Policy Position

Scope-of-Practice Reform

in Health Care


For patients living in rural North Carolina, quality health care can be hard to find. Over 1.4 million people – 14 percent of the state’s population – live in primary-care shortage areas. What’s even more compelling is that, unlike other states, North Carolina doesn’t have a doctor shortage. The supply of physicians in the state is increasing, relative to population growth. Rather, the issue at hand is physician maldistribution. Only 5 percent of family doctors who graduated from residency programs between 2008 and 2011 are practicing in rural areas.

As lawmakers consider ways to bring greater 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.

Currently, if NPs 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 NPs in North Carolina aren’t geographically tied to the collaborating physician’s practice location, one might believe that 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 their practice. For example, an NP may want to operate 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 an NP. Moreover, collaborative practice agreements can be expensive, which makes it difficult for some NPs to grow their own clinics. If an NP in the state would like to recruit another to work at her clinic, she may not be able to afford to do so because the collaborating provider asks for a specific percentage of the clinic’s revenue.

Key Facts

  • Twenty-two states have granted full practice authority to nurse practitioners.
  • NPs are valuable assets to the health care workforce. Of the 6,152 who are licensed in North Carolina, many practice in a primary-care setting and focus on managing chronic disease.
  • According to health care workforce data, 64 percent of North Carolina’s NPs are practicing in the 10 most populous counties of the state. Ending the requirement for a contract with a physician would open opportunities for NPs to deliver patient care in more rural and underserved areas. Other states that have enacted such reforms are already seeing this trend play out. Arizona, for example, granted NPs full practice authority in 2002. Five years later, the state reported a 73 percent increase in the number of NPs practicing in rural counties.
  • Because it takes less time and money for NPs to complete their clinical training compared to physicians, eliminating North Carolina’s collaborative practice agreement provides them an opportunity to fill health care gaps at a faster rate. Based on health care workforce projections between 2010 and 2020, the number of fully trained NPs is expected to increase by 30 percent, compared to an 8 percent rise in the number of physicians.


  1.  North Carolina lawmakers should make changes to the Modernize Nursing Practice Act. Policymakers should change how NPs and other advanced-practice nurse professions, i.e., certified nurse midwives, nurse anesthetists, and clinical nurse specialists, are governed.


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