Policy Position

Scope-of-Practice Reform

in Health Care


Updated as of January 2020.

For patients living in rural North Carolina, quality health care can be hard to find. Over 1.9 million people, 19 percent of the state’s population, live in primary-care shortage areas.

Unlike other states, North Carolina does not have a physician shortage. The supply of doctors in the state is increasing, relative to population growth. Instead, it has a physician distribution problem. Only 3 percent of family doctors who graduated from North Carolina residency programs between 2008 and 2011 are practicing in rural areas.

As lawmakers consider ways to increase access to primary care across the state, it would be wise for them to pass legislation that allows nurse practitioners (NPs) to treat patients to the full extent of their clinical training and without physician oversight. NPs are advanced-practice nurses who have graduate-level clinical knowledge and training to provide patient care directly. They assess patients’ medical history, diagnose ailments, order lab work, and prescribe medications.

As of January 2020, if nurse practitioners want to practice in North Carolina, they must establish a collaborative practice agreement with a physician. The agreement outlines patient management and describes how the providers will interact. Interestingly, NPs are not required to be in the same geographic location as the overseeing physician, and they are required to meet only twice a year. The lack of oversight, then, demands asking why the contracts are even necessary.

Because nurse practitioners in North Carolina aren’t geographically tied to the collaborating physician’s practice location, one might believe the state’s existing practice arrangements wouldn’t necessarily hold back NPs from extending their reach into underserved areas. But these contracts can add uncertainty to the NPs’ practice. For example, an NP may want to operate his/her own clinic, but the collaborating physician moves to another state. The NP must now find another physician who is willing to sign onto a new collaborative practice agreement.

If a collaborating physician becomes employed by a hospital system, that hospital’s policy may also prevent the physician from signing or renewing a collaborative agreement with a nurse practitioner. Moreover, collaborative practice agreements can be expensive, which makes it difficult for some NPs to grow their own clinics. If an NP would like to recruit another to work at his/her clinic, the cost may be prohibitive because the collaborating provider asks for a specific percentage of the clinic’s revenue.

Key Facts

  • Twenty-two states and Washington, D.C., have granted full practice authority to nurse practitioners.
  • Nurse practitioners are valuable assets to the health care workforce. Many of the 6,644 nurse practitioners who are licensed in North Carolina practice in a primary-care setting and focus on managing chronic disease.
  • Nurse practitioners are one of the fastest-growing types of medical professionals. Between 2001 and 2017, the number of nurse practitioners in North Carolina increased by 215.9 percent in non-rural counties and 187.3 percent in rural counties.
  • As of 2017, only 15.3 percent of nurse practitioners reported a primary practice location in a rural county.
  • Ending the requirement for a contract with a physician would open opportunities for nurse practitioners to deliver patient care in more rural and underserved areas. Arizona, for example, granted nurse practitioners full practice authority in 2002. Five years later, the state reported a 73 percent increase in the number of nurse practitioners serving rural counties.
  • Because it takes less time and money for nurse practitioners to complete their clinical training compared to physicians, they may fill health care gaps at a faster rate. Based on health care workforce projections between 2010 and 2020, the number of fully trained nurse practitioners is expected to increase by 30 percent, compared to an 8 percent rise in the number of physicians.


  1. North Carolina lawmakers should grant full practice authority to highly trained nursing professionals. Policymakers should change how nurse practitioners and other advanced-practice nurse professions, i.e., certified nurse midwives, nurse anesthetists, and clinical nurse specialists, are governed.


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