Tag: scope of practice

These Scope of Practice Laws Don’t Improve Health Outcomes, Serve Mainly as Barriers to Entry

Scope of practice (SOP) restrictions in health care professions are often portrayed as a necessary intervention to protect consumer health and safety. Given how common this argument is, there have been surprisingly few studies trying to determine whether SOP restrictions actually have any impact on such outcomes. A new working paper seeks to fill this gap in the literature by determining whether SOP laws for certified nurse midwives (CNMs) affect health outcomes. On average, it turns out that the restrictions do not have a significant impact on maternal behaviors or infant health outcomes. Instead, they “primarily serve as barriers to practice and removing these restrictions has the potential to improve the efficiency of the health care system for delivery and infant care.”

SOP laws are determined at the state level, and regulate which activities and tasks certain professions can perform within the state. Physicians are generally unaffected, but other health practitioners are—in this case, CNMs specifically. Their level of restriction ranges from states with “no barriers,” where CNMs do not have oversight requirements, to states with “high barriers,” where they have to be under the direct supervision of a physician and may not write prescriptions. In heartening news, more states seem to be recognizing the wasteful nature of these laws. The recent trend for this specific case has been a move towards a more relaxed scope of practice environment.  

Scope of Practice for Certified Nurse Midwives by State, 1994 vs. 2013

Source: Markowitz et al.

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In a debate with Larry McNeely in the L.A. Times, Cato’s Michael Cannon suggested “eliminating barriers to competition by nurse practitioners and other mid-level clinicians.”

McNeely responded, “By ending all state licensing and monitoring of physicians…not only qualified nurses but also any quack with a scalpel and some drugs would be able to set up a shingle, call himself a doctor and start cutting.”

Does McNeely pick his doctors at random? How does he know his cardiologist has any relevant experience or training? Licensing creates the impression that all licensed physicians are adequate. Not true. Ask any medical malpractice insurance underwriter.

A state medical license does not restrict a physician’s practice to any particular specialty. If McNeely wants information about a medical professional, he will have to look elsewhere.

State regulation of medical professionals does not insure quality, but does limit access to care and make health care more expensive. Not all audiologists or advanced practice nurses need a doctorate. Physician assistants and advanced practice nurses have been shown to be fully capable of taking over the majority of primary care, yet many states restrict their scope of practice.

McNeely has faith in state licensing and monitoring of physicians that can’t be substantiated with facts. The majority of consumer protection comes from non-governmental entities. Consumers are protected by the annual evaluation and continuing oversight of medical professionals by hospitals, managed care organizations, and medical malpractice insurance underwriters. Malpractice underwriters verify a physician’s training and experience, limit what risky doctors can do, penalize physicians for negligent behavior, reward risk management, and go so far as to assess whether specific equipment and techniques are up-to-date). Consumers are also protected by brand name (as with hospital chains and retail clinics). Private organizations and boards offer certification of education and experience.

More than 80 percent of physicians in the U.S. are specialty board certified; a variety of national organizations certify physician assistants, advanced practice nurses, and other medical professionals.