Many healthcare organizations strive to change scope of practice (SOP) laws for advanced practice professionals (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) in their states. These organizations rally their members to lobby state lawmakers to introduce bills to relax practice restrictions. As lawmakers consider bills impacting NPs and/or PAs, it’s essential for recruiters to stay on top of any approved changes slated to go into effect.

Given the impact changes to SOP laws can have, it’s important to keep up with what’s going on in your state as an APP recruiter—even if those changes take time to get approved and then implemented.

Reasons APPs Support Less Restrictive SOPs

During the COVID-19 pandemic, many states that didn’t already allow full practice authority to NPs adopted temporary stays that suspended all practice agreement requirements or waived select requirements. States that suspended the requirement that NPs have a practice agreement or collaborative arrangement with another healthcare provider increased the number of independent healthcare providers to help manage unprecedented patient loads. 

While relaxing SOP restrictions for NPs was temporary, it proved the value of having these additional providers available. Other reasons some states may be considering relaxing SOP restrictions for APPs include:

• Addressing primary care workforce shortages
• Meeting the critical demand for primary care services in rural and underserved areas across the state
• Expanding access to care in all areas of the state
• Improving patient outcomes due to shorter wait times and delays
• Having a positive impact on the overall health and quality of life of residents

As the temporary stays during the pandemic began to expire, some states scrambled to codify expanded scope of practice laws. Unfortunately, other states faced the drawbacks of allowing those temporary regulations to lapse. State laws that prevent skilled NPs and PAs from providing primary care to patients and limit the tasks they can perform create a restrictive environment that often exacerbates an already limited supply of healthcare providers.

Change is slow due to all the stakeholders involved. While Medicare and state legislatures set many rules, each state may also have various governing bodies with the authority to change scope of practice rules.

Change is slow due to all the stakeholders involved. While Medicare and state legislatures set many rules, each state may also have various governing bodies with the authority to change scope of practice rules. State nursing boards may also have the authority to make changes or be subservient on other boards, resulting in additional administrative and political oversight. The biggest pushback to changes in NP and PA scope of practice laws usually comes from physicians through state medical associations.

Each state varies and may have numerous entities making decisions together or separately, which slows the overall process. It often takes years for any amendments to APP scope of practice to occur, as demonstrated by the recent change in California’s NP laws, which was a decade in the making.

States Looking to Expand Scope of Practice

Nurse Practitioners

Skilled healthcare professionals such as advanced practice registered nurses (APRNs) help fill the gap when primary care providers are in short supply. Nurse practitioners especially play a vital role in patient care, but current laws in states with restricted practice and potentially even some with reduced practice prevent NPs from providing primary care to patients independently. 

State SOP laws dictate the amount of oversight NPs must have to practice, but full practice authority is the ideal situation. At the close of 2022, the U.S. had 26 states that allowed full practice authority. California made it 27 in January 2023, but NPs won’t get to practice independently right away.

California Moves Forward

After failed attempts in 2013 and 2015, California took an important step in 2020 to create a pathway for nurse practitioners to treat patients independently. Governor Gavin Newsom signed Assembly Bill 890, giving nurse practitioners in the state a clear pathway to achieve full practice authority without physician supervision. It’ll take years for NPs to actually reach the end goal, but it’s now an open avenue they can pursue.

California took an important step in 2020 to create a pathway for nurse practitioners to treat patients independently.

The California Board of Registered Nurses (BRN) finalized the steps required to gain full-practice authority, allowing the law to officially go into effect January 2023, about 10 years after the first failed attempt. AB 890 essentially created two new categories for nurse practitioners, commonly referred to as 103 NPs and 104 NPs. 

The new law doesn’t significantly alter the current scope of practice for either category. However, it provides additional authority for NPs to work without entering into a collaborative agreement with a physician, effectively providing them with autonomy to practice. They must follow specific steps to get to full practice authority.

NPs who’ve completed 4,600 hours or three years of full-time clinical practice in California can apply to become a 103 NP. As a 103 NP, they may work without physician supervision, but they must work in a group setting where at least one physician or surgeon also practices. Although they can practice independently, they still have access to a physician should they need to consult with them.

After three years under this arrangement, a 103 NP can apply to become a 104 NP. As a 104 NP, they can work without physician supervision outside a group setting. In other words, they gain full practice authority without restrictions and can open their own practice if they choose. However, full practice authority doesn’t allow NPs to perform any additional duties outside the scope of practice outlined under their current license.

California’s requirements to transition into complete independence are among the most robust in the nation. But expanded practice authority isn’t automatically granted to all NPs practicing in the state. They must meet the minimum qualifications outlined above and apply for each category. 

California’s requirements to transition into complete independence are among the most robust in the nation. But expanded practice authority isn’t automatically granted to all NPs practicing in the state.

The BRN has released the new 103 NP application, so eligible NPs can apply for the first new NP category immediately. Of the 31,000 NPs in California, the California Association of Nurse Practitioners estimate that 20,000 will be eligible to apply in 2023. Because they must complete three years as a 103 NP, nurse practitioners can’t certify as 104 NPs until 2026. Almost two-thirds of the state’s NPs could gain full practice authority at that time. 

In 2022, Governor Newsom also signed Senate Bill 1375 into law authorizing NPs to provide reproductive care and first-trimester abortions without doctor supervision. More information and answers to frequently asked questions about the SOP changes made possible by AB 890 can be found on the California BRN website.

California’s new bill could start a trend of states loosening restrictions on NPs’ practice authority. However, they may wait to see how successful California’s bill is at increasing access to care before following suit.

Indiana Stalls

On Nov. 16, 2022, various groups across Indiana announced the launch of Hoosiers for Health Care Access (HHCA). This coalition represents 10 organizations that signed an open letter calling on the Indiana General Assembly and Governor Holcomb to provide greater access to healthcare by patients’ providers of choice. The goal was to expand access to APRNs to meet Indiana’s growing healthcare needs. 

Indiana was one of several states that temporarily provided patients with direct access to APRNs during the public health emergency. This temporary stay lasted two years until the suspension of the Governor’s executive order earlier in 2022. The HHCA hopes to prod the General Assembly into quickly passing legislation during the 2023 session to make access to care from advanced practice providers permanent.

Indiana was one of several states that temporarily provided patients with direct access to APRNs during the public health emergency.

A primary point in the letter is that companies couldn’t attract talent to the state due to limited patient access to healthcare, which impacted local businesses. It stated that 2.1 million residents lacked access to basic primary healthcare services and that the federal government had designed 117 healthcare provider shortage areas throughout the state. Currently, it remains unknown whether this effort will be fruitful.

Physician Assistants

Physician assistants aren’t seeing the push for change on a state level that nurse practitioners are seeing. At the end of 2022, most state laws still required PAs to enter into agreements with physicians to practice, but they don’t require these physicians to be on-site 100% of the time while PAs see patients.

Furthermore, according to the American Medical Association (AMA), 20 states required physicians to co-sign a specific number or percentage of PA charts. Physicians also have established limits on how many PAs they can supervise or collaborate with at a time in 39 states. All states required PAs to have some sort of supervisory or collaborative arrangement with a physician, but the exact nature of these arrangements differed.

PAs could prescribe Schedule II – V drugs in 44 states but lacked the authority to prescribe Schedule II drugs in 6 states. Most states allow PAs and supervising/collaborating physicians to determine the PA’s scope of practice at the practice site.

On a Federal Level

Although nothing appeared to be imminent in 2023 regarding the relaxation of SOP laws for PAs on a state level, they could benefit from a new bill that expands some of their services if it passes. Senator Jeff Merkley (D-OR) introduced the Improving Care and Access to Nurses (ICAN) Act (HR 8812), while Representatives Lucille Roybal-Allard (D-CA) and Dave Joyce (R-OH) introduced the companion HR 8812 bill to the House on September 13.

Should the bills pass, the legislation would improve healthcare access for Medicaid and Medicare beneficiaries by removing federal barriers to practice for NPs and other APRNs. Some aspects of the bill also include PAs. The bill effectively removes physician involvement in patient care and expands the types of services that non-physician practitioners (NPP) can perform.

The bill removes specific barriers to NP practice that allows:

• Expanded access to cardiac rehabilitation programs and pulmonary rehabilitation programs
• NPs to satisfy Medicare documentation requirements for coverage of certain shows for diabetic patients
• Increased access to hospice care
• Streamlined care delivery in nursing and skilled nursing facilities
• Expanded availability of medical nutrition therapy
• Continued access to home infusion therapy
• Improvements to beneficiary assignments under Medicare’s Shared Savings Program
• Authorization to provide care to Medicaid and Medicare inpatient hospital patients 

Under this same bill, PAs are also included in the removal of the barriers that allow:

• Expanded access to cardiac rehabilitation programs and pulmonary rehabilitation programs
• The ability to satisfy Medicare documentation requirements for coverage of certain shows for diabetic patients
• Streamlined care delivery in nursing and skilled nursing facilities

However, this bill has stiff competition. The California Medical Association (CMA) joined the American Medical Association (AMA) and more than 90 other organizations to voice strong opposition. Their concern is that HR 8812 would expand the scope of practice of NPPs, including NPs, certified nurse midwives, certified registered nurse anesthetists, clinical nurse specialists and PAs, allowing them to perform tasks outside their education and training while narrowing or removing their supervisory requirements.

Implications on APP Recruitment

California offers nurse practitioners the highest average annual salary in the nation, but the beefed-up paycheck still wasn’t always enough to help with advanced practice recruiting. Recruiters in this state may have been losing top talent to Arizona, Nevada and Oregon, where NPs had full practice authority, suggesting some NPs value greater independence over a higher salary. With the implementation of California’s new law, advanced practice recruiting may become easier, at least for NPs.

However, since an NP must gain California licensure and 4,600 hours or three years of full-time clinical practice in the state before they can apply for the first phase, then work three more years before actually gaining full practice authority, it could still be challenging. Some NPs may not want to wait six years, leaving recruiters to struggle to draw them away from neighboring states. 

Other implications on APP recruitment may occur as other states decide whether to move forward with their own lifting of NP and/or PA scope of practice restrictions. Those implications will likely vary based on the magnitude of these changes.

Vivian’s Tools Help You Keep Track

Vivian Health can help with advanced practice recruiting by keeping you informed of upcoming changes in NP and PA scope of practice laws. Our Scope of Practice Guides for Nurse Practitioners and Physician Assistants include interactive maps, a snapshot of each state’s current SOP regulations and links to the full state statutes. Recruiters can use these tools to determine what kind of draws their states might have for APPs. You can also request a copy of our Scope of Practice Pocket Guide.

Contact Vivian Health today to see how we can help you find and recruit advanced practice providers to fill your facility’s needs.

Disclaimer: The information provided in this blog is for informational purposes only and shouldn’t be construed as legal or professional advice. Please contact your own professional advisors for the latest information regarding scope of practice for nurse practitioners in any state in which you practice.