Overview of Michigan scope-of-practice laws
Scope-of-practice restrictions prohibit health care providers from practicing to the full extent of their training. More specifically, scope-of-practice laws are regulations that restrict what tasks physician assistants (PAs), nurse practitioners (NPs), nurses, pharmacists, and other essential health care providers may perform while caring for their patients, regardless of their training, education, or experience. Scope-of-practice restrictions reduce the number of primary care givers available, and fewer choices for patients and consumers mean higher costs, longer wait times, and difficulty in getting treated. This is especially noticeable in rural areas of Michigan as well as during times public health emergencies.
Scope-of-practice laws essentially come down to how much autonomy a health care professional has when treating patients. For example, states have enacted a variety of rules covering nurse practitioners and physician assistants. One type restricts the ability of these professionals to prescribe mediations, including which kinds. Another is whether a nurse practitioner or a physician assistant is required to work under the supervision of a physician.
Opponents of reform argue that these laws are a safety issue for patients, but the evidence suggests otherwise. One study compared outcomes for patients receiving primary care follow-up and ongoing care after emergency department or urgent care visits. Patients were randomly assigned to a nurse practitioner or a physician, but the study found comparable outcomes, with no significant differences in patients’ health status.
In fact, the subjective evaluation of patients revealed a preference for NPs. “Patients were more satisfied with consultations with nurse practitioners than those with doctors.”
Several areas of Michigan have a shortage of primary care physicians. This may be caused by an overall shortage of primary care physicians, or an uneven displacement of them. Regardless of the reason, vulnerable populations — those on Medicaid, the poor and uninsured, Michiganders with disabilities, and those living in rural areas — have less access to primary care providers. Research shows that nurse practitioners are significantly more likely than primary care physicians to care for these vulnerable populations. NPs also accept lower payments, making care more affordable and more accessible.
Pharmacists are another underused health care provider capable of performing more within their scope of practice. They are also the providers that most Michiganders have easier access to, even in shortage areas. Patients find them in community pharmacies, physicians’ offices, hospitals, long-term care facilities, community health centers, managed care organizations, hospice settings, and the uniformed services. Nearly 90% of Americans live within five miles of a community pharmacy, giving these health care providers an opportunity to better integrate themselves into patients’ health care. Also, pharmacists have the most knowledge of medication therapy of any health professional.
Restrictions on Michigan’s primary care professionals
Michigan law allows for nurse practitioners but restricts them from practicing without the supervision of a physician, even though many of these professionals are educated at the doctoral level and have many years of clinical experience. Instead, these advanced practicing nurses must have a formal agreement with a supervising physician to practice. They must be delegated tasks and functions by a physician. Nurse practitioners are also not explicitly recognized in state policy as primary care providers.
While all states impose some form of scope-of-practice restrictions on medical professions, the specifics vary widely. According to Deena Kelly Costa, an assistant professor at the University of Michigan School of Nursing, Michigan has some of the nation’s most restrictive scope-of-practice laws for advanced practice nurses. Costa advised Gov. Gretchen Whitmer’s office in crafting the executive order suspending scope-of-practice restrictions. Costa highlighted research by the RAND Corporation that found eliminating these regulations for nurse practitioners would increase public access to health care.
Nurse practitioners are not the only medical professionals who must be supervised by a doctor. Michigan pharmacists have been able to administer vaccines to patients since 1995, but only as a delegated task under a collaborative practice agreement with a physician.
Recommendation: Allow nurse practitioners to provide patient care without immediate physician supervision to the extent of their training and capacities; expand current state pharmacists’ immunization authority to take advantage of their accessibility and training
In times of a public health emergency, scope-of-practice restrictions have a negative impact on health care delivery, especially as health professionals get sick while caring for patients, while hospital and clinic capacities are pushed to their limits. That’s why we saw several emergency scope-of-practice laws suspended in states across the country, including here in Michigan.
One of Gov. Whitmer’s emergency executive orders allowed physician assistants and nurse practitioners to provide care within their scope of practice without a written practice agreement or the supervision of a physician. The governor acknowledged that “suspending these scope of practice laws saved countless lives and ensured our hospitals were fully staffed to care for COVID-19 patients,” which is why Michigan policymakers should make this reform permanent. Additionally, they should allow PAs and NPs to operate autonomous practices without agreements with physicians, which would expand access to high-quality primary care and reduce costs.
The availability and accessibility of pharmacists provides an immediate opportunity to expand certain aspects of primary care. Policymakers should allow pharmacists to practice at the top of their education and training. In general, a pharmacist is taught how to recognize and dispense medications to treat a patient with chronic diseases, like diabetes, high blood pressure or heart disease. But to do this, pharmacists are required to have a collaborative practice agreement with a physician. For a period during the COVID-19 emergency, this scope-of-practice restriction was temporarily suspended. According to an executive order, the suspension would allow pharmacists to “provide care for routine health maintenance, chronic disease states, or similar conditions,” without a collaborative practice agreement, as long as they had been trained properly.
Many rural pharmacists are not able to obtain collaborative practice agreements due to the time, effort, and cost to maintain the service. Others simply can’t find a physician to collaborate with. Allowing pharmacists to test, treat, and prescribe medication for common illnesses like the flu and strep without these agreements would help reduce costs and improve health outcomes. This is especially valuable for vulnerable groups who have limited access to health professionals. Additionally, increasing a pharmacist’s authority to administer vaccines would improve access to immunizations and decrease health care gaps. Pharmacists should be allowed to offer any vaccine that is approved by the Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices and the Federal Drug Administration, including vaccines that are under emergency use authorization.
In summary, restrictions on various health professionals can strain the health care system and slow its response during public health emergencies. Suspending scope-of-practice restrictions and supervisory requirements would help free up providers to do more.