The COVID-19 pandemic has made clear that government licensing of health professionals blocks access to care. Licensing gives state politicians the final word on allowable categories of clinicians, the education and training requirements for each category, and the range of services each category of clinician may perform. It reduces access to health services by increasing prices and reducing the supply of clinicians who can provide those services. It harms health professionals by preventing them from providing services they are competent to provide and by preventing capable individuals from entering or rising within health professions. By suspending such rules to improve access to care for COVID-19 patients, states have acknowledged that licensing prevents clinicians from providing services they are competent to provide.
A better solution than direct government licensing is a system in which states recognize third‐party organizations that certify the competence of health professionals. In such a system, accredited educational institutions or certificate‐issuing organizations would define clinician categories, determine scopes of practice for each category, and certify the training or skills of individual clinicians. Third‐party certification would allow innovative educational and certification programs, nontraditional career paths, incremental expansion of clinician skills and scopes of practice, and the creation of new categories of health care professionals. The result would be better career opportunities for clinicians and greater access to care for patients.
This system would eliminate the straitjacket that direct government licensing imposes on education, entry, and practice. It would remove politicians from complex and contentious questions on which they have no expertise. It also would generate innovative education and training programs that could increase access while maintaining or improving quality. Reformers offer many ideas for improving medical education that would allow health professionals to add to their knowledge and skills over time. Relying on third‐party organizations rather than direct government licensing to certify health professionals would allow these reforms to proceed. Third‐party certification would better prepare the health sector for crises such as the COVID-19 pandemic and enable the health workforce to respond to them faster.
Introduction
Making quality health care as affordable and accessible as possible requires both ensuring that clinicians have adequate training for the services they provide and avoiding education and training requirements that unnecessarily increase prices. A cost‐effective health care delivery system does not require clinicians to invest in training beyond what is necessary to do their jobs. “Optimal providers are those operating at the right level; these providers are not overqualified but have the appropriate level of knowledge and skills to complete the task."
“Right‐skilling” is the process of striking the proper balance between too much training and too little. A system that right‐skills its clinician workforce continuously increases access to care by eliminating unnecessary education and training costs and allowing lower‐cost paths to demonstrating competence to provide certain services.
Right‐skilling the provision of health services can reduce prices and expand access. Hospitals in India make medical care more affordable by providing workers only such training as is necessary to perform specific jobs:
Women from rural villages with only rudimentary education, for example, are trained to use sophisticated equipment and manage the delivery of medical services, such as administering dialysis. Meanwhile, physicians practice at the top of their license, playing key strategic and supervisory roles, passing down knowledge and tasks to lesser‐trained individuals wherever possible. Such de‐skilling is a hallmark of organizational innovation.… The accumulation of knowledge and experience allows organizations to codify knowledge so less experienced individuals can perform tasks that previously required personnel with advanced training.
Right‐skilling occurs on a limited basis in the United States. Physicians, for example, are increasingly turning to midlevel clinicians to perform certain tasks. One study found that from 2008 to 2016, the share of specialty practices that employ either nurse practitioners (NPs) or physician assistants grew from 23 percent to 28 percent while the share of primary care practices that do so increased from 28 percent to 35 percent.
The study’s authors speculate that “downward price pressure from public and private payers [may be] making the lower costs of advanced practice clinician employment more attractive” to physician groups In 2019, the Edward‐Elmhurst Health system in suburban Chicago de‐skilled the provision of immediate care by replacing 15 staff physicians with NPs. The health system explained, “Patients have made it very clear that they want less costly care and convenient access for lower‐acuity issues (sore throats, rashes, earaches), which are the vast majority of cases we treat in our Immediate Care [facilities].” One of the physicians who lost their jobs acknowledged, “There definitely is a good share of lower‐acuity things, which I think would be fine for a nurse practitioner to see.”
Just as nurses right‐skill tasks that physicians are overqualified to perform, other health professionals right‐skill tasks that nurses are overqualified to perform. “The de‐skilling of the nursing profession has been taking place for quite some time,” writes one nurse. “For example, we have phlebotomists and phlebotomy technicians to draw blood in certain healthcare settings.” Other examples abound.
Right‐skilling is critical to reduce costs across the spectrum of care. Academics and health care providers have proposed using right‐skilling to reduce the cost of primary care by creating such new clinician categories as primary care technicians and community paramedics.
“Psychiatric pharmacists … could help offset the shortage of psychiatrists by providing medication‐management services.” Retired Mayo Clinic urologist Murray Feldstein argues that clinicians could learn to perform high‐quality vasectomies in significantly less time than the 13 years it takes to earn a doctorate of medicine (MD) and qualify for specialty certification in urology.
Oregon recently began letting NPs perform vasectomies. Right‐skilling could reduce prices for the procedure, create better‐paying jobs for competent midlevel clinicians, and increase job satisfaction among higher‐skilled urologists, who could then focus on patients with more complicated needs. Robert H. Brook, a physician and researcher at the RAND Corporation, argues that colonoscopies (a common screening for cancer) do not require a fully trained gastroenterologist, nor does routine cataract surgery require a fully credentialed ophthalmologist. Instead, Brook suggests that two years of focused education and training would yield professionals qualified to perform these procedures, vastly expanding patients’ access to these services.
Right‐skilling could reduce the cost of bone marrow biopsies, tooth extractions, and countless other services.
Government regulation prevents right‐skilling. The central feature of the U.S. system for educating and certifying health professionals is direct government licensing. Under this system, clinicians must receive a license from each state in which they practice. Each state government therefore determines what categories of clinicians may exist in that state and the range of services each category of clinician may provide (i.e., the clinician’s “scope of practice”).
Right‐skilling does occasionally occur despite government licensing. In 2019, Indiana expanded the scopes of practice of emergency medical responders (to include administering flexible nasopharyngeal tubes into patients with obstructed upper airways, using pulse oximetry to measure blood‐oxygen levels, and administering oral glucose to patients with low blood sugar), emergency medical technicians (to include administering continuous positive airway pressure ventilatory assistance, nebulized bronchodilators, beta agonists, and anticholinergics to patients who are struggling to breathe; monitoring and interpreting end‐tidal carbon dioxide for patients with excess carbon dioxide in their lungs; and administering over‐the‐counter pain medication), and advanced emergency medical technicians (to include all of the above plus additional medications, including additional pain medications).
In 2020, unrelated to the COVID-19 pandemic, Florida removed barriers to pharmacists administering flu vaccines. As these examples suggest, right‐skilling takes place largely at the margins of health care.
As a rule, direct government licensing operates as if its purpose is to prevent right‐skilling. Licensing creates opportunities for incumbent clinicians to influence the rules for entering their profession and the scopes of practice of competing professions. Since competition from lower‐cost clinicians and ways of delivering care threatens the incomes of incumbents, incumbent clinicians lobby state governments in favor of licensing and scope‐of‐practice rules that preserve their incomes by blocking such competition.
Direct government licensing does little if anything to improve the quality of care, but it consistently increases prices and reduces access by imposing excessive training requirements, preventing clinicians from providing services they are competent to provide, blocking new categories of clinicians, and blocking alternative paths to certification.
As an alternative to direct government licensing, states could instead recognize third‐party accrediting organizations that would certify the competence of individual clinicians, much like private specialty boards do. Third‐party accrediting organizations could create new categories of clinicians and impose only such education and training requirements as have value to consumers, clinicians, and their employers. They could create alternative, competence‐based paths to certification, rather than require clinicians to fulfill unnecessary or unnecessarily formal education requirements. A system of third‐party certification could reduce existing regulatory constraints, improve access to care for patients, and improve labor‐market opportunities for health professionals.
In particular, it could make the medical workforce and medical education more flexible and better able to respond to public health emergencies such as the COVID-19 pandemic. Such certification organizations already exist and could take the place of direct government licensing.
Right‐Skilling vs. Wrong‐Skilling
Education and training are essential for providing quality health services. Maximizing access to quality health care requires right‐skilling (i.e., striking a balance between too little and too much education and training). Requiring clinicians to receive more education and training than is necessary to do their jobs is wrong-skilling, which harms clinicians by unnecessarily restricting employment opportunities and harms patients by reducing access to care.
Consider nursing. Aspiring nurses can become state‐licensed registered nurses (RNs) after obtaining either a two‐year associate’s degree in nursing or a four‐year bachelor of science in nursing (BSN). In 2017, the New York legislature passed a law requiring all nurses to obtain a BSN within 10 years of initial licensure.
To determine whether it is in the interest of patients to require all nurses to obtain a four‐year BSN, the relevant question is not whether requiring all RNs to obtain a BSN produces benefits. Even if an additional increment of education or training could deliver some benefits to patients, that is not enough to justify requiring clinicians to undertake the additional time and expense required to receive that training. If it were, nurses would not exist—states would require all clinicians to obtain an MD plus board certification in their chosen specialty. The relevant question is whether any added benefits exceed the added costs that those requirements impose in terms of reduced employment opportunities, higher health care prices, and reduced access.
Mandating that every RN receive the additional education and training associated with obtaining a BSN is an example of wrong‐skilling, since not all RN jobs require the additional training that a BSN provides. It is conceptually akin to requiring all health professionals to be board‐certified MDs. A BSN requirement harms workers by increasing the cost of nursing education and restricting entry into the nursing profession. It harms patients by reducing the supply of nurses, increasing prices for nursing services, and reducing access to care.
Right‐skilling requires policymakers to develop rules that free medical educators and health care providers to experiment with flexible education and training requirements to strike the proper balance between too little and too much training.
Direct Government Licensing
Government licensing consistently fails the right‐skilling test. It allows incumbent clinicians to control the education and training requirements for entry into their professions and the ability of other health professionals to compete with them. Incumbent clinicians use these powers to block entrants into their professions, to block other categories of clinicians from entering the markets for certain services they are competent to provide, and to block innovative education and training programs that could reduce entry barriers into their professions and competing professions.
Direct government licensing of clinicians thereby requires patients to pay higher prices than are necessary to receive care from clinicians who have more training than is necessary. From the perspective of clinicians, the resulting unnecessary requirements prevent competent individuals from entering the health professions; legislatively determined scopes of practice prevent clinicians from providing services they are competent to provide; and rigid systems of education and training saddle clinicians with unnecessarily high levels of educational debt.
Incumbent Control
Direct government licensing gives state politicians the final word on allowable categories of clinicians, the education and training requirements for each category, and the range of services each category of clinician may perform. When the political system controls medical education and market entry in this manner, it creates opportunities for members of the regulated professions to enact barriers to lower‐cost competitors.
At first glance, such incentives may seem beneficial. The self‐interest of incumbent clinicians, who form a powerful political constituency, will motivate them to lobby to increase the levels of education and training that workers must receive to enter the health professions, and those higher standards will protect patients. The problem is, it is also in the self‐interest of incumbent clinicians to bar market entry by lower‐cost competitors whose clinical skills are of equal or higher quality, because those clinicians could take market share from incumbents. Indeed, incumbents have relatively little incentive to seek government protection from inadequately trained competitors because market competition and the medical malpractice liability system (see the “What about Quality?” section) will themselves punish low‐quality providers.
The presumed experts on matters of medical education and training—incumbent clinicians and especially physicians—therefore have a stark conflict of interest. Incumbents’ incentives are primarily to demand excessive restrictions on the creation of new clinician categories, educational requirements for entrants into their professions and competing professions, and restrictions on the scopes of practice of competing professions. Incumbents face incentives even to demand restrictions that reduce patients’ access to care, because such restrictions keep incumbent incomes artificially high.
Direct government licensing gives incumbents the ability to impose such restrictions. Since most politicians have no relevant expertise when it comes to health workforce issues, they typically cede control of these decisions to the regulated professions (i.e., to the very incumbent clinicians who face those stark conflicts of interest). States uniformly recognize organizations run by incumbent clinicians as the sole accreditors of education and training programs for their professions. State medical boards require all physicians to graduate from programs accredited by either the Liaison Committee on Medical Education—an organ of the American Medical Association (the AMA, which represents incumbent MDs) and the Association of American Medical Colleges—or the Commission on Osteopathic College Accreditation—an organ of the American Osteopathic Association, which represents incumbent doctors of osteopathy.
The American Dental Association, the American Occupational Therapy Association, the American Optometric Association, the American Physical Therapy Association, the American Podiatric Medical Association, the American Psychological Association, and the American Speech‐Language‐Hearing Association all control accreditation of the training programs that in turn control entry into their professions.
Since state licensing boards recognize profession‐controlled national accrediting organizations as sole accreditors, those groups control both curriculum and the number of accredited programs that are the sole path into their respective professions. That power allows those groups to limit competition from entrants both directly, by limiting the supply of entrants (e.g., by limiting the number of schools or their capacity), and indirectly, by imposing unnecessary educational requirements that make entry cost‐prohibitive for many would‐be competitors. Control over curriculum further allows incumbents to stifle innovations in education and training that might otherwise increase competition and access to quality services.
Economists have long warned against allowing incumbents to control accreditation of education and training programs for their professions. In 1977, the Federal Trade Commission (FTC) warned of the “inherent conflict of interest” in allowing the Liaison Committee to accredit medical schools. The FTC suggested shifting accreditation to groups independent of the AMA and with wider representation.
Blocking Competition from Entrants
Examples of incumbent clinicians using licensing to enact high barriers to entry into their professions include New York’s BSN‐in‐10 law. The American Nursing Association (ANA), which represents incumbent nurses, has advocated since 1965 a legal requirement that all RNs obtain a BSN. New York enacted the law at the behest of the ANA‐affiliated New York State Nurses Association. Other examples include dentists lobbying state legislatures to block the creation of “dental therapists,” who compete with dentists in more than 50 countries to offer lower‐cost oral examinations and routine fillings and extractions.
They include recent requirements that entrants into the markets for audiology and physical therapy services must all earn clinical doctorates—despite the fact that many tasks these clinicians perform do not require such intensive and expensive training. The Accreditation Council for Pharmacy Education, the sole organization that accredits pharmacy schools in the United States, also requires a clinical doctorate as its entry‐level degree. Groups representing incumbent advanced practice nurses have set a long‐term goal of requiring a clinical doctorate for entry into those professions.
A clinical doctorate is not something every pharmacist or advanced practice nurse needs. Whether a clinical doctorate is appropriate depends on the services a clinician will provide. Dampening competition by requiring a clinical doctorate raises barriers to entry into the profession and keeps wages artificially high for incumbent clinicians, who typically receive exemptions from the new requirements.
Physical therapy illustrates how imposing additional educational requirements limits upward mobility for individual clinicians. Physical therapist assistants must earn a two‐year associate’s degree. In the past, when licensed physical therapists needed to complete only a four‐year baccalaureate program, physical therapist assistants who wished to become physical therapists could enter “bridge” programs that would apply some of their two‐year associate’s degree credits toward a four‐year baccalaureate degree. Today, all 50 states, the District of Columbia, and two U.S. territories require licensed physical therapists to obtain a doctorate in physical therapy. Not only does this requirement mean physical therapist assistants must pay for three to four more years of school, but it also prevents them from applying any of their associate’s degree coursework toward that graduate‐level degree.
Requiring that all entrants into a profession obtain the highest, most expensive, and most time‐consuming degree available (e.g., a doctorate) leaves health care providers no room for right‐skilling based on potential job roles. Consider audiology. Several groups representing incumbent audiologists set up the Accreditation Commission for Audiology Education in 2002 to advocate for the doctoral requirement and to accredit doctor of audiology degree programs. By the end of 2006, all master’s degree programs in audiology in the United States had closed.
The requirements for a doctorate illustrate that direct government licensing produces entry barriers that have nothing to do with improving the quality of care. The Liaison Committee requires medical school applicants to take undergraduate courses in the liberal arts, such as history, literature, and the social sciences. By itself, this requirement raises the question of whether the Liaison Committee’s curriculum requirements exist to ensure high‐quality medicine or to protect the incomes of incumbent clinicians by raising barriers to entry into the profession.
Blocking Competition from Other Health Professions
In addition to using licensing to block competition from would‐be entrants into their professions, incumbent clinicians use it to block competition from other types of clinicians. The Department of Justice reports, “Professional associations and individual providers have used a variety of strategies to limit entry by potential competitors and prevent unbundling and de‐skilling of the services that they provide.”
Lobbyists representing each health profession seek to expand their own members’ scopes of practice, which expands the potential market for those clinicians’ services. But they also lobby to reduce the range of services that other categories of clinicians can perform, because such limits reduce competition for their professions—albeit at the cost of increasing prices and reducing access. The current system effectively vests “one type of professional with gatekeeping power over another.”
Direct government licensing therefore requires state lawmakers to arbitrate countless and contentious scope‐of‐practice decisions that they lack the expertise to adjudicate. Such decisions include whether states should allow the following: NPs to practice without physician supervision; NPs to perform bone marrow aspirations, chest tube placements, lumbar punctures, colonoscopies, colposcopies, breast biopsies, and vasectomies; pharmacists to administer vaccines or prescribe birth control; or oral and maxillofacial surgeons to perform elective facelifts, rhinoplasties, and eyelifts.
Opposing groups of medical professionals spend considerable resources on lobbying to influence the outcome of these decisions. The Texas Podiatric Medical Association spent over $1 million between 2001 and 2010 lobbying the state to let Texas podiatrists treat patients’ ankles. Texas medical and orthopedic associations waged a “massive and well‐funded” lobbying campaign to block the proposal. Nurses likewise resist right‐skilling services they provide. Nurses unions complain that “the hospital industry is trying to expand the scope of nurse’s aides and medical assistants.”
Government licensing resolves such decisions in favor of the group with the most political clout. A salient example is the perennial and ongoing battles between physicians and NPs over the latter’s scope of practice. Twenty‐two states, the District of Columbia, and two U.S. territories allow NPs to practice independently. In these states, NPs may evaluate, diagnose, and treat patients—including prescribing controlled substances—on their own authority. Research indicates that allowing NPs to practice independently increases access to care (especially for children), reduces emergency‐room visits, and makes care more convenient and understandable.
Studies examining intensive and acute care settings find an association between use of NPs and physician assistants and improved outcomes.
The remaining states and territories limit their NPs’ scopes of practice by prohibiting them from providing one or more of those services unless they do so in collaboration with a physician. Physicians typically charge $5,000 to $15,000 annually for such supervision arrangements. The AMA boasts that in 2019, its lobbying efforts blocked more than 50 attempts to expand scopes of practice for midlevel clinicians in various states, including efforts in nine states to let NPs practice independently. “Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals,” the AMA writes. “Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.”
According to the Brookings Institution, however, “the academic literature finds no evidence of harm to patients associated with less‐restrictive [scope of practice] laws” and therefore no evidence of benefit associated with the more‐restrictive laws.Yet 28 states and 3 U.S. territories continue to restrict NPs’ scopes of practice, to require NPs to make such payments to physicians, and to reduce access to medical care, for no apparent benefit.
Politics has always dominated government efforts to license clinicians. In 1994, Yale Law School lecturer and associate dean Barbara Safriet wrote:
Whatever may be true of licensure’s fundamental efficacy, one thing is clear: many licensure and statutory scope of practice laws governing non‐physician providers include unwarranted provisions that erect unnecessary barriers to the full utilization of these demonstrably competent professionals. The eradication of these barriers is essential to fundamental health care reform.
In 2011, the authors of The Future of Nursing wrote, “What nurse practitioners are able to do once they graduate varies widely for reasons that are related not to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work.”
In February 2020, a group of health workforce researchers wrote, “Policymakers are increasingly recognizing that differences in state laws and in the ways in which organizations deploy their workforces aren’t based on evidence regarding quality of care or safety. Rather, state laws and organizational policies are informed by lobbying by professional associations that jockey to impose their self‐interested views.”
Blocking Competition from New Education and Training Programs
Direct government licensing allows incumbents to block innovative and lower‐cost education and training programs, which has contributed to the stagnation of medical education. In effect, the Liaison Committee’s accreditation requirements mean that becoming a physician typically takes a decade or more. Aspiring physicians must generally spend eight years in school—four as an undergraduate and four in medical school—and then at least three additional years in a residency program. The high and rising cost of medical education has spurred some schools to find ways to shorten the time to graduation. Some programs integrate bachelor’s degree studies with medical school, allowing candidates to complete medical school in less than the standard eight years.
In 2014, California enacted a law to allow students at accredited medical schools to complete their medical education in three years, offering an alternative track for students “who demonstrate a high level of scientific and medical understanding” in the hope of “churn[ing] quality doctors out faster and with less student debt.” A third of medical schools are reportedly considering creating three‐year MD programs.
Notwithstanding these efforts, medical education remains extremely rigid. Leslie Fall, a medical‐education entrepreneur and adjunct professor at Dartmouth University’s Geisel School of Medicine, wrote in 2017, “Despite a flurry of curricular reforms in the past 10 years medical school has changed little over the last century.” The problem, according to former Harvard Medical School dean Jeffrey Flier, is that “the current high‐stakes accreditation process does not invite the kind of large‐scale experimentation that could lead to improvement.”
The rigidity goes beyond the formal requirements for entry into the profession. As early as the 1970s, Duke University law professor Clark Havighurst noted that the Liaison Committee’s control of medical education imposes a strict ideology within the medical profession:
The educational system subtly shapes such important aspects of medical practice as the balance between scientific and clinical skills, the relative emphasis on primary and acute care, and physicians’ tolerance for and skill in economizing. By limiting educational diversity, professional interests in medicine, as in other professional fields, successfully prevented the emergence of different traditions and of different types of professionals who might have served the consumer better.
Andrew Gavil and Tara Isa Koslov explain, “Regulation can create, promote, and reinforce a sense of normalcy around a particular hierarchy of professionals” and “perpetuate an approach that has become dated.” Legacy regulations “tend to entrench a specific business model and can forestall the development of new business models, even when not designed to do so intentionally,” thereby “embed[ding] that model as the only approach that can satisfy the regulations’ requirements.”
The accreditation requirements that grow from direct government licensing preclude alternative paths to clinical practice. They block, for example, the development of new programs that could allow individual clinicians’ scopes of practice to evolve over time and beyond traditional professional‐degree boundaries. As a result, licensing inhibits innovations in medical education that could reduce the cost of quality health services.
COVID-19 Exposes Licensing as a Barrier to Access
The COVID-19 pandemic has forced federal and state policymakers, Republicans and Democrats, to acknowledge that clinician‐licensing laws block access to care.
In a March 24, 2020, letter to governors, Secretary of Health and Human Services Alex Azar urged states “to extend the capacity of the health care workforce to address the pandemic.” The recommendations included removing barriers to right‐skilling: “relax scope of practice requirements for health care professionals, including allowing professionals to practice in all settings of care … [and] any requirements for written supervision or collaboration agreements”; “allow physicians to supervise a greater number of health care professionals”; and “modify laws or regulations to allow medical students to conduct triage, diagnose, and treat patients under the supervision of licensed medical staff.”
In anticipation of a surge of COVID-19 patients, state officials took numerous steps to remove barriers to right‐skilling. Several states allowed medical and nursing students and recent graduates to perform services they are competent to provide and/or made education requirements in those programs less restrictive. Some states expedited the graduation of medical and/or nursing students (e.g., Alaska, Louisiana, Rhode Island). Some granted temporary licenses to medical residents and/or nursing students (e.g., Arkansas, California, Pennsylvania, Rhode Island). Some allowed certain medical and nursing students to provide services without a license (e.g., Delaware, Kentucky, Minnesota, New York).
(The British National Health Service likewise deployed medical students to cope with the crisis.)
Some U.S. states expedited the licensing process for recent graduates of pharmacy, physician assistant, and respiratory care programs (e.g., Indiana, Iowa) or nurse aide trainees (Oklahoma). Kentucky provided provisional licenses for certain licensing exam applicants. Iowa, Michigan, and other states allowed nursing schools to replace actual clinical experience with simulated clinical interactions. Wisconsin allowed nurse aide training programs to reduce the number of required training hours and allowed new RNs to conduct such training.
At least one state, Wyoming, allowed nursing schools to make sweeping changes to their curricula. “At present there is no need to present substantive changes to the Wyoming State Board of Nursing,” the board wrote to nursing school program directors. “We trust your programs will seek innovative ways to reach student learning outcomes.” In addition to allowing nursing students in their senior year to work with a temporary license prior to graduation, Idaho created a new nurse apprentice program to allow “nursing students [to] perform functions as unlicensed assistive personnel” in which their employers would determine their scope of practice based on each apprentice’s training and skills.
Several states significantly expanded scopes of practice for various clinicians. Of the 28 states that prohibit NPs from practicing independently, 5 (Kentucky, Louisiana, New Jersey, New York, and Wisconsin) completely suspended such barriers, and 16 partially suspended them. Many of these suspensions expanded NPs’ authority to write prescriptions. New Jersey Gov. Philip D. Murphy, a Democrat who suspended his state’s restrictions on advanced practice nurses and physician assistants practicing independently, those clinicians prescribing controlled substances, and the tasks physician assistants may perform in operating rooms, wrote:
It is in the public interest to expand the scope of practice of those health care professionals who under current law practice with individualized physician oversight, so that they can be deployed to meet the anticipated needs with more autonomy, greater agility, and with all necessary tools, including independent authority to prescribe controlled dangerous substances when appropriate.
New York expanded scopes of practice to let nurse anesthetists, physician assistants, and specialist assistants practice independently; to let pharmacy technicians help pharmacists compound, prepare, label, and dispense drugs for home infusion providers; and to increase the number of providers who can supervise emergency medical services personnel.
Alabama expanded scopes of practice for NPs, nurse midwives, nurse anesthetists, physician assistants, and anesthesia assistants, freeing them to “practice to the full scope of their practice as determined by their education, training, and current national certification(s).”
Colorado expanded scopes of practice for a host of health professionals (podiatrists, optometrists, chiropractors, veterinarians, dentists, physical therapists, physical therapy assistants, occupational therapists, occupational therapy assistants, speech‐language pathologists, surgical assistants, surgical technologists, volunteer retired nurses, and nurse aides) as well as (unlicensed) nursing students and medical assistants by allowing NPs and nurse anesthetists to delegate tasks to them.
States including California, Maryland, and North Dakota allowed pharmacists to order and collect specimens for COVID-19 tests. States including Florida and Nebraska expanded scopes of practice for emergency medical technicians. Massachusetts Gov. Charlie Baker, a Republican, suspended that state’s physician‐supervision requirements and restrictions on prescriptive authority for advanced practice nurses with more than two years of experience. Michigan Gov. Gretchen Whitmer, a Democrat, suspended the state’s licensing laws to allow all hospitals, nursing homes, surgical centers, hospice practices and facilities, emergency or other medical transport companies, and other health care facilities to ignore Michigan’s licensing, scope of practice, and physician‐supervision restrictions and decide for themselves how to use every health professional and student, paid or volunteer, that they can find. Maryland implemented a similar waiver with respect to health care facilities. Whitmer explicitly suspended physician‐supervision requirements for NPs and physician assistants and allowed RNs and licensed practical nurses to order COVID-19 tests.
States took other steps that did not directly affect right‐skilling but removed other barriers to care that licensing creates. Most states—including New Jersey and New York—suspended prohibitions on clinicians in other states providing care to their residents, whether in person or via telemedicine, either outright or by way of conditional waivers that require registration or an emergency license.
Several states removed barriers to clinicians providing care after they retired or otherwise allowed their licenses to lapse. A few states temporarily reduced the barriers to entry for doctors already licensed in foreign countries. New Jersey’s Gov. Murphy allowed such doctors to practice in that state without a license if they had practiced in other countries within the past five years and worked in clinics or hospitals for at least five years. New York and Massachusetts did not suspend their requirements that foreign‐trained doctors obtain licenses from those states. But Massachusetts’s Gov. Baker, a Republican, and New York Gov. Andrew Cuomo, a Democrat, issued executive orders that reduced for such doctors the number of required years of graduate medical education to two years and one year, respectively.
Incumbent clinicians resisted the removal of barriers to right‐skilling.
Virginia Gov. Ralph Northam, a Democrat, temporarily allowed out‐of‐state NPs to practice in Virginia and suspended physician‐supervision requirements for NPs who have more than two years of clinical experience. The Medical Society of Virginia—which lobbies on behalf of Virginia physicians—complained that Northam did not consult them before “needlessly” taking these steps.
The organization asked Northam to protect physicians from competition by allowing the waivers to expire, to subsidize physicians, and to provide physicians protection from malpractice liability.
California’s physician lobby loomed large over that state’s pandemic response. The Healthforce Center at the University of California, San Francisco recommended the state expand its health sector capacity by letting NPs and nurse midwives practice independently; allowing hospitals to grant those nurses admitting privileges; and expanding the scopes of practice of certified nursing assistants, licensed vocational nurses, clinical nurse specialists, phlebotomists, medical laboratory technicians, clinical laboratory scientists, and paramedics.
Instead, California Gov. Gavin Newsom, a Democrat, delegated such questions to executive‐branch agencies. The state’s Department of Consumer Affairs refused to allow NPs to practice independently and instead increased the number of NPs each physician could supervise. Critics argued that the change would have little effect. “It’s unclear how this is helping anybody,” said Garrett Chan, CEO of HealthImpact, which advocates for a broader role for nurses in delivering care.
Unlike states that took the initiative to expand scopes of practice for emergency medical personnel, California’s Emergency Medical Services Authority merely agreed to entertain such proposals from localities. Critics attribute California’s relatively tepid measures to the influence of the state’s physician lobby, which “contributed almost $6 million to candidates, political action committees, and other campaigns since mid‐January 2019.”
State government responses to COVID-19 mirror temporary removals of barriers to right‐skilling that governments have implemented during past pandemics. During the 1918 influenza epidemic, Spain sent medical students to practice in towns that lacked physicians. In 2009, many U.S. states responded to the H1N1 influenza outbreak by removing barriers to pharmacists, emergency medical technicians, dental hygienists, medical and nursing students, veterinarians, and other clinicians administering vaccines. Some states have shown an increasing willingness to suspend scope‐of‐practice restrictions to cope with predictable disease outbreaks. In response to the 2013 and 2018 flu seasons, for example, New York’s Gov. Cuomo issued executive orders removing barriers to pharmacists administering flu vaccines.
When public health crises become widespread enough, policymakers readily acknowledge that clinician licensing creates barriers to health care and suspend or discard many of those barriers—sometimes without so much as a nod to the incumbent clinicians who advocate maintaining them. When the public health crises end, however, incumbent clinicians again have their way. The scope‐of‐practice waivers that states implemented in response to Hurricane Katrina, the H1N1 flu outbreak, the 2013 and 2018 flu seasons, and other public health emergencies expired when those emergencies ended. The barriers to care returned, even though many individual health crises remained.
An Alternative: Flexible Education and Credentialing
A system of third‐party certification could deliver lasting reform by insulating such decisions from political influence by incumbent clinicians. Such a system could allow innovative alternative career paths and paths to clinician certification, reduce unnecessary training requirements, and reduce the cost of most health care services.
In such a system, states would not directly license individual clinicians, determine which clinician categories could exist, or delineate scopes of practice. Instead, states would rely upon third‐party private and public organizations to accredit education, training, and certification programs that would perform these functions. To identify reliable accrediting organizations, states could piggyback on the efforts of the Department of Education and the Council for Higher Education Accreditation. Each engages in periodic reviews of organizations that accredit institutions and programs of higher education in the United States.
In addition, states could rely on the National Commission for Certifying Agencies (NCCA) and similar organizations that may arise to accredit nonacademic credential programs. For example, the NCCA accredits specialty certification organizations such as the Oncology Nursing Certification Corporation, which offers certificates that attest to specific knowledge related to the treatment of cancer patients.
Degree‐ or certificate‐issuing organizations would determine the categories of clinicians they would certify, including new categories (e.g., dental therapists, primary care technicians, community paramedics, and assistant physicians), and the education requirements and scopes of practice for each category.
Today, “most health workforce models have taken a silo‐based approach that assumes that each health profession has an exclusive and fixed scope of practice.” In a system with greater flexibility, innovative programs would add new categories of clinicians, offer clinicians an option to expand their scopes of practice incrementally, support nontraditional career paths that rely less on formal education and more on demonstrated clinical competence, or offer quicker and affordable paths for immigrant physicians to practice. The number and shape of such programs would depend on demand from patients, clinicians, and clinicians’ employers.
In addition to verifying credentials, states could choose to maintain lists of all health care workers practicing in the state, indicating their certified scopes of practice. Alternatively, states could use various tools to make clinicians’ credentials accessible to employers and consumers. Options include Credential Engine’s planned online Credential Registry or similar services. Blockchain technology, such as the Learning Machine credential‐verification system that the Federation of State Medical Boards uses, can provide state agencies, employers, and patients with secure, immediately verifiable access to a clinician’s certifications.
Employers could use those resources to screen applicants based on their training, experience, and credentials. Adding a “verified” symbol to a clinician’s record could demonstrate that the clinician has various credentials, malpractice insurance, or hospital privileges or that the clinician belongs to particular health insurance networks. Malpractice insurance and hospital privileges would indicate that competent and legally liable entities have also evaluated clinicians and the organizations that certified their skills.
New educational programs would determine their own and often innovative methods for assessing relevant knowledge and skills. Certificate programs could choose to recognize prior clinical experience, such as that of military medics or emergency medical technicians.
Some certification organizations might offer incremental or stackable credentials, allowing individuals to add skills as they progress in their careers. Programs could train and credential entirely new classes of clinicians, offering new certificates for specific skills. These might include programs to train clinicians specifically to perform discrete procedures such as vasectomies, cataract surgery, and colonoscopies.
Unlike today, new categories of clinicians and new approaches to medical education would not encounter political obstacles on the path toward recognition. Recognition would move forward if employers, health insurance networks, malpractice insurers, and patients find a credential valuable and reliable. Clinicians could practice to the top of their training.
In contrast to today’s monopolistic, incumbent‐controlled approach, which imposes unnecessary education and training requirements that reduce access to care, a competitive system would free clinicians and (liable) employers to rely on programs that right‐skill health services. The potential for such competition would discourage accrediting organizations from either unnecessarily limiting entry or certifying clinicians with too little training.
Innovative Education and Certification
A shift from licensure to third‐party certification could reshape health professions and health care for the better. Reformers have offered many ideas for streamlining medical education; expanding scopes of practice for nonphysician clinicians; innovative alternative approaches to educating health professionals; and allowing clinicians to add to their knowledge and skills over time. Clinicians and academics have proposed establishing new categories of medical professionals. The Blue Ribbon Commission for the Advancement of Osteopathic Medical Education has proposed a competence‐based “New Pathway” to address “inefficiencies inherent in traditional, time‐based educational models.”
Health systems like Kaiser Permanente could develop systems of education and certification based on their patients’ needs.
Removing these decisions from the political process would permit these reforms to proceed simultaneously. The entities that make the rules governing clinicians’ scopes of practice would no longer be competitors who have a financial interest in unnecessarily limiting those scopes of practice. They would be institutions that face incentives to limit scopes of practice only when necessary to avoid harm to patients. Consumers would not have to pay the price for politically motivated limits on innovative ways to improve access to quality care..... (to continue reading click here)
