Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies

Laws Don't Affect Services Provided by Nurse Practitioners But Do Limit Practice Opportunities

News Release
Feb. 28, 2013

Alwyn Cassil (202) 264-3484 or

WASHINGTON , DC—While state scope-of practice laws don’t typically restrict what primary care services nurse practitioners (NPs) can provide to patients, the laws do affect practice opportunities for NPs and appear to influence payer policies, accordingto a new qualitative study by the Center for Studying Health System Change (HSC) for the nonpartisan, nonprofit National Institute for Health Care Reform (NIHCR).

Amid concerns about primary care provider shortages, especially in light of health reform coverage expansions in 2014, some believe that revising state laws governing nurse practitioners’ scope of practice is a way to increase primary care capacity. NPs are registered nurses trained at the graduate level, with a specialization in primary care, acute care or psychiatric/mental health nursing, sometimes with a focus on pediatrics, adult/gerontology or women’s health.

According to the study, state scope-of-practice laws vary widely in the level of physician oversight required for nurse practitioners, with some states allowing NPs to practice independently, and others limiting NPs’ authority to diagnose, treat and prescribe medications to patients without supervision.

The study, which included interviews with NPs and practice managers and physicians working in settings that employ NPs, examined variations in NP scope-of-practice laws in six states—Arkansas, Arizona, Indiana, Maryland, Massachusetts and Michigan, which represent a range of restrictiveness. For example, Arizona allows NPs to practice independently, while Arkansas requires direct physician supervision of NP diagnoses, treatment and prescribing.

States with more restrictive scope-of-practice laws were associated with more challenging environments for NPs to bill public and private payers, order certain tests, and establish independent primary care practices, according to the study.

“Scope-of-practice laws in and of themselves don’t appear to limit what primary care services patients can receive from nurse practitioners, but requirements for documented physician supervision do appear to impact where and how NPs can practice,” said Tracy Yee, Ph.D., HSC researcher and coauthor of the study with Ellyn Boukus, M.A., an HSC health research analyst; Dori Cross, an HSC research assistant; and Divya Samuel, a former HSC research assistant.

The study’s findings are detailed in a new NIHCR Research Brief—Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies—available online at Other key findings include:

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation's changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is affiliated with Mathematica Policy Research.