Scope in the sights

A speech by the Secretary of Health and Human Services Aug. 9 suggests one of health care’s most stoutly guarded cost drivers is now in the sights of the Administration.

That issue is health care professional scope of practice.

“State health care regulations like certificates of need and scope of practice can have a legitimate purpose,” said Secretary Alex Azar to the right-leaning American Legislative Exchange Council. “But, too often, these rules can be a significant barrier to new competition and lower-cost market disruptors.”[1]

It’s not so much that it was said that’s notable. It was the authority of who said it. It’s worth examining what's behind his idea and what actions health care stakeholders should consider.

Because scope of practice laws have been around awhile. A century ago, professionalizing physicians drove them for public safety against the quacks. Because tools can either build or destroy, advocates also wield scope laws politically to protect their economic interests from qualified competition.[2] They prohibit professionals from providing the care that they are educated and skilled to offer. Constraints include requirements for physician collaboration or supervision that increase costs or impair access. Discrimination in payment yields similar effects, as do unjustifiably anticompetitive medical staff rules. It's not unusual for them to hinder modern team models for care delivery.

Though advocates for constraints to practice cry “safety!” the evidence favoring qualified competitors in health care delivery is strong and growing. The Institute of Medicine nearly a decade ago argued for full practice for nurses.[3] Research published in the Journal of the American Medical Association found nurse practitioners provide primary care services superbly, on par with physicians.[4]  No evidence supports costs of physician supervision of nurse anesthetists, says the Cochrane Review,[5] the gold standard for evidence-based care. Smart systems and telehealth technologies extend quality care remotely and reduce costly rehospitalizations.[6] There’s more.

The world of policy has caught on. The Federal Trade Commission[7] called out numerous limitations to professional practice as anticompetitive, reducing choice, increasing costs. The National Governors Association spoke for eliminating barriers to nurse practitioners, dental hygienists, physician assistants, pharmacists and other qualified professionals.[8] The previous Administration’s framework on professional licensure found that excessive regulation impairs health care workforce development and patient access to care.[9] In the political middle, the Brookings Institution backs regulatory reform of scope of practice.[10] On the right, the Heartland Institute favors increased use of advanced practice nurses, physician assistants and dental therapists.[11] The libertarian Cato Institute suggests eliminating scope of practice laws entirely.[12] The largest U.S. consumer group, AARP, says eliminating such “antiquated laws” is a “top priority.”[13]

Secretary Azar’s statement notwithstanding, political change has lagged. Elected officials dislike the jam between two groups of organized, well-funded supporters. Policymakers punt.[14],[15]

So what’s changed? The size of the oncoming hurricane, that’s what. Health care costs and out-of-pocket expenses are climbing. Access to care is deteriorating, especially in rural and medically underserved America. An aging population requires more care. Meanwhile, the supply of physicians and other health care professionals is reaching its retirement age. Historic fiscal constraints keep Uncle Sam from papering it over with cash.[16] Hyperpartisanship limits problem-solving. The increasing number of people with high deductible health plans see their growing out-of-pocket costs and say they’ve had enough. Hospital executives are on the hot seat to cut costs.[17] Heck, everybody is.

How should health care organizations strategically consider this issue in light of what’s coming?

·       Examine whether scope is in your strategic interests. If labor costs, access to care and quality of care are essential to your present and future business, probably so.

·       Consider reframing the issue. Alone, it’s stuck. One profession vs. another, who cares except the participants and their pals? As part of an initiative to make health care work, though, there’s a shot. Because the environment now is different. The costs of inaction are real. People care when moms can’t deliver their children in the community.  Employees care when they can’t book a primary care appointment to prevent or manage a chronic condition.  Everyone cares when health plan premiums climb again for less benefits.  When people’s freedom is at stake, they care.[18]And the interests long defending anticompetitive scope laws may find they have had the wrong foe in their sights all along. Right foes might be illness, injury, need, waste, and a lack of innovation to effectively address them.

·       Expect that policy development favors the intense over the disinterested.[19] People with something to lose fight harder to keep it than people who might gain something they do not have. That said, how you advocate matters. It’s your brand, your business, your membership. When politics shifts from one pole to the other, your reservoir of trust is your currency.

·       The fiscal clock is ticking. Neither political party is expressing this now. It will be expressed upon them sooner not later.[20] Probably next year.

·       Who are your allies?  Whether party control shifts in Washington and state capitals or not, the breadth of legislator, executive and staff retirements coast to coast requires new attention to relationship-building. People with new authority and responsibility may not know. The universe of potential coalition partners who share interests in lower costs, greater access and higher quality of health care is greater than you think.[21] But they’re furniture unless they’re organized. 

The ground is shifting. Are you ready?  What’s your organization’s plan?[22]


Frank Talk is a product of Cardinal Waypoint LLC, a new consultancy for health policy and leadership. You can have Cardinal Waypoint at work for you. Contact Cardinal Waypoint here.


[1] Azar A. Remarks on state health care innovation to the American Legislative Exchange Council. U.S. Department of Health & Human Services Office of the Secretary, Aug. 8, 2018, New Orleans, LA., retrieved 8/14/2018. Also see the Secretary’s tweet on the subject and its replies at

[2] American Medical Association. Scope of Practice. AMA, undated., retrieved 8/14/2018.

[3] The National Academies. The future of nursing: leading change, advancing health. National Academies Press, Washington, DC, 2011., retrieved 8/14/2018. The document ranked in the top National Academies downloads through 2016,

[4] Mundinger M, Kane R, Lenz E. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. Journal of the American Medical Association 2000;283(1):59-68., retrieved 8/14/2018.

[5] Lewis S, Nicholson A, Smith A, Alderson P. Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients. Cochrane Database of Systematic Reviews, July 11, 2014., retrieved 8/14/2018.

[6] Flodgren G, Rachas A, Farmer AJ, Intizari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Sept. 7, 2015., retrieved 8/14/2018.

[7] Gilman D, Koslov TI. Policy perspectives: competition and the regulation of advanced practice nurses. Federal Trade Commission, Washington, DC, March 2014., retrieved 8/14/2018.

[8] National Governors Association. Health care workforce redesign. NGA, Washington, DC, undated., retrieved 8/14/2018.

[9] Department of the Treasury Office of Economic Policy, White House Council of Economic Advisors, and Department of Labor. Occupational licensing: a framework for policymakers. The White House, July 2015. P. 10., retrieved 8/14/2018.

[10] Adams EK, Markowitz S. Improving efficiency in the health care system: removing anticompetitive barriers for advanced practice registered nurses and physician assistants. The Hamilton Project 2018-08, The Brookings Institution, Washington, DC, June 2018., retrieved 8/14/2018.

[11] Glans M. Research & commentary: expanding the role of nurse practitioners will help solve the doctor shortage. The Heartland Institute, Feb. 21, 2018., retrieved 8/14/2018. See also Glans M. Research & commentary: medical licensing and the doctor shortage. The Heartland Institute, July 22, 2014., retrieved 8/14/2018. Similar articles since 2014 have supported greater recognition of physician assistants and dental therapists.

[12] Cato Institute. Cato Handbook for Policymakers, 8th Edition (2017): Health Care Regulation. The Cato Institute, Washington, DC, 2017.

[13] Jenkins J. Advanced practice nurses play an essential role in health care: let’s change antiquated laws that limit what APRNs can do. AARP, May 10, 2018., retrieved 8/15/2018.

[14] Open Secrets. Health: long term contribution trends. Center for Responsive Politics, from data obtained from Federal Election Commission Jul. 23, 2018., retrieved 8/14/2018.

[15] Hoban R. Nurses make a full court press for regulatory changes. North Carolina Health News, March 16, 2017., retrieved 8/15/2018. One example among many.

[16] Congressional Budget Office. The long-term budget outlook under alternative scenarios for fiscal policy. Washington, DC, Aug. 8, 2018., retrieved 8/14/2018.

[17] Sanborn FC. Sustainable cost control tops list of priorities for health care executives, Advisory Board study says. Healthcare Finance, Jul. 11, 2018., retrieved 8/14/2018.

[18] Siwicki W. Here are the 12 healthcare issues that will define 2018 according to PwC. HealthcareITNews, Dec. 14, 2017., retrieved 8/14/2018. Also Kirzinger A. Kaiser health tracking poll: preview of the role of health care in the 2018 midterm campaigns. Kaiser Family Foundation, Washington, DC, May 10, 2018., retrieved 8/14/2018.

[19] Schattschneider EE. Intensity, visibility, direction and scope. American Political Science Review, 51:4(Dec. 1957), p. 933-942., retrieved 8/14/2018. Also see Kendall W and Carey G. The intensity problem and democratic theory. American Political Science Review, 62:1(Mar. 1968), p. 5-24., retrieved 8/14/2018. Classics in the field.

[20] “If something cannot go on forever it will stop.” – Herbert Stein, former chair of the Council of Economic Advisers. Symposium on the 40th anniversary of the Joint Economic Committee, Jan. 16-17, 1986, p. 262.;view=1up;seq=270, retrieved 8/14/2018.

[21] Publius (Madison J). Federalist #10: the same subject continued, the union as a safeguard against domestic faction and insurrection. New York Packet, Nov. 23, 1787., retrieved 8/14/2018. “To secure the public good and private rights against the danger of such a faction, and at the same time to preserve the spirit and the form of popular government, is then the great object to which our inquiries are directed.”

[22] This blog has 22 references and you made it here!