A Comparison of Changes in the Professional Practice of Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives:  1992 and 2000

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This page: Chapter 3.  Professional Practice Indices | Chapter 4.  Nurse Practitioners | Chapter 5.  Physician Assistants

Chapter 3.  Professional Practice Indices

• Introduction
• The Original Practice Environment Indices
• The New Professional Practice Indices

The numerical index scores for NPs, PAs, and CNMs are summarized in State-by-State listings in Chapters 4, 5, and 6, respectively. The detailed professional practice criteria and scores for the original indices for each of the 50 States are provided in Appendix C. The criteria and scores for the new professional practice indices for NPs, PAs, and CNMs are detailed in Appendices D, E, and F, respectively.

Introduction

This chapter describes the effort in this study to replicate these three indices for the year 2000 as part of a larger study of the professional practice of the three professions. Comparisons of the indices for 1992 and 2000 reveal the extent to which the practice environment has changed for the three professions in each of the 50 States over the 8 year period.

In addition to replicating the 1992 index, the current project has also developed a new index with different criteria and weighting schemes that better reflect the current status and roles of the three professions in the health workforce. The overall purpose of the new indices remains the same as that of the original indices, i.e., to define the professional practice options, structural identity, and market recognition of the three professions in each of the 50 States.

The detailed calculations for all the indices presented in Appendices C, D, E, and F include an “optimal score” for each criterion. This optimal score represents the highest score that can be awarded to a State for that criterion, which occurred only when the legal environment for the profession is “optimal” for that criterion. Decisions about what is optimal for each profession are based primarily on statements, observations, and recommendations by the respective professions through their professional associations, and by other interested stakeholders. Input has been received from hundreds of stakeholders as part of this definition process.

The three original indices assigned scores for each State ranging from 0 for “no practice environment” to 100 for “optimal practice environment”. The new index also uses a 0 to 100 scoring system. The summary tables for the three professions presented in Chapters 4, 5, and 6 also present a five-category “grading system”, which may be easier for policy makers to understand as they consider the possible need for changes in professional practice statutes or regulations in the future.

The Original Practice Environment Indices

In their 1994 article, Edward Sekscenski and colleagues presented three statistical indices representing the practice environments for NPs, PAs, and CNMs in the 50 States and the District of Columbia. They also examined the relationships between and among their indices for the three professions (NPs, PAs, and CNMs) and numbers of practitioners per capita and access to care for underserved populations for the 50 States. They theorized that increases in numbers of providers would enhance accessibility. They hypothesized that the number of practicing professionals in a location would be positively correlated with the legal climate within the State in which practice occurred. One of the hypotheses of this study is that States with more hospitable environments (as measured by the professional practice indices) would exhibit greater growth in the numbers of NPs, PAs, and CNMs.

The statistical indices, based on the specific legal status, reimbursement, and prescriptive authority for the three professions in the fifty States, resulted in the assignment of values from 0 to 100 for each State, based on practice environments in 1992. Although there was commonality among the three professions in their basic focus on primary care, the professions were distinct in professional practice, health orientation, and skills required in the different States. It was determined that accurate evaluation required examination of each profession on the basis of specific criteria relevant to that profession.

The current study includes a replication of the scoring criteria used by Sekscenski et al to assess the legal practice environments in individual States in the year 2000 using the same criteria and weights as in the original study. This replication suffers from several limitations:

• The original documentation was unavailable as a resource for the replication.
• The absence of fundamental documentation from the primary study made it very difficult to score the more discrete criteria accurately for the year 2000.
• Practice environments have evolved rapidly and significantly in the intervening 8 years. The elements of the scale which were relevant to practice in the early 1990s have shifted in value and importance as the legal and health care environments have advanced. In addition, several influential factors affect practice differently in 2000 than in 1992.
• The categories are broad and do not capture important differences and nuances of current professional practice legislation.

In order to complete the scoring, a number of assumptions were made about the allocation of the scores in 1992 in order to score for the year 2000. The final index scores for NPs, PAs, and CNMs are summarized in Chapters 4, 5, and 6, respectively, and the details of the scoring are presented in Appendix C.

The New Professional Practice Indices

After replication and review of the original indices, it was decided that more detailed indices of current practice regulations were needed to better reflect the healthcare environments of the three professions in the year 2000. The purpose of these new indices was to more accurately represent the variations across the States based on more comprehensive and detailed sets of criteria than were used in the original indices. In creating the new indices, some of the basic assumptions of the original scales were retained in order to allow some comparison between the two scales. The new scale incorporates the following features:

• Since the broad categories of legal authority, reimbursement, and prescriptive authority remained valid, they were retained from the original indices.
• The weights for each category were shifted to a more equitable division on the 100 point scale from the original scoring distribution used by Sekscenski et al (i.e., legal status = 20 points; reimbursement = 40 points; and prescriptive authority = 40 points).
• The weighting of each category in the new indices depended on the profession being scored. NPs and CNMs (legal status = 35 points, reimbursement = 35 points, and prescriptive authority = 30 points) were scored differently than PAs (legal status = 35 points, reimbursement = 25 points, and prescriptive authority = 40 points). This was done because reimbursement impacts practice differently for CNMs or NPs practicing in a more independent model of practice. Since PAs are educated to practice under the supervision of physicians, direct reimbursement is not as important for them. Prescriptive authority, which is presently almost universally available to CNMs and NPs, is a major focus of the PAs who are more restricted in prescriptive privileges than the other two professions.
• Legal status is assumed to be a driver of the other categories, although it is not considered a more important category. If the legal description of professional practice was permissive in language or privilege, it was expected that reimbursement rules and prescriptive privileges would be commensurately liberal. Conversely, if the language was restrictive, it was suspected that reimbursement and prescriptive authority would be limited. A total of 35 points is possible for this category for all three professions.
• Reimbursement for services is a complex issue affected by State and Federal regulations, by State and Federal reimbursement and insurance law, by individual insurance company practice, and by employer choices. Fieldwork discussions in several States indicated that reimbursement was an important issue in many States for the three professions. It is the “new frontier” for professional practice changes for the professions in a number of States. Reimbursement is often predicated on limitations that dictate how, where, by whom, and under what conditions health services are provided. The scoring of this category was extremely challenging.
• As presented, the reimbursement score is intended to capture the broader legislative and regulatory environment. The authors recognize that legislation merely enables the process, and may not fully reflect actual reimbursement practices. Implementation of statutes and regulations is interpretative and individual payers are guided by business principles and practices, legal exemptions, and employer prerogatives in their reimbursement policy. A detailed account of actual reimbursement practices in each State would require an exhaustive study of third party payers, which was not possible within the scope of this study. This category was allocated 35 points in the indices for NPs and CNMs, and 25 points for PAs.
• Prescriptive Authority has changed in most States since the original index was scored, and many State practice environments have evolved considerably with respect to prescriptive privileges. A total of 30 points were allotted to this category for NPs and CNMs, while 40 points were allotted in the PA index. As previously indicated, prescriptive authority is a particularly important issue for the PAs since they have limited or no authority in several States.

The Autonomy of the Three Professions

The criteria chosen for the new scoring system were synthesized from several sources. Ideal legislation composed and proposed by various professional organizations which represent NPs, PAs, and CNMs were major resources when determining items to be scored.

The new indices attempt to identify receptive practice environments that are conducive to professional autonomy. Language that adequately expresses the benchmarks for practice was difficult to identify. Capturing factors that contribute to an ideal practice environment within the confines of a scoring instrument was problematic since what is considered ideal varies by profession. The use of the words ‘independent’ and ‘autonomous’ generated considerable discussion among researchers, advisors, experts, and informants consulted by project staff. Autonomy is perhaps best described as “the extent to which a..[professional]…can determine independently the range of tasks… (s/he)… will perform.” [Chumbler, et. al. p. 2]

Autonomy should not be confused with practice that is independent of other health care providers. NPs, PAs, and CNMs provide care in an interdependent healthcare delivery system that demands the varying expertise and competencies of a wide range of providers. The use of the words ‘independent’ or ‘autonomous’ in this report is not intended to suggest that these providers need not communicate with and seek advice or approval from other professionals when making clinical decisions. Rather this terminology is intended to convey the ability of the professional to make decisions within the limits of the particular education, skill, and professional competency of the provider which results in efficient use of resources unimpeded by restrictive regulations, rules, and oversight.

Health care delivery requires an interconnected network of professionals that supply care within a spectrum of services. Effective practice and rational use of health resources is most encouraged by and best achieved in a system that recognizes the complementarity of various medical professions and encourages efficient use of providers.

The three professions practice in complex environments in a medically sophisticated society in which there are both competing and complementary interests. There are both similarities and differences among and between the three professions whose roles are highly technical, very specialized, and narrowly focused. The proliferation of new technologies and changing organizational and operational structures has effected each of these professions. While there is sometimes overlap in functions, each possesses a discrete identity and a distinct place in the system. To acknowledge this diversity and to recognize their individual professional natures, a unique scale was developed for each profession. The characteristics of a receptive environment do vary depending on the profession.

The Scoring Methodology

Structuring and scoring the new professional practice indices required the establishment of certain rules:

• Only legislative changes passed by December 31, 2000 were to be scored. This meant that legislation enacted in early 2001 was not considered. The need to establish a deadline dictated this decision.
• Scores were determined by rules found in legislation and regulation only. Variations in actual practice environments were not considered. If the category was not addressed in statute or regulation, no score was awarded.
• NPs were scored as a single profession. Although there are many specialties within the NP profession, legislation is generally focused on the broad category of NP rather than on the sub-specialties.
• Scoring was generally explicit, with scores based on specific provisions found in a statute, regulation, or rule that were relevant to the category. There were a few cases where the score was implicit. If the professional practice was sufficiently broad (such as in Oregon where no direct physician involvement is written into the statute enabling NP practice), certain assumptions were made. Practice as a self-employed nurse practitioner implied the ability to refer or to order diagnostic tests, even if those functions were not explicitly enumerated in statute or regulation. These functions were implicit to providing a continuum of care for the patient.
• NPs and CNMs vary greatly from PAs in their basic orientation to physicians. PAs “practice medicine with supervision by licensed physicians” [PAs, 8th edition p iii], and are inextricably linked to physician direction in a medical model of care. NPs and CNMs are educated in a nursing model which emphasizes patient education and management. These professionals tend to view their expanded roles “as nurses with a broadened professional practice and do not define themselves as physician-supervised professionals.” [Buppert, p. 11]. These orientations create differences in the desired mode of practice of the three professions.

The new scoring system was designed to reveal smaller, more subtle differences and distinctions in professional practice across the States than was possible with the original indices developed by Sekscenski et al. The broad criteria used for each profession are presented in chapters 4, 5, or 6. The detailed point allocations for each of the criteria can be found in Appendices D, E, and F.

Chapter 4.  Nurse Practitioners

This chapter summarizes the original practice environment index for NPs developed by Sekscenski et al, the 2000 update of this index, and the new professional practice index developed in this study for NPs for the fifty States plus the District of Columbia. It includes the following subsections:

• Introduction
• The Original Practice Environment Index for NPs
• The New Professional Practice Index for NPs
• Discussion

Detailed criteria and scoring sheets for the three professional practice indices for NPs for the 50 States and the District of Columbia can be found in Appendices C and E.

Introduction

Nurse practitioners (NPs) are registered nurses (RNs) with advanced academic and clinical experience which enables them to diagnose and manage acute, episodic and chronic illness, either independently or as part of a health care team. NPs provide some care once offered only by physicians, and in most States they have the ability independently to prescribe medications.

As of 2000, all States and the District of Columbia had statutes or regulations governing the qualification and professional practice for NPs. Most jurisdictions required NPs to pass one of a number different general or specialty-specific certifying exams. [NCSBN, 1998] Laws in most States allow NPs to provide patient services independently in collaboration with a physician.

Their clinical knowledge and experience as RNs, coupled with their advanced clinical training, enables NPs to work with patients on a wide range of clinical tasks. NP practice blurs the discipline boundaries between nursing and medicine so their services can both substitute for and complement the care of physicians. This ability to work across the spectrum of care delivery sites and manage patients in both hospital and ambulatory care settings has found acceptance in a growing number of settings and specialties. On the other hand, because the number of NPs is much smaller than the number of physicians, they are currently used in only a fraction of the sites where physicians work.

An important long-term question is whether NPs will continue their penetration of the health care system. If they do, they could play a dramatically larger role in the health care system of the future. The roles of NPs are continuing to evolve in the health care system, however, and the future is not entirely clear. Recommendations by the recent AHA-sponsored Commission on Workforce for Hospitals and Health Systems [2002] suggests that NPs could play greater roles in the staffing of hospital care teams. If penetration of NPs continues in different medical and surgical specialties, there will clearly be a significant growth of the NP profession. The current attention to patient safety and health care quality suggests that NPs will be integral to future health care delivery across the U.S.

The Original Practice Environment Index for NPs

The original NP practice environment index developed by Sekscenski et al for 1992 was based on three broad criteria and point allocations reflecting the then present practice environment for the profession. The broad criteria and point allocations used in creating the index were Legal Status (Maximum Score  = 20);  Reimbursement (Maximum Score = 40); and Prescriptive Authority (Maximum Score = 40). The detailed point allocations for the original index for NPs in 2000 are presented in Table C-1 in Appendix C.

The original professional practice index scores for NPs for the 50 States based on the criteria in Appendix C are summarized in Table 4-1. The scores show a definite trend toward broader professional practice across the fifty States and the District of Columbia between 1992 and 2000. The increases in the index scores indicate greater professionalization, socialization, and standardization of professional practice for NPs over the last decade.

The New Professional Practice Index for NPs

To better reflect the subtle differences that often exist in professional practice across the 50 States, a new index was developed as part of this study that incorporates more criteria and more variability in the scores assigned. The new professional practice index more accurately reflects the practice environments of NPs across the U.S. Most States scored lower on the new index than on the original index for 2000, indicating that the expectations/possibilities about professional practice for NPs had increased since 1992.

The broad scoring criteria for the new NP Professional Practice Index are the same as for the original index, but the point allocations are different. The three criteria are: Legal Status (Maximum Score  = 35);  Reimbursement (Maximum Score = 35); and Prescriptive Authority (Maximum Score = 30). The detailed point allocations for the new index for NPs for each of the 50 States are presented in Appendix E.

The new professional practice index scores for NPs for the fifty States and the District of Columbia resulting from the application of these criteria are presented in Table 4-1. A qualitative overlay to the new professional practice index scores has been provided to identify States that provide Excellent, Favorable, Acceptable, Limiting,  or Restrictive practice environments for NPs. These terms and categories are not hard-and-fast. They are provided only to help readers to characterize the general practice environments in different States. The terms and ratings generally conform to characterizations of the practice environments in States by knowledgeable NPs.

Discussion

The scores on the original NP practice environment index reveal a trend toward greater practice opportunities for NPs across the fifty States and the District of Columbia between 1992 and 2000. The scores indicate the trend towards greater professionalization, socialization, and standardization of the NP profession over the last decade. Additional analyses of the index scores are described and summarized in Chapter 7.

Table 4-1 shows that most States scored lower on the new index than on the original 2000 index. This is an indication of the impact of the changing health care delivery system which places greater demands and requirements on health professionals in both clinical practice and practice management. The lower scores also reflect the greater efficiency of the new index in capturing nuances in practice options. For example, the prescriptive authority component of the original index had only a three-point scale for prescriptive authority, with 40 points for “full authority”, 0 points for no authority, and an incompletely defined 1 to 39 points for “partial authority”. The prescriptive authority component of the new index on the other hand has seven parts, the largest of which is a graduated scale for type of authority that assigns 1 point for legend drugs only, 3 points for Schedule V drugs, 6 points for Schedule IV and V drugs, 9 points for Schedule III to V drugs, and 12 points for Schedule II to V drugs. Thus, the new index provides a better basis for identifying differences in professional practice options for NPs in different States in 2000 than does the original index.

As is true with many such indices, the true differences that underlie small differences in the scores are generally very small. Thus, states that are close on any of the indices are not significantly different in their professional practice.

Comparisons of individual NP professional practice scores on a State-by-State basis should be made with caution. The scores reflect general, not particular, conditions in the State regulatory environments. Comparing one State with another on the original practice environment index may not fully reflect similarities or differences in actual practice patterns. The index is a good basis for assessing trends toward broader practice environments, but it does not capture or reveal detailed variations in State environments.

Chapter 5.  Physician Assistants

This chapter summarizes the original practice environment index developed by Sekscenski et al, the 2000 update of this index and the new professional practice index developed in this study for Physician Assistants for the fifty States plus the District of Columbia.  It includes the following subsections:

• Introduction
• The Original Practice Environment Index for PAs
• The New Professional Practice Index for PAs
• Discussion

Detailed criteria and scoring sheets for the three professional practice indices for PAs for the 50 States and the District of Columbia can be found in Appendices C and D.

Introduction

From the beginning, PAs have provided primary care services to patients in a wide range of settings including physician offices, hospitals, health clinics, correctional facilities, emergency centers, outpatient clinics, and a variety of military settings. PAs are recognized as providers of quality health services who are closely tied to physicians in medical practice. PAs work under varying degrees of supervision ranging from direct or personal supervision to indirect or remote supervision depending on the State in which practice occurs, on the setting in which care is offered and on the particular services which are being provided.  

In 2000 there were about 40,000 PAs in active practice^[32] working in both primary and specialty care. PAs are increasingly finding work in specialty practices including emergency medicine, allergy, orthopedics, cardiology, and neurosurgery.  In recent years, the supply of PAs has expanded considerably with a variety of opportunities emerging for the profession. The practice environments of PAs vary significantly across States.

The Original Practice Environment Index for PAs

The original PA practice environment index developed by Sekscenski et al for 1992 was based on three broad criteria and point allocations reflecting the then present practice environment for the profession. The specific criteria and point allocations used in creating the index were Legal Status (Maximum Score  = 20);  Reimbursement (Maximum Score = 40); and Prescriptive Authority (Maximum Score = 40). The detailed point allocations for the original index for PAs in 2000 are presented in Table C-2 in Appendix C.

The original practice environment index scores for PAs for the 50 States resulting from the criteria in Appendix C are summarized in Table 5-1. The scores show a definite trend toward greater professional practice opportunities across the fifty States and the District of Columbia between 1992 and 2000. The increases in the index scores indicate greater professionalization, socialization, and standardization of professional practice for PAs over the last decade.

The New Professional Practice Index for PAs

To better reflect the subtle differences that often exist in professional practice across the 50 States, a new index was developed as part of this study that incorporates more criteria and more variability in the scores assigned. The new professional practice index more accurately reflects the practice environments of PAs across the U.S. Most States scored lower on the new index than on the original index for 2000, which reflects the greater ability of the new index to distinguish subtle differences in professional practice that the original index.

The broad scoring criteria for the new PA Professional Practice Index are the same as for the original index, but the point allocations are different. The new PA index incorporates more detailed criteria than those used in the original index to more accurately reflect the practice environments of PAs across the U.S. The three criteria are: Legal Status (Maximum Score  = 35);  Reimbursement (Maximum Score = 25); and Prescriptive Authority (Maximum Score = 40). The detailed point allocations for each of the criteria in the new index for PAs for each of the 50 States are presented in Appendix D.

The resulting professional practice index scores for PAs are presented for the 50 States in Table 5-1. A qualitative overlay has been applied to the new index scores to identify States that provide Excellent, Favorable, Acceptable, Limiting, and Restrictive practice environments for PAs. These are not hard-and-fast terms or categories, and they are provided only to help readers to characterize the practice environments in the different States. The ratings do generally conform to characterizations of the practice environments in States by knowledgeable PAs.

Discussion

The scores on the original PA practice environment index reveal a trend toward greater professional practice options for PAs across the fifty States and the District of Columbia between 1992 and 2000. The scores indicate the trend towards greater professionalization, socialization, and standardization of the PA profession over the last decade. Additional analyses of the index scores are described and summarized in Chapter 7.

As is true with many such indices, the true differences that underlie small differences in the scores are generally very small. Thus, States that are close on any of the indices are not significantly different in their professional practice. The authors have applied a qualitative overlay to the new index scores to identify States they believe provide Excellent, Favorable, Acceptable, Limiting, and Restrictive environments for PAs. These are not hard-and-fast terms or categories, and they are provided only to help readers to characterize the practice environments in the different States in a more qualitative way. The terms do generally conform to characterizations of the practice environments in States by knowledgeable PAs.

Comparisons of individual PA professional practice scores on a State-by-State basis should be made with caution. The scores reflect general, not particular, conditions in the State regulatory environments. Comparing one State with another on the original index may not fully indicate the similarities or differences in actual practice patterns. The index is a good indicator of the trend toward broader practice environments, but it does not effectively capture the detailed variations in State requirements.

Preface | Executive Summary | Introduction | Key Findings | Discussion | Chapter 1.  Study Overview | Chapter 2.  Background and Context | Chapter 3.  Professional Practice Indices | Chapter 4.  Nurse Practitioners | Chapter 5.  Physician Assistants | Chapter 6.  Certified Nurse Midwives | Chapter 7.  Factors Related to Professional Practice Indices | Chapter 8.  Field Work in Seven States | Chapter 9.  Access to Care | Appendix A.  Project Advisory Committee | Appendix B.  Professional Organizations | Appendix C.  Original Index Calculations | Appendix D.  Professional Practice Index Calculations for PAs | Appendix E.  Professional Practice Index Calculations for NPs | Appendix F.  New CNM Scope Index Calculations | Appendix G.  Field Work Details | Appendix H.  References