The Emerging Consensus

More recently, several reports by research organizations, as well as statements by health policy analysts, have focused on the need for reform of the regulations affecting both practice boundaries and payment for providers such as APNs. A short summary of these commentaries further confirms that the views of health care analysts are converging on a central conclusion: the current scope-of-practice framework must be changed.

  • In cautioning against the “Siren Song of GME [Graduate Medical Education]” expansion as a means of addressing the need for more primary care services, Fitzhugh Mullan and Elizabeth Wiley note: “The increased need for physician services can be met by better use of the physicians we have now … and by the increased use of nurse practitioners and physicians assistants in primary care and specialty care settings. The important principle underlying this latter strategy is that all clinicians should work to the maximum of their training and licensure [emphasis added]” (Health Affairs, 2009).

  • In identifying necessary foundations for cost containment and value-based care, the Engelberg Center at Brookings included as a key reform for improvement of the health care workforce: “Create incentives for states to amend the scope of practice laws to allow for greater use of nurse practitioners, pharmacists, physician assistants, and community health workers [emphasis added]” (Engelberg Center for Health Care Reform at Brookings, 2009, p. 2).

  • In a report for the Business Roundtable evaluating the effects of health care reform through the lens of the private sector, Hewitt Associates recommended that, as part of the concept proposed in some current reform bills to create an Innovation Center at the Centers for Medicare and Medicaid, test models should include measures to fund “nurse-practitioners and physician assistants to manage chronically ill patients,” and to enhance greater professional service capacity by “greater utilization of nurse practitioners” (Hewitt Associates, 2009, pp. 8, 22).

  • In a comprehensive analysis of the need for a national, coordinated health workforce policy, the Association of Academic Health Centers found that “Inconsistencies in scope of practice laws engender numerous challenges.” The report went on to add that “lack of national uniformity in scope of practice limits health professionals’ mobility and practice,” and that “many professionals and policymakers believe that the appropriate response to workforce shortages is to expand the scope of practice of various health professionals. Such a change would also contribute to leveraging workforce capacity and increase access to care.” Unless and until this is done, “patients may be unable to obtain the services of skilled



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