A service of the California Health Care Foundation

Think Tank

Should California Expand Providers’ Scope of Practice?

This month, state Sen. Ed Hernandez (D-West Covina), chair of the Senate Committee on Health, plans to introduce legislation that would expand the scope of practice for mid-level health care providers in California.

Hernandez and many stakeholders say the state does not have enough physicians to meet demands of millions of newly insured Californians when the Affordable Care Act’s mandatory coverage provisions kick in next year.

His bill would allow physician assistants to treat more patients with more latitude and to allow nurse practitioners to establish independent practices. His bill also will propose that pharmacists and optometrists be able to serve as primary care providers and diagnose and manage some chronic conditions.

We asked legislators, stakeholders and experts if California should give mid-level providers more autonomy and more authority.

We got responses from:

Nurse Practitioners Play Critical Role

The implementation of the Affordable Care Act will extend health benefits to an estimated 50 million uninsured people in the United States. Nearly seven million of those uninsured people are here in California and will soon be accessing the health care delivery system in record numbers. What California’s policymakers are beginning to grapple with is the fact that there are not enough medical professionals to address this increased demand for access to care. In many parts of California where providers are in short supply, coverage does not guarantee access.

Sen. Hernandez has taken a leadership role in confronting these issues. On March 13, a joint hearing of the Senate Business and Professions and Health Committees will examine the workforce demands that need to be met to properly implement the ACA. What the Legislature will discover is that nurse practitioners will play a critical role in filling the gap and ensuring the success of the new health care law.

There are more than 16,000 nurse practitioners in California — advanced practice registered nurses who have completed graduate-level education such as a masters or a doctoral degree. The Legislature will find that in many cases they deliver the same high quality of health care provided by physicians, but often at lower cost. The Institute of Medicine recently released an extensive report on the future of nursing and recommended that nurse practitioners and all health care providers be allowed to work to the full level of their education and training to provide care for our population. Studies published in the Journal of the American Medical Association and by the Rand Corporation show that if nurse practitioners are allowed to do so they provide equal quality of care and health outcomes as physicians.

Nurse practitioners are already in the exact places where demand for health services will increase. In California, they work in community clinics and urgent care centers, hospice facilities and nursing homes, school campuses and veterans facilities, hospitals and private practices. In many medically underserved communities throughout the state, nurse practitioners are on the front lines of the health care delivery system, providing access to patients who would otherwise not be seen by a medical professional.

Nurse practitioner practice includes key primary care functions such as diagnosing acute and chronic diseases, ordering and interpreting diagnostic tests, prescribing medication, ordering physical therapy and other rehabilitation treatments, and counseling patients on health behaviors and treatment options.

The health and well-being of the patient ought to remain the primary focus at all levels within the health care delivery system. Nurse practitioners will be a vital part of maintaining a high quality of care and ensuring smooth implementation of the new health law.

Clinical Integration, Not Fragmentation

The Affordable Care Act promises health care coverage and the real benefits of preventive care and chronic disease management for millions of Californians, many of whom have been without access to a physician for years. These patients will need access to quality primary care from a trained physician who can diagnose, treat and manage a wide range of health conditions.

But will there be enough physicians to provide that care? Not unless things change. 

An aging population and physician retirements compounded with an influx of newly insured patients will create an effective health care shortage. However, we have an opportunity as physicians and caregivers to be innovative and collaborative in finding solutions for both the short and long term.

Looking ahead, California needs more medical schools, expanded residency training programs and incentives for new doctors to enter primary care and work in medically underserved areas. While we cannot speed up medical school, we can increase funding to create more slots for residents in California, and we can grow programs like the Steve Thompson Loan Repayment and Scholarship Programs, which provide medical school debt relief in exchange for a commitment to practice in underserved areas throughout the state.

While it will take time to bring more physicians into the pipeline, we can begin implementing integrated care teams led by physicians right now. Such teams may include a variety of health professionals, and leveraging the skills and training of each team member in order to provide higher quality care to more patients — a true increase in capacity. Pediatric diabetes care teams and palliative care medical homes are proven examples. This kind of model will be essential if we are to effectively anticipate the wave of newly insured patients and markedly changing health care payment and delivery systems.  

Changing the law to allow the current non-physician workforce to practice without the supervision and direction of a highly trained physician just creates an inequitable two-tiered system in which some patients have better access to better medical care than others. It will not increase overall patient access to quality medical care. Real health reform requires developing new ways for health professionals to work together with a singular focus on providing quality patient care.

Expanded use of clinically integrated care teams comprised of physicians, nurse practitioners, physician assistants and others, led by physicians is the best approach for the rapid change that lies ahead for California patients and their medical care.

Team-Based Model Makes Most Sense

California’s problem of a lack of primary care providers is not new. The challenge however is even more overwhelming when you consider the millions of those soon eligible who will come to our health centers in less than a year. The California HealthCare Foundation released a report more than two years ago showing that six of nine regions in the state had a shortage of physicians. Our medical schools are not turning out enough primary care physicians to meet the needs of our state and many California physicians are now approaching retirement. Even more severe is the lack of physician diversity in California. In a state where nearly 40% of the population is Latino, only 5% of our physicians are.

Community clinics and health centers have worked over the years to address this issue and utilize the team-based model of care, where a patient is treated by a team of providers, not just one physician. This model often includes nurses, physician assistants, nutritionists and specialists, and is one way to provide quality patient care through a practice that doesn’t rely solely on one type of provider. We at the California Primary Care Association believe that this is the best model of care and is one that should be utilized more throughout the entire health care system.

The patient-centered health home model, which is supported by the ACA, builds on the team-based approach in order to meet a broad set of patient needs including acute care and chronic care, as well as prevention. Our hope is, as we move forward in implementing the ACA, team-based models of care spread to provide our patient populations with the highest quality of care possible.

The California Endowment recently committed $30 million to advance the patient-centered health home model in California. CPCA believes that is a positive step toward addressing our workforce issues.

Moving forward, initiatives that address the ancillary positions central to the patient-centered model of practice are also needed, and at a minimum, we need to ensure that providers are operating at the top of their scope.

Finally, we believe that having culturally and linguistically competent physicians in California is essential to meeting the triple aim of providing high quality care, increasing access and ensuring affordability. 

The debate has started in the Legislature around scope of practice. It is our hope that we can be innovative in advancing solutions that address the team-based model of care that is prevalent in community clinics and health centers and should be the model for the future.

Integrated Teamwork Is Best Approach

As our state struggles with a serious shortage of primary care physicians, leaders of the California Academy of Family Physicians are examining every avenue that would ensure Californians’ access to quality primary care. One thing we know will not work is the further fragmenting of care. In our current health care system, comprehensive prevention and chronic care management — care that keeps patients as healthy as possible — often are simply not available to them.

Family physicians welcome the expansion of health care coverage that will make care more accessible for millions more people in our state. To best provide that care, we are committed to working with nurse practitioner and physician assistant colleagues to identify ways our primary care teams can operate more efficiently. We would not rule out certain changes in law to support these efforts.

Patient safety and quality of care always will be our foremost concern as we consider changes in law. It’s important to note that, while valuable members of the health care team, mid-level practitioners do not possess the depth and breadth of medical knowledge that primary care physicians have. A newly graduated nurse practitioner, for example, may have as few as 500 patient care hours, while a physician has 12,000 to 16,000 clinical experience hours. Such additional training makes a critical difference. Nurse practitioners and physician assistants can very competently handle many aspects of primary care, but they’re not equivalent providers to family physicians.

High-quality, cost-effective health care requires that we end fragmentation. We need changes in the law that further integrate providers into one team connected by information technology. Creating independent silos of care will have the opposite effect.

Research and practice show that the primary care physician-led patient-centered medical home —  a coordinated, integrated health care delivery model — improves health outcomes while reducing costs.  Achieving excellence requires creating high-performing health care teams in which nurse practitioners, physician assistants, nurses, medical assistants and others practice at the very top of their licenses and training. Primary care physicians provide the necessary medical oversight and higher-level medical treatment. Better standardized procedures and written protocols are one way to make it possible for all health care providers to make the best use of their training and experience. 

We look forward to working as teams to find the best ways forward.

Update Professional Practice Acts To Expand Primary Care

Californians deserve high quality primary care offered by a range of safe providers. The professionals at the heart of today’s question — physician assistants, nurse practitioners, pharmacists and optometrists — have all significantly advanced their educational, testing and certification programs over the past decade. They’ve enhanced clinical training, moved to graduate or advanced degrees, and upgraded program accreditation processes.

Other states have recognized these advances with practice acts that align with professional competence. But California’s practice acts have not kept pace.

California lags precisely when we should be ready to answer calls for appointments from millions of newly insured under the ACA. That fact alone should give us pause; we’re not meeting current need now. But even without the ACA, we have changing practice patterns (team-based care), shifting disease burdens (chronic conditions), and new technologies (telehealth and electronic health records) that call for practice law modernization.

We can no longer afford to get by on a fraction of our professional capacity. Why delay care when we have providers who could serve? Why encourage students to learn, with education funded in part by public dollars, to practice at one level and then limit their practice upon graduation? And why ignore the experience of doctors who work side by side with nurse practitioners, physicians assistants, pharmacists and optometrists as colleagues, and realize that everyone provides optimal care when everyone does what he or she knows best?

Though tempting to some, it would be ingenuous to call for more research now. I’ve been looking at the mountain of evidence regarding these professions for 20 years. The question — whether the evidence supports the assertion that they can safely provide some primary care that was historically reserved to doctors — can be answered affirmatively. Remaining opposition cannot be justified by insufficient proof.

Our country’s best academic and clinical researchers have produced premier studies confirming the safety and quality of care these professionals provide. Our country’s best communicators, from Mark Twain to Hollywood screenwriters, have weighed in on scope of practice battles more eloquently than I can.

We should already be dealing with integrating care, training teams, overhauling financing mechanisms, and incorporating technology into patient-centered care. The turf battles posed above are yesterday’s fights, ready for the history books. Of course California should update these particular practice acts and move on to imminent and even greater challenges.

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