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Mid-level providers are moving on up

Study shows that states are increasing power and decreasing oversight for mid-levels.

Over the past several decades, there has been a dire need for primary care services across the United States, especially in rural and poor urban settings. This need has increased dramatically with more citizens insured through the . Mid-level providers such as nurse practitioners (NPs) and physician assistants (PAs) have been utilized more recently within the past several decades to address the immediate and critical shortage of primary care providers. Over the past decade, mid-level providers have seen significant changes in their scope of practice as regulated by state laws. A new study in Medical Care Research and Review evaluated the changes in regulations on the scope of practice and educational requirements for mid-level providers in various states.

Source: DIBP images

Source: DIBP images

The study examined data on state NP and PA regulations from the Pearson Report and the State Regulation of Physician Assistant Practice report between 2001 and 2010. This included information on entry-to-practice qualifications, physician involvement in treatment and diagnosis, and the authority to prescribe medications.

Ten states loosened physician involvement requirements for NPs. Eight states went as far as to relieve NPs from physician involvement in treatment and diagnosis at all. While several states gave PAs the authority to prescribe medication, none changed the level of physician involvement in treatment and diagnosis.

The researchers found that though state-level regulations vary widely regarding regulation of NP and PA practice, overall state laws expanded mid-level provider responsibilities. Additionally, their educational and training requirements also became more stringent.

Although mid-level providers have a needed and respected role in the nation’s health care delivery system, viewing these providers as (PCPs) is dangerous. The role of PCPs remains critical and unparalleled within the nation’s health care system especially in medically underserved communities. PCPs in these communities must care for patients with more acute and complex disease processes without the availability of subspecialties within close proximity. These physicians are typically more equipped to handle more complex patients based on their extensive training.

commentary by Tyree Winters, DO


Nurse practitioners and physician assistants can alleviate some of the primary care shortage facing the United States, but their scope-of-practice is limited by state regulation. This study reports both cross-sectional and longitudinal trends in state scope-of-practice regulations for nurse practitioners and physician assistants over a 10-year period. Regulations from 2001 to 2010 were compiled and described with respect to entry-to-practice standards, physician involvement in treatment/diagnosis, prescriptive authority, and controlled substances. Findings indicate that most states loosened regulations, granting greater autonomy to nurse practitioners and physician assistants, particularly with respect to prescriptive authority and physician involvement in treatment and diagnosis. Many states also increased barriers to entry, requiring high levels of education before entering practice. Knowledge of state trends in nurse practitioner and physician assistant regulation should inform current efforts to standardize scope-of-practice nationally. PMID: 25542195.

Gadbois EA et al. Med Care Res Rev. 2015; 72(2): 200-19.

Tyree Winters, DO
About Tyree Winters, DO

Lead Analyst – Continuity of Care & The Workforce Dr. Winters has contributed to Policy Prescriptions® since 2010. He received a Bachelor of Arts in Psychology from University of Michigan-Dearborn and completed his medical education at Ohio University College of Osteopathic Medicine. Dr. Winters completed a pediatric residency from Nationwide Children’s Hospital/Ohio State University Medical Center/Doctors West Hospital and is board certified in Pediatrics. He currently is an associate professor of pediatrics at the Ohio State University College of Medicine. Dr. Winters originally hails from Detroit, MI. Contact: Facebook | Twitter | More Posts