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“California could save at least $1.8 billion over ten years if full practice authority Nurse Practitioners were allowed”

Can we expand access and save money by having clinicians “practice to the top of their licenses?”  The Bay Area Council Economic Institute thinks so at least when it comes to Nurse Practitioners. According to their April 2014 report, if Nurse Practitioners in California were granted full practice authority licenses, they could provide 2 million more preventative care visits than are currently available. That would be an increase of more than 10%.

The report states that “In states with limited NP practice authority, the average cost for a preventive care visit can be as much as $16 higher than in states with full practice authority.” They estimate that relaxation of scope of practice regulations in the state could save $1.8 billion just on the cost of preventative care visits alone over the first ten years after reform is enacted.

So, what is Full Practice Authority?

According to the American Association of Nurse Practitioners, full practice authority is defined as follows:

“Full practice authority is the collection of state practice and licensure laws that allow for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications—under the exclusive licensure authority of the of the state board of nursing.”

Full authority means that advanced practice nurses could practice independent of physician oversight. NPs in full authority license states have the ability to prescribe and administer both pharmacologic and non-pharmacologic interventions without the requirement to get physician sign-off. Full practice authority does not mean NPs are lone rangers or cowboys practicing without accountability. Rather, the oversight would be related to the requirements of their licensing organizations and would include continuing education and certification. By the way, PCPs also should not be lone rangers, practicing without any oversight. Good medicine, we are increasingly understanding, is a team sport.]

As of 1/2013, there were 17 states that had adopted full practice licensure:  Alaska, Arizona, Colorado, District of Columbia, Hawaii, Idaho, Iowa, Maine, Montana, Oregon, New Hampshire, New Mexico, North Dakota, Rhode Island, Vermont, Washington, and Wyoming. Nevada will become the 18th state in July 2014.


What about cost, quality, and the care experience?

The literature on the cost, quality, and satisfaction measures for nurse practitioners vs primary care physicians is reviewed in the Josiah Macy Foundation’s 2010 report on Primary Care. To sum it up, in high-quality studies, researchers found that the quality of care was equal to and sometimes better than physicians. NPs spent more time with patients and had expanded access so the care experience was often better as well. I have already mentioned that the cost of care is lower.

Calls for Action

Numerous reports from prestigious organizations have declared that it is time to allow every health care professional, including advanced practice nurses, to practice to the top of their licenses. Included among them are the following:

Given the paltry number of medical students choosing to train in primary care – only 1,916 U.S. medical school grads were matched to primary care residency programs in the 2013 match (3,715 primary care matches if you also count international graduates), we need to consider a realistic alternative to a physician-based based primary care work force.

In contrast to medical students, Nurse Practitioners choose to a primary care practice in large numbers. Of the 150,000 NPs currently eligible to practice, approximately 2/3 opt for primary care. Further, they are willing to practice in underserved areas, take care of low income populations, and practice in a variety of community settings, such as schools and retail clinics.

Given the growing need for primary care providers because of expanded coverage by the newly implemented ACA as well as the increasing chronic care needs of an aging population, why should we continue to enforce outmoded “Scope of Practice” laws that limit Nurse Practitioners ability to fully utilize their knowledge and skills?


  1. All my experiences dealing with Nurse Practitioners and PA has been nothing but positive in all ways – they are clinically very competent and seem to have more ’empathy’ than some MDs I have met (not to mention inflated egos). This shouldn’t be taken as a generality but my personal observation having worked with so many providers.

  2. I think this is the right thing to do, but let’s not delude ourselves into thinking it will save costs. The 15% of the visit charge that NPs or PAs save (they’re typically reimbursed around 85% of what a physician would be reimbursed) is more than made up by the extra tests that they order. See

    I don’t even argue that it’s a bad thing that NPs order more tests – with less clinical experience and less training, they are often correct to send more consults and order more tests, to be safe. But the net “cost savings” is not the goal, or the outcome. It’s expanded access for patients. That’s what NPs and PAs can offer. And it’s a good thing. Just let’s not buy into the magical thinking that it’ll be cheaper.

    • Other studies suggest overall costs are lower. Docs over-order too – thus the Choosing Wisely campaign.


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