The COVID-19 pandemic has highlighted some of the shortcomings in our health care system, but a longer-term crisis is also lurking around the corner—a national shortage of physicians. According to the U.S. Department of Health and Human Services, “37 states are projected to have a shortage of primary care physicians in 2025.” California alone could experience a shortage of 1,550 primary care physicians by 2025.
Allowing non-physician providers like nurse practitioners (NPs) to practice independently and to the full extent of their training can help alleviate the coming shortage. Fortunately, the California Legislature recently passed— and Gov. Gavin Newsom signed—Assembly Bill 890, which does just that.
About half of the states across the country already allow nurse practitioners to practice independently. Unfortunately, many physician groups strongly oppose this sensible solution to the crisis. The American Medical Association (AMA), a group representing physicians and medical students, tried to get Gov. Newsom to veto the bill and will likely continue to fight similar reforms in other states.
The AMA claimed that eliminating supervision requirements would fail to address problems with rural access, raise health care costs, and threaten public safety. However, the bulk of evidence refutes each of these claims.
Expanding Access to Health Care
Multiple studies have concluded that removing restrictions on nurse practitioners’ scope of practice increases access to health care. A systematic review of the literature from 2015 concluded that states where NPs have greater practice authority “tend to exhibit an increase in the number and growth of NPs, greater care provision by NPs, and expanded health care utilization, especially among rural and vulnerable populations.”
Another paper from 2018 found that supervision requirements tend to result in nurse practitioners collocating with supervising physicians. The study’s authors further suggested that such restrictions limit the ability of NPs to provide care in areas that lack access to primary care physicians.
The AMA letter claims that “states that require physician-led team-based care have seen a greater overall increase in the number of nurse practitioners compared to states that allow independent practice.”
It is difficult to assess the veracity of this claim because the letter fails to provide evidence for it, but citing the overall number of nurse practitioners is likely misleading. A more appropriate measure of access would be the number of NPs per capita. Simply looking at the overall increase in the number of NPs biases toward high-population states like California, Texas, Florida, and New York, which have historically been more restrictive.
A 2018 analysis found that, on average, rural counties in states with less restrictive NP practice environments had more nurse practitioners per 100,000 population between 2009 and 2013. There was no statistically significant difference in the rate of increase between states.
The labor costs for nurse practitioners are considerably lower than for physicians. Therefore, there is reason to believe that substituting NPs for physicians in some circumstances could result in cost savings. This effect would likely increase over time given employment trends across these occupations.
While the United States and California are expected to experience physician shortages in the coming years, the supply of NPs is increasing rapidly. In fact, U.S. Department of Health and Human Services projections indicate that California will have a surplus of nearly 5,000 primary care NPs by 2025.
The AMA letter claims that “nurse practitioners order more diagnostic imaging than physicians, which increases health care costs.” While the letter cites two studies supporting the claim that NPs tend to order more diagnostic tests, this only indirectly suggests independent practice would lead to higher costs. Studies that assess costs directly have consistently found nurse practitioner-provided care to be cost-effective.
A study published in the Journal of Law and Economics found that more restrictive SOP policies resulted in between 3 and 16 percent higher costs for well-child visits. Another paper from 2019 found that states allowing full independent practice had significantly lower outpatient costs and prescription drug costs.
Quality of Care
Nurse practitioners are highly skilled health care professionals capable of providing many of the same services as primary care physicians. In fact, a report from the former congressional Office of Technology Assessment concluded that nurse practitioners could perform a substantial proportion of tasks normally provided by primary care physicians and “as much as 75 percent of the well-person care for both adults and children.”
More recently, a 2017 analysis concluded that scope of practice laws had no effect on the quality of care. Other studies have found that, compared to resident physicians, NPs were associated with higher rates of patient satisfaction.
The AMA letter points to differences in training and education as evidence for its claim that NPs are ill-equipped to practice without supervision. Of course, physicians receive more rigorous training and play a critical role. That is precisely why we should let them focus on the patients that are in the greatest need of their attention. Expanding the role of nurse practitioners offers a safe and cost-effective way to expand access to care and combat the looming shortage of primary care physicians in California.
There is widespread agreement that policy change is necessary to expand access to care. An abundance of evidence suggests that nurse practitioners can help address the growing gaps in the physician workforce. However, opposition from physician groups is not surprising. One recent paper found that when nurse practitioners are given greater independence, their wages increase while physicians’ wages decrease. Rather than heed the unfounded warnings of physicians’ groups, more states should follow California’s lead and allow nurse practitioners to practice independently and to the full extent of their training.