• The cost of care is increased and much time is wasted by unnecessary physician supervision, and by duplication of services resulting from required “confirming” visits with a physician and co-signatures for prescriptions or orders.

• Educational and training functions and opportunities are distorted by disparate reimbursement eligibility for supervision of medical residents or students, on the one hand, and APN students on the other.

• Flexibility in deployment, both between and within existing delivery systems, is unnecessarily reduced.

• The risk of disciplinary action looms over even routine provider–patient interactions (such as a telephone consultation or filling a prescription) when these activities cross state borders.

• Millions of dollars and countless hours are spent in state and federal legislative and administrative proceedings focused on restricting or expanding scopes of practice or payment policies.

• The promise of new technologies and practice modes remains significantly unrealized. Telepractice or telehealth systems, for example, would allow APNs and other providers to utilize telecommunications technology to monitor, diagnose, and treat patients at distant sites, but their use is stymied by multiple and conflicting licensure laws and payment provisions.

The principal causes of the existence and continuation of unnecessarily restrictive practice conditions for APNs can be grouped into three categories: (1) purposeful or inertial retention of the dysfunctions resulting from the historical evolution of our state-based licensure scheme, (2) lack of awareness of APNs’ roles and abilities, and (3) organized medicine’s continued opposition to expanding the authority of other providers to practice and be paid directly for their services. All of these causes are rooted in the historical evolution of the state-based licensure scheme. The relevance of that history to the current regulatory environment can scarcely be overstated, and it is there that we must begin if we are to understand the present situation.

Historical development The United States was one of the first countries to regulate health care providers, and physicians were the first practitioners to gain legislative recognition of their practice. By the early 20th century, each state had adopted a so-called “medical practice act” that essentially claimed the entire human condition as the exclusive province of medicine. The statutory definitions of physicians’ scope of practice were—and remain—extremely broad. The following medical practice act is representative.