Toolkit: Policy and Advocacy on Scope of Practice

Published: 1/2/2024

A physician-led health care team enables health care professionals to deliver care commensurate with their training and strengths.

ACTION:

ACP members can access members-only actionable materials.

Background:

Federal and state legislators are increasingly introducing legislation to expand the scope of practice of non-physician health care professionals. For example, twenty-seven states and the District of Columbia have adopted the “full practice model,” which allows all nurse practitioner (NPs) to evaluate patients; diagnose, order, and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances.

In December 2023, the Annals of Internal Medicine published “Principles for the Physician-Led Patient-Centered Medical Home and Other Approaches to Team-Based Care” which updated ACP’s 2013 “Principles Supporting Dynamic Clinical Care Teams” position paper and ACP’s 2006 “The Advanced Medical Home: A Patient-Centered Physician-Guided Model of Health Care” policy monograph. The paper highlights the importance and benefits of team-based care, affirming that teams should be led by physicians, underscoring the need for payment models to promote team-based care, and recommending interprofessional training to foster collaboration and cooperation among health care professionals. These principles represent a renewed call for policymakers to ensure that all patients – including those residing in rural and other medically-underserved areas – have access to a personal physician with leadership of a highly-skilled health care team trained to deliver whole-person comprehensive, and longitudinal care.

As a member of the Scope of Practice Partnership (SOPP), ACP partners with the American Medical Association, the American Academy of Family Physicians, and others on scope of practice issues, including opposing regulations to expand Advanced Practice Registered Nurse (APRN) scope of practice in the VA system and to extend the Public Health Emergency expansions of scope of practice as so granted by the U.S. Department of Health and Human Services.

Federal Activities

The federal government has significantly expanded the role of non-physician health care professionals since the start of the COVID-19 pandemic.

On March 24, 2020, Health and Human Services (HHS) sent a letter to state governors with guidance on various actions they could take to address the COVID-19 public health emergency. The guidance included a request for states, territories, and the District of Columbia to take immediate action to “waive restrictions on licensure, scope of practice, certification, and recertification/relicensure consistent with the changes announced for federal programs.”

On April 21, 2020, the U.S. Veterans Health Administration (VHA) issued a directive allowing non-physician health care professionals in 32 specialties to operate “within the full scope of their license, registration, or certification” and encourages all VA medical facilities to allow CRNAs to practice without physician oversight during the national health emergency.

Legislation has also been introduced in Congress to expand the scope of practice for nurse practitioners and pharmacists. The “Improving Care and Access to Nurses Act,” or the “ICAN Act,” (H.R. 2713) that would allow Medicare and Medicaid hospital inpatients to be under the care of a nurse practitioner without physician supervision. ACP expressed our concerns to the sponsor, Representative Allard, about the legislation. The “Equitable Community Access to Pharmacist Services Act” (H.R. 1770, S. 2477), would expand Medicare coverage to permanently include select services provided by a pharmacist in limited but significant ways. ACP sent a letter to the bill sponsors opposing this legislation. ACP also has concerns about The Chiropractic Medicare Coverage Modernization Act (H.R. 1610, S.799) that would amend the definition of physician to extend Medicare coverage for services furnished by chiropractors beyond the manual manipulation of the spine.

State Activities:

Many states have considered or have already adopted policies to modify their scope of practice laws for advanced practice registered nurses (such as nurse practitioners), physician assistants, and other non-physician health care professionals. ACP tracks state-level scope of practice legislation and regularly advises state chapters on responding to policy proposals. To find out what bills have been introduced in your state or for more information about state laws on scope of practice, the National Conference of State Legislatures has an interactive map with information about scope of practice laws in all 50 states, the District of Columbia, and U.S. territories.

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