Scope of practice expansion efforts

DOs help defeat bills that seek to cut doctors out of health care

As APRNs and nurse-midwives ramp up their efforts to practice independently, DOs are fighting back.

This summer the American Association of Nurse Practitioners, which represents nearly 250,000 nurse practitioners in the United States, announced a $2 million advocacy campaign to push for independent practice rights.

Meanwhile, the American Academy of Physician Assistants is calling for the elimination of any legal requirements for PAs to maintain a collaborative relationship with a physician in order to practice.

The trend has the potential to create a two-tiered health care system in which those who can afford it get to see doctors and those who can’t are limited to getting care from unsupervised nurse practitioners and physician assistants, said William S. Mayo, DO, president of the American Osteopathic Association. 

“Often we find that patients are unaware of their health care provider’s credentials and there is a clear need for transparency, particularly when it comes to the management of complex patients in the primary care setting,” Dr. Mayo added. “It’s important for legislators to understand the difference in qualifications and why those differences matter.”

Advocating for physicians and patients

Studies have shown that less qualified professionals cost the system more. Specifically, researchers found that nurse practitioners make poorer quality referrals to specialists,  expose patients to increased radiation by ordering more diagnostic imaging and prescribe more drugs than physicians.

Currently, 22 states and the District of Columbia allow nurse practitioners to diagnose patients, order and interpret diagnostic tests, and prescribe medication, including controlled substances like opioids, without any physician involvement or oversight.  Additional legislation seeking to expand the independent practice rights of non-physician clinicians is expected to be introduced in several states this year.

“It’s extremely clear that these groups of non-physicians are using the physician shortage as a lever to push states into letting them independently practice medicine without attending medical school. While physicians highly value the care they provide, and the system clearly needs them, it is dangerous to substitute nurses and PAs for doctors,” Dr. Mayo said.

Recent victories

Working with state affiliates, AOA has defeated several bills that would have cut physicians out of the health care equation.

In 2018, Oklahoma Senate Bill 570 aimed to greatly expand the scope of practice for Advanced Practice Registered Nurses (APRNs), allowing them to perform a wide range of primary care services,  such as prescribing medication without any physician involvement. The bill would have also allowed APRNs to replace physicians as a patient’s primary care provider of record.

In Wisconsin, House Bill 568 sought to repeal requirements that nurse-midwives must practice with an obstetrician and maintain malpractice insurance, and in Kentucky, House Bill 445 would have allowed APRNs to prescribe controlled substances independently after four years prescribing under a collaborative agreement, which could have been made with another APRN.

Those bills failed, as did legislation to enact the APRN Compact in West Virginia, Iowa, Nebraska and Minnesota this year.

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Future battles

Although it professes to improve patient access to care, the APRN Compact usurps state law regarding APRN scope of practice by eliminating physician involvement requirements for APRNs who practice under a multistate license, regardless of state law to the contrary, according to David Pugach, JD, AOA senior vice president of public policy.

So far, Idaho, North Dakota and Wyoming have enacted the compact, which becomes effective if 10 states approve the legislation.

Responsibility without accountability

Some independent practice states allow nurses who have passed a single licensure exam at the end of a two-year master’s program to perform many of the same duties of a primary care physician. Classes may be online, with minimal hands-on experience and no supervised postgraduate training.

Despite their lower training, in some states independent practice nurses are not required to maintain a physician’s level of malpractice insurance to compensate patients in the event of an adverse outcome.

Pugach noted that when such events occur, physicians must step in to fix a problem that could have been minimized or prevented if the patient’s care had been properly supervised from the outset. Such avoidable adverse outcomes not only harm patients but unnecessarily drive up the costs of health care for everyone.

“The AOA’s position is clear,” said Pugach. “Team-based health care is a winning model and nurses and physician assistants play vital roles. We will partner with our state affiliates to protect patients by ensuring that physicians are leading those teams.”


  1. Martha Oreilly

    I can’t believe that 22 states allow the practice of medicine without a medical licence. AANP speaks of cost effective care while pushing for pay parity even as their undertrained constituents order shotgun tests and prescribe antibiotics “just in case”. Cost effective and high quality? Not so much.

    1. Daryl W

      I was a PA before I had the privilege of becoming a DO. No matter what letters follow your name we all have limits in what we can and should do. I don’t do brain surgery! The best ‘doc’ is one with a humble, servant heart that strives to help his fellow human as best he can but knows when to ‘punt’. Humble hearts are rare in the arena of politics…..

      1. Dr. Al

        A doctor is as limited as she/he decides to be along its training. The same can not be said for PAs or ARNPs

  2. Dr. Mark

    Glad that the AOA has my back. Keep up the good work.

    Whenever I see weird or odd medications being prescribed and search the “provider” it is always a PA or NP!

    We resident physicians would also like pay increases to the level of the NP PA.

    Thanks for your help and keep up the good work!

  3. Docs only

    Yes nps want equal pay but at the same time save money. Ha!

    Just look to if you want to see how militant nurses are

  4. dr. freeman

    thank you, thank you, thank you for helping patients by fighting this battle. all patients deserve physician-led care. reading this has helped make up my mind and i will be renewing my dues.

    continue to let us know how we can help in this!

  5. DO

    I would go straight to state boards and have them continue to require NPs and PAs to maintain an appropriate supervisory agreement with an appropriate physician.

    In many states, these are being removed inappropriately.

  6. Dr. K.

    I get a newsletter from the state medical board about doctors who lose their license. Lot if DO names there. The state is Alabama. How about quality control AOA? What’s up with these new schools?

  7. Captain Obvious

    Quite frankly, I don’t understand this. If physicians really want to end it they can today. All day have to do is have specialists accept ONLY referrals from other physicians. This will limit the burden of accepting non-essential cases and reduce the NP/PA heightening of boundary crossing[qualifications] into the medical field. Done. Today.

  8. Thank You, D.O.

    Thank you for all you are doing and have done. Physicians should be the leaders and ultimate decision makers in healthcare. It is proven that NPs and PAs increase healthcare costs through unnecessary referrals, treatments, tests, and medications. Physicians should be the only independent provider of healthcare. NPs and PAs have a role. That role should not be to see patients completely independently of physicians. The training is not even close. Patients deserve physicians to care for them.

  9. Ursula Inge Ferguson

    Federal Government Dept of Veterans Affairs (the VA) trains RN’s internally to become NP’s and allows independent privileges. This was passed quietly and most physicians, veterans, nor general public made aware. This is VA’s response to the shortage of physicians.
    I know some excellent NP’s in practice but I question the qualifications of others, especially internally trained. Some RN’s took this route due to RN dissatisfaction, not because they truly had lifelong dreams to serve as a ‘doctor’.
    BTW VA does not require transparency on name badges if you are DNP, MD, or DO. They all get the title of “you are scheduled with Dr ____”
    Physicians fight battles all around JUST to able to practice high quality patient care – battling insurance, administrators, health care costs, and now their own team :( . It is no wonder physician shortage and burnout is an issue.

  10. Michael

    I have found NP’s and PA’s to be effective in hospitals when they work directly under physician supervision. However, even in this scenario, I found that my PA’s not uncommonly overstepped their boundaries.
    My experience with NP’s and PA’s in semi-autonomous settings such as clinics and other outpatient care settings has been for the most part very disappointing. They simply do not have the knowledge base and experience that a physician gains in the years of medical school and residency. As a result, many of them simply don’t know what they are doing.
    The public and lawmakers have been sold a false bill of goodbye these allied health professionals and their representatives. This problem is now out of control.

  11. John Smith, DO

    Why not team up with the AMA to help address this issue? Seems to me, that it would only make sense to collaborate with other PHYSICIAN groups to help address this cause. It is fine for PAs/NPs to obtain practice rights in areas of need. Just as the same as “GP”s were able to do so without residencies. However, I think there is enough segregation now – time for MDs and DOs to unite on fronts in this era for a common cause.

  12. P Slocum

    This is a highly complex issue with advantages and disadvantages for both approaches of accepting and rejecting this approach. I find it interesting that several osteopathic schools appear to have “muddied” the controversy by starting on line Doctor of Medical Science programs so PAs and ANPs can obtain a “DOctoratelevel” degree without having to go through the rigors of medical education. Why isn’t the AOA addressing these threats?

  13. Concerned gynecologist

    As an OBGYN working alongside WHCNPs in an FQHC, I am living in a realm where physicians are considered replaceable/interchangeable by non-clinical administrative staff. I often question administrative understanding of mid-level training and how it differs from a physician’s because, afterall, they just refer to everyone as ‘providers’ without much effort to create a distinction for patients. If our state passes laws to enable independent practice, I foresee these clinics running without physician oversight entirely in an effort to greatly decrease the operating costs.
    Additionally, we should remember that the original role of a NP was to supplement healthcare by caring for uncomplicated patients. However, once these patients became complex, their care would be assumed by a physician. This just doesn’t happen today, and many times the NP unfortunately may not recognize an issue or the need for referral. I have seen many charts with glaring issues where there was a lack of recognition or understanding for an investigative approach to a patient presentation. In my specialty, this has resulted in years of untreated dysmenorrhea, pelvic pain, wasted years of fertility, etc. for many patients. Unfortunately, in most cases, I feel it is because the NPs simply ‘do not know what they do not know’.

  14. Kevin

    The ambiguity of the title, role, and ability of mid-level providers is a major concern in clinical practice. Graduates of “Doctor of Nursing Practice” (DNP) programs can be tempted to use their credential in ambiguous ways and it causes confusion and stress for patients. Providing patients with a clear and concise understanding of the roles of each member of the healthcare team could help solve many of the discrepancies in understanding shared by most patients. Name tags with explicit credentials, unambiguous titles, and clearly partitioned roles is the first step to alleviating the confusion.

    In our modern healthcare environment, the entire team is imperative for successful patient outcomes. Maintaining an open line of communication between our patients and team members will eliminate the confusion and ensure that we are providing the highest standard of care possible.

    comment 3 of 4

  15. Jim Scott

    I am perfectly happy with NPs / PAs when my symptoms are fairly routine … but after 66 years I have come to know my body’s quirks pretty well (and my unspoken opinion usually coincides with the NP’s / PA’s assessment). BUT if anything is off (i.e., atypical symptoms), I want a real MD / DO on the case even if only by proxy through an NP / PA. Sometimes that extra few years in school and the residency make all the difference. Keep in mind that medicine is one of the few fields where mistakes often get buried (literally and figuratively).

    Perhaps the answer to the “doctor shortage” isn’t lowering the standard but rather assisting more gifted NPs / PAs to go on to school to get their MD / DO degrees. We would all benefit. Surely there are some foundations, et al, that could work on this. For example, Bill and Melinda have spent billions on medical research / support all over the world. Perhaps they could be persuaded to fund a lottery to send a 100 or so NPs / PAs back to school every year. Not a huge number but certainly it would help. Sounds like a win-win to me. The most promising might even find their way into the biotech field! ;-)

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