Recap: The stated mission of the American Medical Association (AMA) is to “promote the art and science of medicine and the betterment of public health.” But the AMA is also a lobbying organization that promotes the self-interest of its members: physicians and medical students. And sometimes the AMA put self-interest before the common good. Case in point: the AMA’s relentless campaign against allowing nurse practitioners (NPs) full authority to practice without physician supervision. As documented in the last post, the AMA gives “three big reasons” for opposing independent nurse practitioners:
It won’t solve the rural access problem.
It will raise healthcare costs, not cut them.
It threatens patient safety.
I tackled rural access and healthcare costs in the last two posts. This time I will address the third reason the AMA gives for opposing independent NPs.
It threatens patient safety. “NPs are essential members of the physician-led care team, but they are plainly not trained to practice independently…’In fact,’ Dr. Madara wrote, ‘the evidence shows that states that require physician-led team-based care have seen a greater overall increase in the number of nurse practitioners compared to states that allow independent practice.’ American Medical Association, 2020
Comment: “Practice independently” refers to state practice and licensure laws that “permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments including prescribing medications and controlled substances”, without physician supervision (American Association of Nurse Practitioners). As for the 11 states that disallow NP independent practice, these include California, Texas and Florida, the most populous states in the nation. It follows that they would also have the most NPs – 29% of NPs in the entire country - as well as the greatest overall increase in NPs. This says nothing about whether NPs should always be supervised by physicians. More relevant is the growing number of states that do grant NPs full practice authority - currently, 28 states, as well as Washington, D.C.
What other researchers say: Public safety is often used as an argument against expanding scope of practice (SOP) for nurse practitioners, despite the benefit of filling unmet health care demand. As a response to the COVID-19 Pandemic, some states expanded SOP for nurse practitioners to accommodate the unprecedented healthcare challenge. We analyze the effect of the expansion of SOP on daily COVID-19-related mortality, exploiting the quasi-random state policy changes at the beginning of the COVID-19 pandemic…there is absolutely no evidence that states that expanded scope of practice performed worse than states that chose not to in terms of public safety. Bhai & Mitchell, 2025
Links:
https://pmc.ncbi.nlm.nih.gov/articles/PMC6080248/ https://www.oregoncenterfornursing.org/wp-content/uploads/2024/07/2020_PrimaryCareWorkforceCrisis_Report_Web.pdf
https://digitalcollections.ohsu.edu/record/685?v=pdf
https://pmc.ncbi.nlm.nih.gov/articles/PMC6583766/
https://healthforce.ucsf.edu/news/policy-perspective-how-nps-expand-healthcare-access-rural-areas
https://www.dailynurse.com/oregon-study-state-needs-primary-care-nps/
https://www.aanp.org/advocacy/state/state-practice-environment
https://www.beckershospitalreview.com/quality/nursing/states-by-nps-per-capita-2024/
References:
Bhai, M., & Mitchell, D. T. (2025). New evidence on the labor market effects of scope of practice laws for physicians and nurse practitioners. Contemporary Economic Policy, 43(1), 31-51. https://doi.org/10.1111/coep.12683
Lozada, M.J., Raji, M.A., Goodwin, J.S. et al. Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. J GEN INTERN MED 35, 2584–2592 (2020). https://doi.org/10.1007/s11606-020-05823-0
McMichael, B.J. (2021), Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing. The Milbank Quarterly, 99: 721-745. https://doi.org/10.1111/1468-0009.12524
Makeeva, Valeria, C. Matthew Hawkins, Andrew B. Rosenkrantz, Danny R. Hughes, Laura Chaves, and Richard Duszak Jr. "Diagnostic imaging examinations interpreted by nurse practitioners and physician assistants: a national and state-level Medicare claims analysis." American Journal of Roentgenology 213, no. 5 (2019): 992-997. https://doi.org/10.2214/AJR.19.21306
Mizrahi DJ, Parker L, Zoga AM, Levin DC. National Trends in the Utilization of Skeletal Radiography From 2003 to 2015. J Am Coll Radiol. 2018 Oct;15(10):1408-1414. DOI: 10.1016/j.jacr.2017.10.007 Epub 2018 Mar 23. PMID: 29580717.
Yang BK, Johantgen ME, Trinkoff AM, Idzik SR, Wince J, Tomlinson C. State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review. Medical Care Research and Review. 2020;78(3):183-196. doi:10.1177/1077558719901216
Xue, Ying, Viji Kannan, Elizabeth Greener, Joyce A. Smith, Judith Brasch, Brent A. Johnson, and Joanne Spetz. "Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties." Journal of Nursing Regulation 8, no. 4 (2018): 5-13.https://doi.org/10.1016/S2155-8256(17)30176-X