Scope-of-Practice Laws

Scope-of-practice laws are state-specific restrictions that determine what tasks nurses, nurse practitioners (NPs), physician's assistants, pharmacists and other healthcare providers may undertake in the course of caring for patients. These rules restrict the supply of primary caregivers, a problem which is particularly serious in rural areas. Fewer primary care givers means higher costs, longer wait times, and patients who have to drive much farther to see a doctor.

By increasing the number of providers, states could dramatically reduce the cost of care for their residents and increase access to care, especially for low-income families. If all states allow NPs to practice autonomously without physician oversight, one estimate puts the potential cost savings at $810 million.

Scope-of-Practice Laws Do Not Make Us Safer

The evidence shows that nurses and physician assistants can perform just as well as doctors in terms of patient outcomes. And one study even found that “patients were more satisfied with consultations with nurse practitioners than those with doctors.”

Scope-of-Practice Laws and Healthcare Costs

A recent study by the Mercatus Center explores how the licensing requirements for physician assistants and nurse practitioners affect medical outcomes for Medicaid recipients. It found that prohibiting physician assistants from prescribing drugs to patients significantly raises costs by more than 11 percent on average, translating to about $109 in extra expenses for each Medicaid beneficiary. Relaxing these restrictions would result in savings for Medicaid beneficiaries and would not cause any changes to the availability of health care. Allowing nurse practitioners and physician assistants to prescribe drugs has not been correlated with an increase in the rate of prescription claims per Medicaid beneficiary.

Another study by Edward Timmons and Conor Norris examines the effects of the Clinical Laboratory Improvement Amendments of 1988, which allow pharmacies to apply for waivers to conduct low-risk medical tests. The study shows that pharmacists and lab technicians can accommodate routine medical testing in their current job duties without affecting the number of hours they work. This indicates that a more broad scope of practice for these healthcare professionals can increase access to care for consumers without significantly increasing cost.

Variability Across States

The good news is that dozens of states have already removed these barriers. Scope-of-practice regulations vary in stringency across states. New Mexico and Vermont, for example, are among the 23 states that allow nurse practitioners to operate full practices, meaning that they may be primary care providers and may diagnose, treat, and independently prescribe drugs. Other states, such as Virginia and North Carolina, only permit restricted practices, allowing NPs to be primary care providers but only under physician supervision.

The variability in scope-of-practice laws from state to state allows researchers to estimate the effects of these regulations. One study analyzes how these regulations affect wages, employment, costs, and the quality of certain types of medical services. On balance, it seems that these regulations privilege certain providers under the guise of consumer protection. Scope-of-practice laws reduce NP wages while boosting physician wages. The authors find that more stringent regulations limit the hours worked by NPs and that restricting NPs’ ability to write a prescription increases the cost of a well-child medical exam by about $16 (or 16 percent). Furthermore, the authors find that these regulations seem to have no discernable effect on outcomes such as infant mortality or malpractice premiums. 

The Healthcare Openness and Access Project

Nurse practitioner scope-of-practice laws are one of the variables used in the occupational regulation subindex of the Healthcare Openness and Access Project (HOAP). HOAP provides a set of tools providing state-by-state measures of the flexibility and discretion that patients and providers have in managing health and health care. 

Growing evidence indicates that NPs can perform many primary care services as safely and effectively as physicians perform them. States that allow healthcare organizations to determine for themselves which procedures NPs may receive a higher HOAP score for the occupational regulation indicator.