Scope of Practice

What’s the cost of scope creep? Start counting in the millions

Marc Zarefsky , Contributing News Writer

AMA News Wire

What’s the cost of scope creep? Start counting in the millions

Oct 25, 2023

Ninety-five percent of U.S. voters believe it's important to have a physician involved in diagnosis and treatment decisions. Two recent studies show that this type of physician-led, team-based care also is—contrary to the rhetoric—more cost-effective and beneficial than care provided independently by nonphysician providers. 

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One study focused on the Hattiesburg Clinic in Mississippi, while the second examined data sourced from the Veterans Health Administration. Both found that scope of practice expansions that allow nonphysician providers to practice without physician supervision cost health systems millions of dollars.

"We hear this a lot—that nonphysicians provide high-quality care at a lower cost," said Kimberly Horvath, senior attorney with the AMA Advocacy Resource Center. "These studies clearly demonstrate that that is not true."

Horvath talked about the two studies and the key takeaways from each in a recent episode of “AMA Update.”

Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.

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

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In 2005, the Hattiesburg Clinic employed 26 physician assistants and nurse practitioners. Fifteen years later, that number was up to 118. Combined with certified registered nurse anesthetists and optometrists, there were 186 nonphysician providers at the clinic.

A look at cost data revealed that the care provided by those nonphysician providers was more expensive than care delivered by doctors. Horvath explained the reason for the cost increase was that nonphysicians relied on more services than their physician counterparts.

"They ordered more tests," Horvath said. "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."

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Care provided primarily by physician assistants and nurse practitioners was shown to increase the cost of care by $43 per patient per month. That difference had the potential to lead to more than $10 million in additional annual spending at Hattiesburg Clinic, which is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

Those numbers were even greater when patient complexity was factored in. Horvath explained that once risk adjustment was inserted into the equation, the monthly per patient cost of nonphysician providers would be about $119 more compared with physician care—or $28.5 million annually.

Finances were not the only difference when it came to care. Physicians outperformed nonphysicians in nine out of 10 quality metrics and scored higher in patient satisfaction surveys.

The findings led the Hattiesburg Clinic to redesign its care model. The nonphysicians were still deemed important to the clinic—in fact, the physician-owned health system went on to hire more—but the decision was made to always have physician-led primary care in place.

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A second study compared the care provided by nurse practitioners and physicians in the emergency department within the Veterans Health Administration. The data showed care provided by nurse practitioners without physician oversight increased the cost of emergency department care by 7%—or about $66 per patient.

The study also found that the current use of nurse practitioners in the emergency department would result in a net cost of $74 million each year. That meant it would cost more to employ the nurse practitioners than physicians, Horvath said, even when considering the difference in their salary.

Like the Hattiesburg Clinic data, this study found that the added costs were a result of using more resources, ordering more tests, and seeking more consults from specialists. The study also identified that even with additional tests, increased time in the emergency department, and extra consults, patients who saw a nurse practitioner ended up having worse outcomes compared with those who saw a physician.

"It really reinforces that scope expansions can lead to higher health care costs," Horvath said. "Physician-led care provides the highest quality care at the lowest cost. … 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."

AMA Update” is your source for physician-focused news. Hear from physicians and other experts on trending public health concerns, practice issues and more—because who’s doing the talking matters. Catch every episode by subscribing to the AMA’s YouTube channel or listen to all AMA podcasts at