grow faster than that of physicians for the rest of the decade. AANP estimates the current number of nurse practitioners in the United States to be close to 300,000, while the National Commission on Certification of Physician Assistants estimates the number of PAs to be 139,000. The U.S. Bureau of Labor Statistics predicts that the job outlook through 2029 for PAs and CRNAs will be much better than average. So will their median pay ($115,800 for APRNs in 2019, and $112,260 for physician assistants in 2019).

Given all that, this statement about scope of practice from the American Nurses Association sounds accurate: “In a profession as dynamic as nursing, and with evolving health care demands, changes in scope of practice and overlapping responsibilities are inevitable in our current and future health care system.”

Scope of practice: A concern for many specialties

Scope-of-practice disputes span many medical specialties, including eye care and behavioral health care.

In September 2020, for example, the Arkansas Supreme Court cancelled a scheduled public referendum that would have asked voters to repeal a 2019 bill that allowed optometrists to perform a variety of in-office procedures (with the exception of cataract surgery, LASIK surgery, or other major eye surgeries that ophthalmologists regularly perform). The referendum, backed by Safe Surgery Arkansas, an ophthalmologist-backed advocacy group, was rejected by the high court on technical grounds related to the procedure by which signatures had been collected.

In January 2019, members of the U.S. Congress introduced the Medicare Mental Health Access Act (HR 884), which would have given psychologists independent practice authority in all Medicare treatment settings, and would have expanded the definition of “physician,” for purposes of the Medicare program, to include a clinical psychologist with respect to the furnishing of qualified psychologist services.

The American Medical Association, American College of Physicians, American Psychiatric Association, American College of Surgeons and others voiced displeasure with HR 884. In a September 2020 letter to Congressional leaders, the organizations wrote that the proposal “jeopardizes the safety of patients in the Medicare program and would create silos in the delivery of appropriate mental and physical health care,” and that the legislation “runs counter to efforts to coordinate and integrate the delivery of care to patients with mental illnesses and co-occurring health conditions.”

The bill failed to pass the 116th U.S. Congress, nor has it been reintroduced in the 117th Congress.