Scope of Practice

Independent practice for NPs fails to solve rural access problems

Kevin B. O'Reilly , Senior News Editor

What’s the news: A bill moving close to passage in California’s legislature would remove critical patient protections by allowing nurse practitioners (NPs) to practice without physician supervision. The bill—AB 890—lacks critical details related to NP competency requirements, scope limitations, requirements to actually serve underserved populations or regions, and many other details. As it stands, it is a dangerous bill to move forward and will do nothing to improve access to health care in California.

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The bill was approved by the California State Assembly in January and was passed by a key state Senate committee last week. Now it is before the Senate Appropriations Committee, which could hear the bill as early as today.

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.

AB 890, which is opposed by the California Medical Association (CMA) and the American Medical Association, threatens that option by allowing NPs to replace doctors in underserved communities. These communities are already suffering from higher rates of chronic diseases and poorer health outcomes. Members of these communities deserve to have access to physicians, as well as high quality physician-led teams in charge of their care. AB 890 does the opposite.

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States that protect physician-led care have more physicians and NPs serving them than do states without requirements for physician-led team-based medical care. California is already suffering from a shortage in its health workforce, and AB 890 exacerbates the problem by eliminating team-based care. AB 890 will also increase overall health cost and threaten patient safety by allowing NPs to order, perform and interpret x-rays, mammography, and ultrasounds. Such policies may end up costing California more in the long run due to overutilization of diagnostic tests, inappropriate prescribing, and improper specialty referrals by undertrained NPs.

For example, one study in the Journal of the American College of Radiology which analyzed skeletal x-ray utilization for Medicare beneficiaries from 2003 to 2015 found ordering rose by more than 400% among nonphysicians, primarily NPs and physician assistants.

Moreover, the bill offers false solutions for California. Data shows that, in states that have allowed NPs to practice independent of physician supervision, nurse practitioners have not chosen to locate or practice in underserved or rural areas. By contrast, states that support physician-led teams have seen greater increases in the number of primary care physicians and nurse practitioners.

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“In discussing the future of health care access in California, we must make sure we neither inadvertently drive up costs nor lower training standards,” Ted Mazer, MD, past president of the CMA, wrote in an op-ed on the bill that was published in the San Diego Union-Tribune.

“Rather, we must do everything we can to ensure patients have confidence in the competency and training of the medical professionals trusted with their care. Improving access to such care doesn’t require lowering standards,” wrote Dr. Mazer, a head-and-neck surgeon.

Learn more: If you’re a physician in California, you should urge your state senator to vote no on AB 890. You can take action now with a single click at the CMA’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.