by Jordan Roberts
Former Director of Government Affairs, John Locke Foundation
This is the second part of a four-part “healthcare freedom” series I am blogging this week. As I said in Part 1, this week I am going to discuss four issues raised by a federal report on healthcare reform. The problems raised in the report could be reformed in the state in order to bring more choice, freedom, and competition into the healthcare sector. Further, each issue I discuss could be addressed by North Carolina lawmakers immediately. Today we will be looking at Scope-of-Practice reform.
So, what is “scope of practice?”:
State licensing and scope-of-practice (SOP) restrictions are common components of state
licensure statutes and regulatory codes for healthcare professions. Licensure regulates
entry into an occupation since a worker must obtain the permission of a government agency
or government-authorized regulatory board before providing certain services. For
numerous healthcare occupations, a state licensing authority stipulates minimum
education, training requirements, and certification, among other criteria, for those who seek
to acquire or maintain a license to practice a given profession or provide certain services.
SOP regulations “describe the metes-and-bounds of licensure—what a given professional
license permits a person to do and, often, prohibits others from doing.”
This probably sounds reasonable. No one wants someone who is uneducated or unqualified to perform a medical procedure on them. We trust that the state medical boards will only grant licenses to physicians that have completed the proper training. But as is the case with most government regulation, there are unintended, negative consequences:
When state regulators impose excessive entry barriers and undue restrictions on SOP for
particular types of providers, they often are not responding to legitimate consumer
protection concerns. There is a risk that healthcare professionals with overlapping skill sets
will seek these restrictions; they view SOP restrictions as an easy, state-sanctioned
opportunity to insulate themselves from competition. The risk of anti-competitive harm
may be even greater when the regulatory board that imposes SOP restrictions on one
occupation is controlled by members of another, overlapping occupation that provides
complementary or substitute services,94 and the board members are themselves active
market participants with a financial stake in the outcome.
If this sounds similar to our discussion of Certificate-of-Need laws yesterday, it should. This is a classic form of guild economics. State-sanctioned monopolies will always benefit one group at the expense of others. There are incumbent physicians who use occupational licensing laws to their advantage by blocking new entrants from a market. The report gives us a great illustration of this phenomenon:
For example, advanced practice registered nurses (APRNs), physician assistants (PAs),
pharmacists, optometrists, and other highly trained professionals can safely and
effectively provide some of the same healthcare services as physicians, in addition to
providing complementary services. Similarly, dental therapists and dental hygienists can
safely and effectively provide some services offered by dentists, as well as complementary
Services. SOP statutes and rules often unnecessarily limit the services these “allied health
professionals” can offer. A 2011 Institute of Medicine (IOM) report surveyed
“[e]vidence suggest[ing] that access to quality care can be greatly expanded by increasing the use of . . . APRNs in primary, chronic, and transitional care,” and expressed concern
that SOP restrictions “have undermined the nursing profession’s ability to provide and
improve both general and advanced care.” In fact, research suggests that allowing allied
health professionals to practice to the full extent of their abilities is not a zero-sum game
for other medical professionals, and may actually improve overall health system
capacity. The previously mentioned IOM report found that APRNs’ scope of practice
varies widely “for reasons that are related not to their ability, education or training, or safety
concerns, but to the political decisions of the state in which they work.”
Due to the inherent risks which are taken in receiving medical care, it is easy to understand why medical licenses are so important. What may not be as easy to understand is the negative, unintended consequences that occupational licensing laws can have on an industry and consumers.
In North Carolina, Nurse Practitioners (NPs) disproportionately bear the burden of strict licensure requirements. Opening up the scope of practice laws to let different types of nurses practice at the top of their license would have many positive effects. Most importantly, allowing NPs and others to practice at the top of their license without an agreement with a physician would increase levels of access around the state especially in rural areas. It would increase access to cheaper care, that is of the same level quality.
The most important thing to remember with the issue of licensure requirements in North Carolina is that to allow people to practice at the top of their license wouldn’t be creating a world where unlicensed NPs would be offering services completely unregulated. The NPs still have to go through rigorous training and complete continuing education. The change would allow them more freedom to provide the full scope of care that they were trained for.