Stanford Medicine Study Challenges the AMA’s Fight Against Scope Creep

Currently, nurse practitioners have full practice authority in 27 contiguous states and Hawaii, Alaska, Guam, and the Northern Mariana Islands. In these states, NPs manage patient care, including prescribing medication and controlled substances, without physician oversight.

Full practice authority has not been well-received by all medical professionals and organizations, including the American Medical Association (AMA), which uses the term “scope creep” to describe the idea of full NP practice authority. Let’s dive into the AMA’s objections and the most recent data revealing that NPs are as safe as physicians when prescribing medication to senior adults.

The AMA developed a “Recovery Plan for American Physicians” that includes addressing the overuse of prior authorization, supporting telehealth, reducing physician burnout, reforming the Medicare payment system, and fighting scope creep.

According to the AMA, scope creep describes the “expansion of the medical services and procedures nonphysician health professionals are allowed to perform.” The AMA continues that “allowing nonphysicians such as nurse practitioners (NPs) or physician assistants to diagnose and treat patients without any physician oversight is a step in the wrong direction,” and the best way to lower costs and improve care is for physicians to be leaders of the healthcare team.

The AMA’s stated position is, “Patients deserve care led by physicians — the most highly educated, trained and skilled health care professionals. That’s why the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety, and it’s why fighting scope creepis a critical component of the AMA Recovery Plan for America’s Physicians.

In response to initiatives like the AMA’s, and to provide more representative data for legislators, policymakers, and regulators, researchers at Stanford Medicine conducted a study — the largest of its kind — to analyze the prescribing patterns of nurse practitioners and physicians in states where nurse practitioners had full prescriptive authority.

Researchers gathered data from more than 73,000 primary care physicians and nurse practitioners, analyzing prescribing patterns for Medicare beneficiaries aged 65 years or older from 2013 to 2019. They calculated the rate of inappropriate prescribing according to Beer’s Criteria developed by the American Geriatric Society.

“Older adults account for a huge proportion of all prescriptions written,” said senior author David Studdert, LLB, ScD, a professor of health policy and law. “They are also especially vulnerable to adverse drug events from inappropriate prescribing.

According to the study’s results, “Nurse practitioners were no more likely than physicians to prescribe medications inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians.”

Seana Rutherford MSN, APRN, FNP-C, CWS, is a nurse practitioner with privileges at Cleveland Clinic’s Fairview Hospital who owns her own practice. She recently spoke with NurseJournal about the results of the Stanford Medicine study.

“I’m passionate about our profession. I’m not surprised by the results of the study. It’s not a good look for NPs to be at the top and bottom of the evaluation. Physicians are my peers. It’s been hard-earned respect from these guys,” she said.

The inability to practice to the full extent and capacity of their licensure could create inefficiencies and restrictions to healthcare. A 2021 paper analyzed a data set of electronic health records and claims to quantify the effect of increasing the scope of practice laws. They found that when NPs were granted greater authority in the state, there was some evidence that NPs began practicing more autonomously. Yet, there was no evidence that it changed the volume or allocation of patients to NPs within large practices.

In other words, even with greater authority, NPs tended not to open their own practices. The limits and boundaries states set on the care NPs are allowed to independently deliver can limit high-quality, accessible care to patients as there is also a physician shortage that limits access to healthcare.

Rutherford talked about how operating under reduced practice authority in Ohio impacted patient care, including the ability to prescribe medications.

The American Medical Association has expressed concerns that expanding the scope of practice for advanced practice registered nurses is a bad idea that could lead to higher healthcare costs and reduced safety for patients.

“Patients are better served when all members of the health care team share information and decision-making based on their unique skills — all with the common goal of improving the health of the patient,” AMA President Susan R. Bailey, MD, told the Nebraska APRN Technical Review Committee.

“Expanding the scope of practice of APRNs to allow independent practice and prescriptive privileges will increase utilization of diagnostic services, antibiotic prescribing, and opioid prescribing — all of which can take a real toll on health care costs as well as threaten the health and safety of patients,” Bailey continued.

However, Stanford Medicine researchers believe that opening the door to greater prescriptive authority across the U.S. could have a positive impact on healthcare:

“If expanding patient access while ensuring quality and safety system-wide is the goal, fixation on the question of whether NPs or other nonphysician providers should be allowed to prescribe may be less impactful than identifying and addressing deficient performance among all clinicians who prescribe, regardless of practitioner type or practice location,” the researchers wrote.

Rutherford agrees that the healthcare system should focus on patient safety, no matter who is delivering care.

“We should have a support system built within the healthcare system for NPs and MDs. There should be a system for checking prescriptions so NPs and physicians have a hard stop, whether that’s in a computer system in the hospital or the pharmacy,” she said.