Scope of Practice

How scope of practice impacts the rising cost of health care with Kimberly Horvath, JD


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Scope of practice expansions that allow nonphysician providers to practice independently cost large health systems millions each year, two health care data studies show. Kimberly Horvath, a senior attorney with the AMA’s Advocacy Resource Center, joins to discuss the studies’ findings and what they mean for practice leaders and legislators. AMA Chief Experience Officer Todd Unger hosts.


  • Kimberly Horvath, senior attorney, AMA Advocacy Resource Center

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Unger: Hello and welcome to the AMA Update video and podcast. Today, we're discussing two studies that show the impact of scope of practice expansions at large health systems. Joining me in our Chicago studio to discuss the results is Kimberly Horvath, a senior attorney with the AMA's Advocacy Resource Center. I'm Todd Unger, AMA's chief experience officer. Kim, we're so glad to have you back in the studio.

Horvath: It's great to be here.

Unger: Well, we're eager to talk about these two different studies. The first one comes from Hattiesburg Clinic in Mississippi where over the last 15 years the health system expanded its care teams with non-physician providers. And in primary care, these providers practice independently alongside physicians. Why don't we just start by talking about what happened when Hattiesburg leadership looked at how that was working?

Horvath: Yeah. So as an ACO, Hattiesburg Clinic gets a lot of data from CMS. So they dove into that data, and they discovered that care provided by non-physicians, particularly physician assistants and nurse practitioners, was more expensive than care provided by physicians. Specifically, the data showed that on the primary care side per member per month cost increased were $43 higher per patient for those who primarily saw a non-physician, again, compared to a physician.

And if you extrapolate this out, that led to or could lead to an additional cost, about $10.3 million in annual spending. So big numbers. When they risk adjusted that number because the patients seen by non-physicians were generally less complex, so when they then risk adjusted for patient complexity, they found that per member per month that patient cost would actually be about $119 or $28.5 million more annually.

So what they did is they kind of wanted to dig into a little bit more, and they found out that the reason for those cost increases—and this is found in other studies as well, but so it was no surprise, but increased utilization of services. They ordered more tests. They were more likely to refer a patient to a specialist. Their patients were more likely to use the emergency department. So that's all what led to the increased cost.

Hattiesburg Clinic also wanted to look at the quality of care. And so they did some quality measures and looked at the quality measures. And physicians outperformed the non-physicians in 9 out of 10 quality metrics and also scored higher in patient satisfaction surveys as well.

Unger: All right, so that's a pretty significant difference across a number of very, very important measures. And when Hattiesburg leadership looked at those results, what did they decide to do with that information?

Horvath: Yeah, the findings prompted the leadership to redesign and refocus the clinic's care model. Now a physician is the primary care physician for all the patients in the primary care model. And no one sees a non-physician exclusively. They may see a non-physician on every other visit. But a physician is always going to be the primary care physician for that patient.

They took about one year to transition it, making sure that patients knew, making sure that all of the health care professionals in the system knew. But they also made sure to underscore that non-physicians are still really important. They need them. They actually hired more. They want them as part of the care team model. They did not want them being the primary care leader. They needed to make sure that physicians led the health care team.

Unger: Well, that's a very, very clear example and support for why the AMA advocates for physician-led care teams. But they're not the only health system to support that idea with data. We've got a second study this time from Stanford. And it had data that was based on Veterans Health Administration data. So let's talk about that. What do we find in that study?

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Horvath: Yeah, so that study compared the care provided by nurse practitioners in the emergency department to physicians. And it was within the Veterans Health Administration, so a closed system. And what it found is that nurse practitioners increased the cost of emergency department care by 7% or about $66 per patient. The authors also looked at the productivity of nurse practitioners compared to physicians and found that using the current staffing model of allocation of nurse practitioners in the emergency department would result in a net cost of $74 million annually, meaning that nurse practitioners are actually more costly to employ than physicians, even accounting for a difference in their salary.

The authors of the study cited similar reasons for the increased cost, more utilization of resources, more likely to order tests, seek consults from specialists and others. And they also found that—and this is important that despite using more resources, despite patients being kept in the ED longer because it takes time to have all these tests come back and have these extra consults, the patients seen by the nurse practitioner actually ended up with worse outcomes in the ED compared to those seen by a physician.

Unger: So this is really interesting. So we have pretty similar results to what we saw in Hattiesburg. And I think that probably goes against maybe some common conceptions given the information that you cite there about which actually is more expensive. So you really have to think through and look at this data. And even though there are similar results, there is something special that I want you to cover about this Stanford study in terms of how it was conducted.

Horvath: Yeah, the productivity profession study is really kind of a top tier study. Other studies that looked at the cost and quality of care often do it in a correlative analysis. The Stanford study used a high quality causal analysis, so a very high quality study. Also, a lot of the other studies in this body of literature actually look at nurse practitioners practicing within a physician-led team, with physician supervision or collaboration.

This study was done within the VA actually within a time period where nurse practitioners were truly practicing independently. They were not being supervised or collaborating with physicians in the ED. And it really reinforces that scope expansions can lead to higher health care cost. It also helps to more clearly demonstrate the importance of physician-led care.

Unger: So many scope expansion issues across the country at different kind of state levels right there. And I know a lot of the discussion will often center on experience training, years of education between physicians and non-physicians. This discussion we're having today is different because we're talking about costs and real differences in cost and patient outcomes, so to speak. When you use data like this, does it have a different effect when you go to talk to legislators about issues around scope?

Horvath: Yeah, absolutely. I mean, we definitely incorporate this information when we reach out to lawmakers, the state medical associations and specialty societies do as well. It's really helpful to push back against the notion that—we hear this a lot that non-physicians provide us high-quality care at a lower cost. These studies clearly demonstrate that that is not true.

They're also really great examples of the importance of physician-led care because both of them came to the conclusion that physician-led care provides the highest quality care at the lowest cost. And they both also, though, do demonstrate that, again, nurse practitioners and physician assistants are important members of the health care team. But they simply don't have the same skill set as physicians.

Unger: So for other health systems out there, I know many of them are looking very closely at the studies coming out of these two places. For those who haven't done their own analysis but do have a lot of non-physician providers, what steps should they take to really look deeply at their own data?

Horvath: Yeah, we would encourage them to do their own study. Particular ACOs, but health systems in general, have data like Hattiesburg Clinic did. Take a look. Put a microscope on those health care costs. It's an important checkpoint both on the health care team model but also on the cost and quality of care that is being provided to the patients, which is ultimately what matters is the high-quality care that we're providing to patients.

Unger: Well, Kim, thank you so much for being here today. The studies are complex obviously. And it's great to have you here to make sense of them. Really appreciate it. You can find out a lot more about scope of practice and the AMA's efforts in that by looking at the AMA Recovery Plan for America's Physicians on the AMA site. You can find that at

We'll be back soon with another AMA Update. In the meantime, you can take a look at all our videos and podcasts at Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.