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Health Reform

Expanding Scope of Practice for Health Care Providers: Improved Access and Cost Savings for Patients

February 28, 2019


With the cost of care in the United States skyrocketing and millions of individuals struggling to access care at all, policymakers must consider new ways to get patients in front of providers at a lower cost. One way in which states have taken action is through scope of practice expansions for health professionals.

A health professional’s scope of practice (SOP) defines the types of services they are permitted to undertake based on the individual’s education, training, and certifications. These provisions not only detail what certain medical professionals are allowed to do, but also what activities medical professionals may not engage in based upon their qualifications. Limitations and requirements are put in place to protect patients and ensure adequate care by qualified providers. However, these well-intentioned regulations can stand in the way of well qualified medical professionals providing safe and effective care to those who need it most.   

SOP parameters are developed on a state-by-state basis through state law and professional board regulation. For example, a dental hygienist in Colorado can own their own practice, independently examine their patients, review patient x-rays, perform cleanings, apply sealants, make diagnoses and prescribe anti-infective medications as needed. However, that same dental hygienist operating in Louisiana, with the same education and training, is required to work under the direct supervision of a dentist with a written treatment protocol and is never allowed to prescribe medications. Six states allow dental hygienists to practice without supervision. The remaining 44 states do not.

In Maryland, a woman can obtain birth control directly through a pharmacist who has the authority to screen a patient and write a prescription within minutes. With 93 percent of Americans living within five miles of a pharmacy, this provides a unique way to access care, often 24-hours-a-day, for those with limited resources. In many of Maryland’s neighboring states however, a woman is required to see a doctor before obtaining contraceptives, placing an additional time and cost barrier between her and protection against pregnancy.

Excessive SOP restrictions can limit patient choice, create barriers to care, increase costs, and reduce healthcare competition with little, if any, benefit to patient safety. Often, resistance easing these restrictions come from medical professionals that prefer no overlap with the services they provide. A new report released by the U.S. Department of Health & Human Services explains that the risk of anti-competitive harm is even greater when a regulatory board that imposes SOP restrictions on one occupation is controlled by members of another, especially when the board members have a financial stake in the outcome. An example of this would be dental hygienists whose practices are governed by the Board of Dentistry in most states. In this situation, dentists are making the decision on whether to allow dental hygienists to practice independently and provide some of the same services that a patient would usually have to pay a dentist for.

Even in states that have made strides to expand SOP, limitations still exist, often requiring non-physician and non-dentist providers like dental hygienists, nurse practitioners and pharmacists to enter into collaborative practice or indirect supervision agreements with physicians and dentists. These agreements serve as an additional burden and often increase costs and limit the number of health care professionals able to provide services without any benefit to patient safety (states often limit the number of providers that a physician or dentist may collaborate with and supervise.)

In many states, political leverage and funding of health care providers interested in limiting SOP for other providers in the same practice trump the ability, education, and training of those medical providers to provide safe and effective care to patients. Allowing healthcare providers to practice to the full extent of their education and training can increase access to safe and effective care while driving down patient costs.

As state and federal governments move toward expanded scopes of practice they must also consider accompanying proposals with provisions to allow non-physician and non-dentist providers to be paid directly for their services where evidence supports that the provider can safely and effectively provide that care. Creating accompanying reimbursement provisions make services provided under scope of practice expansions viable.

This post was prepared by Mellissa Sager, senior staff attorney– Network for Public Health Law Eastern Region Office. The Network provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation.

For legal advice, readers should consult a lawyer in their state. Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.