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Reforming America’s Healthcare System Through Choice and Competition




Section 3 Healthcare Workforce and labor Markets

Recommendations: Broaden Scope of Practice

  • States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.
  • The federal government and states should consider accompanying legislative and administrative proposals to allow non-physician and non-dentist providers to be paid directly for their services where evidence supports that the provider can safely and effectively provide that care.
  • States should consider eliminating requirements for rigid collaborative practice and supervision agreements between physicians and dentists and their care extenders (e.g., physician assistants, hygienists) that are not justified by legitimate health and safety concerns.
  • States should evaluate emerging healthcare occupations, such as dental therapy, and consider ways in which their licensure and scope of practice can increase access and drive down consumer costs while still ensuring safe, effective care. P.31

“For example, advanced practice registered nurses (APRNs),96 physician assistants (PAs),97 pharmacists,98 optometrists, 99 and other highly trained professionals can safely and effectively provide some of the same healthcare services as physicians, in addition to providing complementary services. Similarly, dental therapists and dental hygienists can safely and effectively provide some services offered by dentists, as well as complementary services. P.100

SOP statutes and rules often unnecessarily limit the services these “allied health professionals”101 can offer. A 2011 Institute of Medicine (IOM) report surveyed “[e]vidence suggest[ing] that access to quality care can be greatly expanded by increasing the use of . . . APRNs in primary, chronic, and transitional care,”102 and expressed concern that SOP restrictions “have undermined the nursing profession’s ability to provide and improve both general and advanced care.”103 In fact, research suggests that allowing allied health professionals to practice to the full extent of their abilities is not a zero sum game for other medical professionals, and may actually improve overall health system capacity.104 The previously mentioned IOM report found that APRNs’ scope of practice varies widely “for reasons that are related not to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work.” P.105

State decisions about scope of practice and reimbursement can also affect the development and utilization of allied health professionals, particularly in public programs. Private insurance has the flexibility to incentivize patients to find lower-cost, higher-quality provider alternatives when feasible. Public programs, more restricted by state regulations, can be less responsive to such changes in the healthcare workforce, even after scope of practice regulations accommodate them. Currently, for example, states vary widely in the degree to which they permit their Medicaid programs to reimburse allied health professionals directly for services. Services provided under the direct supervision of a physician are reimbursed as if the physician provided those services. State Medicaid programs can also pay for PA, nurse practitioner, and certified nurse midwife (CNM) services provided outside of a physician’s office, but only if state scope-of-practice laws do not require onsite supervision by physicians. Some states allow allied health professionals to bill Medicaid directly, while other states require them to bill under the physician’s number. For patients to realize the benefits of changes to state SOP restrictions, state Medicaid programs would need to reimburse allied health professionals independently for their services.”

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