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Research & Commentary: Expanding the Role of Nurse Practitioners Will Help Solve Doctor Shortage

February 21, 2018

In this Research & Commentary, Matthew Glans examines a proposed bill in Virginia that would expand the scope of responsibilities permitted for nurse practitioners.

Like many states, Virginia faces a growing doctor shortage, leaving many patients looking for basic primary care services. The Robert Graham Center has estimated to maintain current rates of primary care utilization, Virginia will need “an additional 1,622 primary care physicians by 2030, a 29% increase compared to the state’s current (as of 2010) 5,471 [the primary care physician] workforce.” 

Avoiding a physician shortage is complicated by the fact that becoming a licensed physician is an expensive and slow process. Strict licensing standards have become a significant barrier to entry in many fields, but nowhere is the influence of licensing more sharply felt than in the health care industry. In many instances, states control licensing standards, professional discipline, and the various costs associated with the process. These standards are usually championed by existing practitioners to slow or block entry of new competitors.

Supporters of strict state licensing standards argue they assure quality, but critics argue the arduous and often expensive licensing process harms the health care market by hindering entry for new physicians and thereby impeding the competition that lowers costs and improves consumer access to healthcare services.

Shirley Svorny of California State University at Northridge and the Cato Institute argued in a 2008 paper that the current licensing system for physicians serves to benefit incumbent clinicians instead of consumers, and that the health care market would be better served by eliminating professional licensing. “Licensure not only fails to protect consumers from incompetent physicians, but, by raising barriers to entry, makes health care more expensive and less accessible,” Svorny wrote.

One reform that could help provide care for patients that Virginia lawmakers are now considering is the expansion of the scope of responsibilities permitted for nurse practitioners (NPs). In Virginia, nurse practitioners are allowed to provide some services to patients, which is superior to what is permitted in most states, but they are required to operate under the supervision of a licensed doctor. This limits the effectiveness of the nurse practitioner and creates problems if a doctor’s circumstances change. For instance, if a doctor relocates, retires, or dies, a nurse can no longer provide these services without finding another doctor willing to supervise him or her.

A new bill has been introduced in Virginia that would allow nurses to practice medicine without direct supervision. Sponsored by state Del. Roxann Robinson (R- Midlothian), the bill would let nurse practitioners practice medicine independently after a probationary period of supervision.

Allowing NPs to administer care would greatly reduce the upcoming doctor shortage and increase access to care. Currently, 21 states and the District of Columbia allow NPs to diagnose and provide some form of treatment for illnesses without a supervision requirement. Although critics of these efforts claim expanding the scope of practice will lower the overall quality of care, a 2012 article in Health Affairs reviewing 26 studies noted the “health status, treatment practices, and prescribing behavior [of NPs] were consistent between nurse practitioners and physicians.”

A complete repeal of medical licensing may not be practical, but expanding the scope of practice of nurse practitioners is a strong first step Virginia can take to address its doctor shortage.

The following articles examine the doctor shortage, scope of practice, and medical licensing from varied perspectives.
 

How to Make Health Care More Affordable
https://reason.com/archives/2018/01/17/how-to-make-health-care-more-affordable
A. Barton Hinkle of the Richmond Times-Dispatch examines Virginia’s efforts to expand the role of nurse practitioners in the state and how it could benefit patients in Virginia.

Healthcare Openness and Access Project: Mapping the Frontier for the Next Generation of American Health Care
https://www.heartland.org/publications-resources/publications/healthcare-openness-and-access-project-mapping-the-frontier-for-the-next-generation-of-american-health-care
The Healthcare Openness and Access Project (HOAP) is a collection of state-by-state comparative data on the flexibility and discretion U.S. patients and providers have in managing health care. HOAP combines these data to produce 38 indicators of openness and accessibility. The project provides state-by-state rankings over a number of variables, including occupational licensing.

End State Licensing of Physicians
https://www.cato.org/publications/commentary/end-state-licensing-physicians
Shirley Svorny of the Cato Institute argues in this article for the ending of state licensing for physicians. Svorny says the state licensing system is both costly and unneeded. “The benefits of state licensing are overstated. Licensing authorities verify education and training, but little else. State licenses do not indicate an individual physician’s specialty-specific skills. Specialty certification is the purview of medical specialty boards, which are private,” wrote Svorny.

Medical Licensing: An Obstacle to Affordable, Quality Care
http://heartland.org/policy-documents/medical-licensing-obstacle-affordable-quality-care
Shirley Svorny of the Cato Institute argues licensure not only fails to protect consumers from incompetent physicians, it also makes health care more expensive and less accessible by raising barriers to entry. Only institutional oversight and a complex network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today. 

The Medical Monopoly: Protecting Consumers or Limiting Competition?
http://heartland.org/policy-documents/medical-monopoly-protecting-consumers-or-limiting-competition
Sue A. Blevins of the Cato Institute examines the effect of government health care policies on the health care market. Blevins finds licensure laws appear to limit the supply of health care providers and restrict competition to physicians from non-physician practitioners. The primary result is an increase in physician fees and income, driving up health care costs. 

Medical Licensing in the States: Some Room for Agreement – and Reform
http://www.cato.org/blog/medical-licensing-states-some-room-agreement-reform
Charles Hughes of the Cato Institute discusses the growing doctor shortage, how it is likely to increase with the implementation of Obamacare, and the steps some states are taking to address the issue. 

A Cure for what Ails Us
http://heartland.org/policy-documents/cure-what-ails-us
Justin Owen, Trey Moore, and Christina Weber of the Beacon Center of Tennessee analyze the current predicament facing Tennessee policymakers in the wake of the Affordable Care Act. The report also offers state-led solutions that would move the nation’s health care system in the proper direction, treating the diseases that weaken the system themselves, rather than merely treating symptoms. 

Medical Licensing Impedes Quality, Affordability of Care
http://news.heartland.org/newspaper-article/2008/12/01/medical-licensing-impedes-quality-affordability-care
This article from the Heartlander discusses a report by Shirley Svorny of the Cato Institute that argues medical licensing is ineffective and inefficient. Svorny also says patients would be better served relying on brand recognition when choosing doctors. 

Six Reforms to Occupational Licensing Laws to Increase Jobs and Lower Costs
http://heartland.org/sites/default/files/occupational_licensing.pdf
Byron Schlomach of the Goldwater Institute argues reforming licensing could open career opportunities and reduce costs without sacrificing consumer safety. The paper recommends six reforms. 
 

Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute. For further information on this subject, visit The Heartland Institute’s website and PolicyBot, Heartland’s free online research database. 

If you have any questions about this issue or The Heartland Institute’s website, contact Lindsey Stroud, a state government relations manager at The Heartland Institute, by email at lstroud@heartland.org or by phone at 312/377-4000.

Author
Matthew Glans joined the staff of The Heartland Institute in November 2007 as legislative specialist for insurance and finance.