Scope of Practice

3 big reasons why letting NPs practice independently is a bad idea

Kevin B. O'Reilly , Senior News Editor

What’s the news: The AMA is strongly urging California Gov. Gavin Newsom to veto a bill—A.B. 890—that would allow independent practice nurse practitioners (NPs) to practice without physician supervision.

In a letter to Newsom, AMA Executive Vice President and CEO James L. Madara, MD, explains that the bill “will not expand access to care in rural and underserved areas, increases overall health care costs and threatens the health and safety of patients in California.” 

Why it’s important: Patients, especially those with chronic conditions, want and expect their medical care to be directed by a physician. An AMA patient survey has found that 86% of respondents agree that patients with one or more chronic diseases benefit when a physician leads the primary health care team.

A wealth of research illustrates these three main reasons why Newsom should veto the bill allowing independent practice for nurse practitioners.

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It won’t solve the rural access problem. Oregon, for example, has for decades allowed independent practice for NPs, yet “there is no measurable shift of nurse practitioners to the rural areas,” Dr. Madara wrote, pointing to maps illustrating the state’s health workforce patterns.

“In fact,” Dr. Madara wrote, “the evidence shows 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.”

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It will raise health care costs, not cut them. That’s because NPs in states that allow independent prescribing tend to prescribe 20 times more opioids than NPs in states that do not. NPs also order more diagnostic imaging than physicians. Studies looking at Medicare claims data from 2003 to 2015 found skeletal x-ray ordering increased over 400% among non-physicians, primarily NPs and physician assistants.

It threatens patient safety. NPs are essential members of the physician-led care team, but they are plainly not trained to practice independently. They are not required to undergo years of medical residency training and get only 500–720 hours of clinical training, compared with the 10,000–16,000 hours that physicians receive.

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“But it is more than just the vast difference in hours of education and training,” Dr. Madara notes, “it is also the difference in rigor and standardization between medical school and residency and nurse practitioner programs.”

The AMA’s letter also notes the expert evaluation of A.B. 890 by Lawton R. Burns, PhD, which was submitted to the California Senate Appropriations Committee. He examined three practice functions allowed in the original Senate version of the bill, prescribing of antibiotics and opioids, and reading of mammograms. 

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Those added “services and utilization may not be entirely favorable to the public’s health,” wrote Burns, who chairs the health care systems department at the University of Pennsylvania Wharton School of Business. That element of the bill “will likely lead to greater fragmentation and dispersion of care, higher health care costs, lower quality of care, and perhaps higher patient mortality among patients receiving these services.”

Learn more: If you’re a physician in California, you should urge Gov. Newsom to veto A.B. 890. You can take action now with a single click at the California Medical Association’s grassroots action center.

Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety. 

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Editor’s note: This story was updated Oct. 9 to more clearly explain research on nurse practitioner ordering patterns.