RESEARCH BRIEF NO. 21 | NOVEMBER 2017 Provider Scope of Practice: Expanding Non-Physician Providers’ Responsibilities Can Benefit Consumers cope of practice regulations originated as a means the medical, dental and behavioral health spectrum are Sto protect the public from healthcare practitioners trained to perform tasks that can improve healthcare administering care they were unqualified to provide, due value and lower costs. These providers include physician to differences in training. Emerging emphasis on patient- assistants (PAs), dental therapists, dental hygienists and centered care where nurses, physicians, and other members advanced practice registered nurses (APRNs)—a term that of the care team practice to the fullest extent of their includes certified registered nurse anesthetists (CRNAs), training has focused attention on the potential advantages certified nurse midwives, nurse practitioners (NPs) and of expanded scope of practice in overall care delivery.1 clinical nurse specialists. Provider scope of practice regulations define Currently, non-physician providers can face a variety the breadth of services a given type of healthcare of regulatory barriers that may limit their independent professional is permitted to provide based on their level practice authority, prescribing authority and hospital of education, training and experience.2 While physicians attending/admitting privileges. In some states, scope of have traditionally been considered the ‘leaders’ of the practice laws limit the extent to which physicians can healthcare delivery team, non-physician providers across delegate tasks and services to non-physician providers.3 This brief explores how relaxing regulatory barriers facing non-physician practitioners has the potential to SUMMARY significantly increase access to providers, improve quality If state scope of practice laws are overly restrictive, and lower the cost of providing care. they can prevent non-physician providers from Impact on Quality and Access practicing to the fullest extent of their training. Medical associations and physician groups have largely Expanding scope of practice laws can specifically objected to expanded scope of practice due to concerns benefit rural populations and other areas with about quality, particularly stemming from the difference fewer primary care providers and lower access in technical and clinical training between physicians and to primary healthcare services. Evidence suggests other providers. There is no evidence to suggest these that non-physician practitioners have the potential fears are well founded. Recent studies find that there is no to significantly increase provider capacity and statistically significant difference in quality of care between reduce the cost of providing healthcare, with few NPs and PAs when compared to physicians in the primary quality concerns. Moreover, studies show that care setting.4 expanding provider scope of practice can benefit Studies exploring the impact on outcomes are closely consumers in terms of wait times and overall tied to expanded access to services. A study on the access to services. However, more evidence is relationship between scope of practice laws granting needed on if and how savings can be passed independent practice authority to nurse practitioners found a 14 percent reduction in acute care sensitive (ACS) onto consumers. condition emergency department admissions in full- HEALTHCARE VALUE HUB practice authority states two years after practice regulations Non-Physician Providers Acronym were relaxed.5 As high ACS admissions are an indicator of low-quality office-based care, these results would suggest Advance Practice Registered Nurses APRN that expanding scope of practice laws had a positive effect on quality. Nurse Practictioners NP Other evidence includes a study that used the National Certified Registered Nurse Anesthetists CRNA Ambulatory Medical Care Survey’s Community Health Clinical Nurse Specialists CNS Center sample to compare the impact of receiving care delivered by NPs and PAs versus primary care physicians. Certified Nurse Midwives CNM Investigators found that for seven of the nine patient- Physician Assistants PA level outcomes examined, there were no statistically significant differences in NP- or PA-delivered care compared with PCP-delivered care in community health dental therapists appeared to be practicing safely, and centers.6 The bottom line is that physician assistants and clinics where they worked reported improved quality nurse practitioners do not appear to have a detrimental and high patient satisfaction. A similar study using data effect on patient outcomes, and can play a valuable role in from Alaska’s Yukon Kuskokwim Delta community found optimizing the healthcare team by assuming responsibility that increased use of dental therapists were significantly for less-complex patients. associated with higher child and adult preventive Dental hygienists provide preventive and non-surgical care utilization rates and lower rates of extraction periodontal treatments alongside dentists.7 Hygienists are procedures—patterns consistent with improved usually the first point of contact for a patient before seeing outcomes.13 a dentist. A study examining an expanded role for dental Clinical nurse specialists (CNSs) work primarily in hygienists in Oregon found expanded access to oral health inpatient hospital settings, although some also practice services for patients and improved outcomes, particularly in nursing homes, clinics and other community-based among children. The evaluation focused on the state’s settings like home care.14 They can provide value by Expanded Practice Dental Hygienists, who are permitted assisting with the development of facility quality controls, to provide care to limited access populations without the serving as case managers and delivering primary care. 8 permission of a dentist. Unfortunately, there are few studies that have focused Dental therapists are an emerging oral health provider specifically on the quality of care provided by clinical nurse trained to provide preventive and restorative dental care. midwives (CNMs) or clinical nurse specialists. Dental therapist licensure requires an additional two Restrictive scope of practice rules can impede 9 years of education compared to dental hygienists. Alaska evaluations of quality for non-physician providers. When and Minnesota were among the first states to begin APRNs and PAs cannot practice independently they bill licensing dental therapists in the U.S. and examining their services under ‘incident to’ provisions, indicating their impact on access and patient experience.10 In 2009, the physician supervision or collaboration. Payers then Minnesota passed legislation authorizing two types of reimburse at 100 percent of the physician fee schedule and dental therapists: a traditional dental therapist and an the quality of patient care is attributed to that physician.15 advanced dental therapist with two additional years of Essentially, non-physician providers cannot be adequately training and a year of direct, on-site supervised practice.11 evaluated on care quality metrics when not all services the By 2014, the Minnesota Department of Health observed provide are billed under their name. Increasing instances that patients experienced shorter travel and wait times of independent non-physician billing will yield more for dental appointments and expanded capacity at dental informative quality metrics. clinics serving vulnerable populations.12 They also found RESEARCH BRIEF NO. 21 | November 2017 PAGE 2 HEALTHCARE VALUE HUB Impact on Costs physician), some states restrict admitting privileges.23 This results in CNMs being used mainly as a “physician The available evidence on non-physician providers extender,” a role that does not necessarily cut costs since suggest that expanding scope of practice will lower their services would be charged as an additional physician healthcare costs. For example, Medicare and most visit.24 Studies have shown that midwifery care can result private insurers reimburse nurse practitioners (which in lower charges to patients due to their tendencies to 16 comprise 60% of the U.S. APRN workforce ) and order fewer tests; their patients also are less likely to have physician assistants at 85 percent of the physician fee costly Caesarean deliveries.25 schedule when they bill independently and not under physician supervision.17,18 Lower reimbursement Strong evidence suggests that non-physician suggests that hospitals and medical groups can increase cost-effectiveness by employing these non-physician practioners have the potential to significantly providers independently. However, evidence that these increase provider capacity and reduce the cost of savings are passed on to consumers is weak. providing healthcare, with few quality concerns. While nurse practitioners and physician assistants practice within multiple settings and populations, certified registered nurse anesthetists (CRNAs) are Dental hygienists’ prescriptive authority and ability to primarily trained to provide anesthesia services. In initiate treatment without requiring the specific consent fact, they provide the majority of these services in rural of a dentist comprise the central issues pertaining to and underserved urban communities where physician their scope of practice.26 Because reimbursement for 19 anesthesiologists are rare. A 2016 Lewin Group dental procedures varies across government and private study commissioned