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Policy and Advocacy on Scope of Practice

ACP Chapter Action Tool Kit
Prepared by ACP’s Division of Governmental Affairs and Public Policy
March 1, 2021

Summary

ACP recognizes that issues related to licensure and scope of practice are becoming more predominant at both the state and federal levels, not only in the context of the COVID-19 pandemic but in a much broader sense.  Chapters are being approached by other organizations with requests to join “scope of practice” state-based campaigns or otherwise comment on or support specific scope of practice bills at the state level.

ACP has developed this comprehensive tool kit as a resource for chapters because we do not have the bandwidth to review the multitude of scope of practice bills that are being developed and introduced in state legislatures across the nation.  The tool kit is meant to give you a broad overview of ACP policy on licensure and scope of practice that should empower you to join in efforts at the state level to influence state bills and laws that are not consistent with ACP policy on scope of practice, without having to get permission from ACP.  This resource includes important questions that you should apply when considering scope of practice bills at the state level. 

The College has extensive policy on licensure and scope of practice across many disciplines, as outlined below, and is included in numerous position papers as developed by ACP over the years.  Links to all of those resources and position papers can be found at the end of this tool kit.  ACP continues to partner with the American Medical Association, the American Academy of Family Physicians and others on scope of practice issues, including opposing regulations to expand APN scope of practice in the VA system and to extend the Public Health Emergency expansions of scope of practice as so granted by the U.S. Department of Health and Human Services.

Excerpts from Relevant ACP Policy on Licensure and Scope of Practice

Clinical Care Teams:

  • ACP reaffirms the importance of patients having access to a personal physician who is trained in the care of the “whole person” and has leadership responsibilities for a team of health professionals, consistent with the Joint Principles of the Patient-Centered Medical Home.
  • Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams, well-functioning teams will assign responsibilities to advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.
  • Physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals have different training, skills, knowledge bases, competencies, and experience in patient care.
  • Although some training and competencies overlap, physicians have more years of training, and the range of care appropriately provided by each discipline is not equal.
  • Advanced practice registered nurses and physician assistants cannot substitute for or replace the skills and expertise of physicians within their discipline, but when they practice to the top of their licenses, they can provide complementary and unique approaches, as well as additional skills in the service of patients and families.
  • Patients have the right to be informed of the discipline, educational background, and competencies of the members of the clinical care team. To minimize patient confusion and ensure informed choice, the clinical care team should be able and prepared to provide patients and families with information about the training of all health professionals within the team and the meaning of all professional designations (such as MD, DO, NP, DNP, PA, PhD, PharmD, and LCSW-C), including information on the differences in the years of training and clinical experiences associated with their professional designations. Such information should always be available for each clinician providing care.”
  • Because patients view the term “doctor” as being synonymous with “physician” when used in a health care setting, it is incumbent on all health care professionals with a doctoral degree other than MD or DO to clarify that they are not physicians when using the term “doctor” in the patient care setting.
  • The purpose of licensure must be to ensure public health and safety.
    • Licensure should be evidence-based. It should protect the public from receiving care from clinicians that is beyond their training, skills, clinical experience, and demonstrated competence; licensure should not restrict qualified clinicians from providing care that is commensurate with, but does not extend beyond, their training, skills, clinical experience, and demonstrated competence.
    • Licensure should ensure that each member of the health care team practices within ethical standards as a condition of obtaining and maintaining their license. 
    •  Licensure should ensure a level of consistency (minimum standards) in the credentialing of clinicians who provide health care services.”
  • Licensing bodies should recognize that the skills, training, clinical experience, and demonstrated competencies of physicians, nurses, physician assistants, and other health professionals are not equal and not interchangeable.

Nurse Practitioners in Primary Care:

  • Physicians and nurse practitioners complete training with different levels of knowledge, skills, and abilities that while not equivalent, are complementary. As trained health care professionals, physicians and nurse practitioners share a commitment to providing high quality care. However, physicians are often the most appropriate health care professional for many patients.
    • Whenever possible, the needs and preferences of every patient should be met by the health care professional with the most appropriate skills and training to provide the necessary care.
    • Patients with complex problems, multiple diagnoses or difficult management challenges will typically be best served by physicians working with a team of health care professionals that may include nurse practitioners and other non-physician clinicians.
    • Patients have the right to be informed of the credentials of the person providing their care to allow them to understand the background, orientation and qualifications of the health care professionals providing their care and to better enable them to distinguish among different health care professionals.
    • The College recognizes the important role that nurse practitioners play in meeting the current and growing demand for primary care, especially in underserved areas.
    • The College advocates for research to develop effective systems of consultation between physicians and nurse practitioners as clinically indicated.
  • Collaboration is defined as ongoing interdisciplinary communication regarding the care of individuals and populations of patients in order to promote quality and cost-effective care. Recognizing the importance of coordinated care to improving health outcomes, we offer the following principles on collaboration between physicians and nurse practitioners:
    • Effective interdisciplinary collaboration is critical to ensuring that all patients receive the highest possible quality of care.
    • Members of a health care team should understand their complementary roles in the delivery of care as defined through their respective professional practice acts.
    • Collaboration among physicians and nurse practitioners can occur during both face-to-face encounters and electronically through the use of technology, including telephone, e-mail, telehealth, and electronic health records.
    • Effective collaboration among nurse practitioners and physicians requires appropriate sharing of information and mutual acknowledgement and respect for each professional’s knowledge, skills, and contributions to the provision of care.
    • Payment systems should provide sufficient reimbursement for the coordination of care and collaboration between nurse practitioners and physicians.
  • Licensing and certification examinations for nurse practitioners should be developed by the nursing discipline and based on standardized training involved in graduating from advanced practice nursing programs as well as scope of practice statutes and regulations. Certification examinations should be carefully constructed so as to avoid any appearance of equivalency of training/certification with physicians. ACP therefore opposes use of test questions (past or present) developed by the National Board of Medical Examiners (NBME) for Step 3 of the U.S. Medical Licensing Exam in the certifying examination of Doctors of Nursing Practice (DNPs).

Retail Health Clinics:

Retail health clinics should have a well-defined and limited scope of clinical services that are consistent with state scope-of-practice laws and with the more limited physical space and infrastructure that such a setting permits. These well-defined and limited services should be clearly disclosed to the patient prior to or at the visit.

Managed Care Setting:

ACP supports scope of practice legislation or designation by managed care organizations that are consistent with ACP policy that focuses on physicians’ training and expertise rather than legislative mandates or managed care policies that specifically name medical specialties as primary care physicians. (HoD 95; reaffirmed BoR 08; reaffirmed BoR 19)

COVID-19/Public Health Emergencies:

  • The effective utilization of volunteer physicians and health care providers in public health emergencies should be coordinated by federal or state agencies that are clearly authorized to determine licensing and register volunteers.
  • ACP supports a streamlined approach to obtaining medical licenses that would facilitate telehealth services across state lines during public health emergencies while allowing states to retain individual licensing and regulatory authority. In the context of the COVID-19 public health emergency, we appreciated CMS’ temporary waiver allowing physicians to provide telehealth services across state lines, as long as physicians meet specific licensure requirements and conditions. ACP recommends that Congress keeps these changes in place at least through the end of 2021, or until such a time when effective vaccines and treatments are widely available, with an option to extend it even further based on the experience and learnings of patients and physicians who are utilizing these flexibilities. These waivers offer an opportunity to assess the benefits and risks to patient care in addressing the pandemic as well as the ability to maintain longitudinal care for patients who move across state lines. While these waivers do not supersede any state or local licensure requirements, they provide the opportunity to promote state-level action that may further promote more streamlined licensure requirements across the country.

On March 24, 2020, Health and Human Services (HHS) sent a letter to state governors with guidance on various actions they could take to address the COVID-19 public health emergency. The guidance included a request for states, territories, and the District of Columbia to take immediate action to “waive restrictions on licensure, scope of practice, certification, and recertification/relicensure consistent with the changes announced for federal programs.”

The letter encouraged states to work with licensing boards to place moratoria on enforcement of scope of practice and licensure issues “to ensure that health care professionals can quickly respond to the COVID-19 emergency without fear of penalty or license revocation” and recommended that states take action to permit nurse practitioners, physician assistants and other health care professionals to “practice to the fullest extent of their license and without restrictive supervision requirements.” If states do not make changes to scope of practice requirements, HHS encourages relaxation of geographic restrictions on physician supervision and temporary expansion of the number of health care professionals a physician may supervise. In addition to state-based changes, HHS is permitting temporary scope of practice changes to other federal programs. For example, Medicare is waiving certain physician supervision requirements and allowing non-physician clinicians to care for hospitalized patients in accordance with the state’s emergency plan.  State chapters should note that HHS’ recommended policy interventions are temporary measures to address health care workforce needs during the COVID-19 emergency.

In the context of the current public health emergency, and the immediate need to devote attention and resources to addressing COVID-19, ACP recommends that state chapters not challenge a temporary easing of physician supervision and other state licensure restrictions that are consistent with HHS request, as long as they would be in effect only for the duration of the declared national emergency.

Applying ACP Policy to State Scope of Practice Legislation

Chapters should consider the following questions when evaluating scope of practice legislation:

  • Does it support or undermine physician-led teams?
  • Does it recognize differences in the training and skills of physicians compared to other clinicians?
  • Does it provide transparency on professional qualifications including use of the term “doctor”?
  • Does it allow non-physician clinicians to practice at the full level of their training and skills within a dynamic clinical care team?
  • Does it allow them to practice beyond their training and skills?

ACTION:

Chapters are encouraged to work with their state medical associations, to the extent possible, to track and address any scope of practices changes that occur in their state.

We also encourage chapter leaders to review HHS’ guidance on addressing workforce needs during the COVID-19 emergency.

Resources: