By Chris Cheney
At the beginning of this year, the National Commission on Certification of Physician Assistants predicted that the reform of scope of practice, supervision, and delegation of authority legislation would be a top trend regarding physician assistants.
The NCCPA's expectation seems to be correct as more states are pushing for legislation to expand scope of practice for advanced practice practitioners.
But expanded scope of practice for advanced practice practitioners has been contentious. Physician groups have insisted on medical-doctor supervision of advanced practice practitioners. For example, in 20 states, a physician must co-sign a percentage or number of physician assistant charts, according to the American Medical Association. In 39 states, there are limits on the number of physician assistants a physician can supervise or with whom a physician can collaborate.
However, advanced practice practitioners have been equally insistent on gaining expanded scope of practice across the country. For example, in several states, laws that expand scope of practice for physician assistants (PA), nurse practitioners (NP), and advanced practice registered nurses (APRN) have already been adopted.
Twenty-two states and the District of Columbia allow NPs to function in a "full practice environment," which includes evaluating patients, ordering and interpreting diagnostic tests, managing treatments, and prescribing medications.
Now the decades-long struggle over regulation of advanced practice practitioners is playing out in Rhode Island and Florida.
Efforts to change state law
In Rhode Island, legislation would allow physician assistants greater autonomy from physicians, with the creation of a more collaborative model. The legislation also would end physician legal liability for the work of physician assistants.
In Florida, Florida House Bill 821 and its Senate companion, SB 972, are moving through the state legislature and would grant expanded scope of practice to PAs and APRNs.
The Florida legislation would allow PAs and APRNs to work independently of physicians as long as they had not been disciplined in the previous five years, had accrued at least 2,000 clinical practice hours within a three-year period, completed graduate-level courses in pharmacology, and maintained specified levels of professional liability coverage.
However, the legislation is not expected to become law this year, says Deborah Gerbert, PA-C, co-chair of the Legislative and Governmental Affairs Committee at the Florida Academy of Physician Assistants.
The legislation has passed the Florida House, but it has not passed the state Senate and this year's legislative session is set to conclude on May 3.
"I never say never until the last gavel is put on the table, but the fact that it has not been heard at all in the Senate committees has been a deliberate block of the legislation by the chairman of the Health Policy Committee and the president of the Senate. They do not want this issue heard," Gerbert says.
If the state Senate does not pass the legislation this week, advocates of the scope-of-practice expansion would have to start over next year, she says.
Weighing educational requirements
Representatives of physicians and nurse practitioners have starkly different views on the proposed Florida legislation's clinical practice hour requirement.
Jay Epstein, MD, a practicing anesthesiologist and chair of the American Society of Anesthesiologists' Florida chapter Committee on Governmental Affairs, says the training of physicians is superior to the training of advance practice practitioners.
"I had to do 12,000 hours over a three-year anesthesiology residency. I then passed my anesthesiology boards to be board-certified in anesthesia, then I passed my boards in critical care medicine. So right off the bat, I had six times the clinical hours of this legislation's requirement," he says.
Epstein says the proposed Florida legislation should have more specificity about the level of clinical practice hours and the specificity of those hours.
"My 12,000 hours over three years were in the operating room, in the labor suite, in the pain clinic, in the intensive care unit, and in the cardiac catheter lab—wherever the patient required surgical or procedural sedation. Florida House Bill 821 does not define where those 2,000 hours are going to come from," he says.
However, Taynin Kopanos, DNP, NP, vice president of state government affairs for the American Association of Nurse Practitioners in Austin, Texas, says the proposed Florida legislation's clinical practice hour requirement is overkill.
"AANP believes that these requirements are unnecessary for safe practice by nurse practitioners and can impede direct access to patient care. We understand that some state legislators find that this is a political compromise option that they are willing to move forward from," Kopanos says.
"Nurse practitioners follow the literature on evidence-based outcomes and the evidence supports that care provided by nurse anesthetists is safe, high-quality care and the patients have the same outcomes as they do from physicians. So, the evidence on patient outcomes do not support that there is a difference in quality of care between the two providers," she says.
Addressing physician shortages
Part of Kopanos' argument for scope-of-practice expansion is that it could help ease the country's physician shortage, she says, making it essential for advanced practice practitioners to work independently of physicians and to bring their full knowledge and skill set to the treatment of patients.
PAs are widely viewed as part of the solution to the country's physician shortage.
"A clarifying point around this issue is the word independent. What we are looking at in Florida is whether it is legal for an NP to provide care to patients outside of a relationship with a physician. Right now, it is illegal for nurse practitioners to bring their knowledge and expertise to provide care to patients based on existing licensure laws," she says.
Kopanos says HB 821 and SB 972 are a step in the right direction to not only improve access to care but also focus on other challenges. "These bills are about making it legal for people to practice their profession and help address healthcare shortages and disparities, provide better choices, and address healthcare costs in the state."
However, Epstein says requiring advanced practice practitioners to work under the supervision of a physician is the safest way to help address physician shortages.
"APRNs and physician assistants working in a care team would be ideal. That is the model we have had for a long time in anesthesia, and it's a model that can be widely applied to other specialties. It gives you the benefit of the physician being present for preoperative optimization, intraprocedural care, and postoperative complication management," he says.
Epstein says supervision of advanced practice practitioners is essential for patient safety in acute care situations, making an analogy to the aviation industry.
"Things go quite wonderfully most of the time; but the minute there is a problem, you need the education, the background, and the experience to make critical decisions. We are always going to have a situation where physicians are needed to be available for immediate rescue. There are cases in the hospital that are less acute where we can start talking about broadening the supervision ratio to something higher than 1 to 4," he says.
Resolving the controversy?
Kopanos says states that have expanded scope of practice for advanced practice providers have shown that NPs, PAs, APRNs, and physicians can cooperate effectively and safely as equals.
"For example, there are networks in Washington state where pharmacy boards, nursing boards, physician boards, and their associations get together and craft legislation on how those providers who are going to write controlled substances manage them, and all of those providers are treated equitably," she says.
The struggle over scope of practice should be viewed as an effort to modernize licensure laws, Kopanos says.
"It really is incumbent on states to move forward with full practice authority. With 50 years of evidence for safe, quality NP care, this is not a turf war. This is about recognizing that healthcare has evolved and grown, and that NPs have expertise in health disciplines that can help address patient care needs in the country," she says.
However, Epstein says legislators should not take a one-size-fits-all approach to scope of practice for healthcare providers.
"As a first step, we should determine what is appropriate for a given situation because nothing is ever black and white, it's always gray. We should determine where it makes sense to use physician extenders without physician supervision or with limited supervision, or with full physician supervision," he says.
Patient safety should be the paramount concern, Epstein says.
"If we also start with the safety of the patient and what's in the best interest of the patient, we'll settle this controversy quicker. It will help turn down the heat on the discussion if we have a rational dialogue on differentiating between an acute care specialty like anesthesiology and the practice of other specialties in medicine like family practice, where the decisions are not as acute."
Christopher Cheney is the senior clinical care? editor at HealthLeaders.