Upcoming Changes to NP & PA Scope of Practice
Healthcare organizations are actively working to modify scope of practice (SOP) laws for advanced practice professionals (APPs) such as nurse practitioners (NPs) and physician assistants (PAs). These groups encourage their members to engage with state legislators to promote bills that alleviate practice limitations. Recruiters need to be aware of legislative changes affecting NPs and PAs once they are ratified. Given the substantial effects these SOP law changes can have, it is vital for APP recruiters to stay informed about state developments, even if changes take a while to be enacted.
Reasons for Supporting SOP Relaxation During the COVID-19 pandemic, many states temporarily relaxed SOP laws for NPs, allowing them to practice independently by suspending or modifying practice agreement requirements. This increased the number of healthcare providers available to manage the surge in patient care needs. Though these changes were temporary, they highlighted the necessity for additional providers. Reasons for considering permanent SOP relaxation for APPs include addressing shortages in primary care, meeting urgent healthcare needs in underserved areas, improving access to care, and enhancing patient outcomes by reducing delays.
As temporary measures ended, some states moved to permanently expand SOP laws. However, others experienced drawbacks from allowing temporary rules to expire. Restrictive laws limiting NPs and PAs exacerbate the healthcare provider shortage. Change often occurs slowly due to the involvement of various stakeholders, with Medicare and state legislatures setting regulations. Different governing bodies influence SOP rules, often causing delays. For example, recent changes in California's NP laws took a decade to implement.
Expanding SOP in States Advanced practice registered nurses (APRNs) are crucial in filling gaps in primary care. NPs play a key role, but restrictive state laws can hinder their ability to provide independent care. SOP laws dictate NP oversight levels, with full practice authority representing the ideal scenario. By the end of 2022, 26 states allowed full practice authority. In January 2023, California became the 27th state, though NPs must wait to practice independently.
California Advances SOP After unsuccessful attempts in 2013 and 2015, California made strides in 2020 with Assembly Bill 890, allowing NPs to treat patients independently. The California Board of Registered Nurses (BRN) finalized the steps for full practice authority, effective January 2023, a decade after initial efforts. AB 890 introduced two NP categories: 103 NPs and 104 NPs. The law grants independent practice authority without the need for physician collaboration, but specific procedures are required. NPs with 4,600 hours or three years of full-time clinical practice can apply to become a 103 NP, enabling them to practice independently while working in settings where a physician is available for consultation. After three years, a 103 NP can become a 104 NP, granting full practice authority in any setting.
California's requirements for full independence are among the strictest in the nation. Not all NPs automatically receive expanded authority; they must meet qualifications and apply for each category. The BRN has made the 103 NP application available, with estimates suggesting about 20,000 NPs will be eligible to apply in 2023. However, as NPs must spend three years as a 103 NP before becoming a 104 NP in 2026, potentially, two-thirds of the state's NPs could achieve full practice authority by that time. Senate Bill 1375, passed in 2022, allows NPs to provide reproductive care without physician supervision. Details on SOP changes from AB 890 are accessible on the California BRN website.
California's legislation may influence other states considering similar NP practice authority changes, although many may wait to evaluate its effectiveness before proceeding.
Challenges in Indiana On November 16, 2022, a coalition in Indiana called on the General Assembly and Governor to enhance healthcare access by allowing patients to choose their providers. This coalition seeks to expand APRN access to meet Indiana's growing healthcare needs. During the public health emergency, Indiana permitted direct APRN access, but this ended with the executive order suspension in 2022. The coalition aims to secure permanent legislation in the 2023 session for APP care access.
The coalition's letter noted that limited healthcare access hindered talent attraction to Indiana, impacting local economies. It highlighted that 2.1 million residents lacked primary care, with numerous healthcare shortage areas identified federally. The initiative's success remains uncertain.
Progress for Physician Assistants PAs have not experienced the same movement towards change in SOP law as NPs. By the end of 2022, most states required PAs to establish agreements with physicians, although continuous presence was not mandated. The American Medical Association reports that 20 states require physician co-signatures on PA charts, and 39 states limit the number of PAs a physician can supervise. PAs can prescribe controlled substances in 44 states, though six restrict Schedule II drugs. Typically, the PA's SOP is determined by the supervising physician.
Federal Legislation While state-level SOP law relaxation for PAs seems unlikely in 2023, federal legislation may expand services if passed. The Improving Care and Access to Nurses (ICAN) Act, introduced in Congress, could facilitate improved access to care for Medicaid and Medicare recipients by removing barriers to practice for NPs and APRNs. The bill would also benefit PAs by eliminating required physician involvement and broadening the range of available services.
The bill proposes removing specific NP barriers to enhance access to rehabilitation programs, fulfill Medicare documentation needs, increase hospice access, streamline services in nursing facilities, and improve medical nutrition therapy and home infusion therapy access. PAs would benefit from similar provisions. However, the bill faces opposition from medical associations that express concerns about extending NPPs' SOP beyond their training and reducing supervisory roles.
Implications for APP Recruitment California offers the highest average NP salary in the United States, but high compensation has not always attracted APPs. Recruiters may have lost talent to neighboring states, indicating that many NPs prioritize independence. With the new law in effect, recruitment opportunities for NPs in California may improve, although challenges remain. Because NPs must obtain California licensure, accrue 4,600 hours or three years of full-time clinical practice, and then spend three additional years before gaining full practice authority, some NPs may hesitate to wait six years, complicating efforts to entice them from bordering states.
As other states evaluate their own adjustments to NP and PA SOP restrictions, broader implications for APP recruitment may emerge, influenced by the extent of these changes. A dedicated service can assist with advanced practice recruitment by keeping you updated about changes in NP and PA SOP laws. Their resources include interactive maps, summaries of each state's current SOP regulations, and links to full state statutes. Recruiters can utilize these tools to assess their states' appeal to APPs. Contact a dedicated service today to learn how they can aid in recruiting advanced practice providers to address your facility's needs. Note: This blog is intended for informational purposes and should not be considered legal or professional advice. For the latest SOP information in your state, please consult with professional advisors."
