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Reforming and Improving the Efficiency of Health Care Delivery: Scope-of-Practice Wars

Ann Marie Marciarille:

Missouri State of Mind: Missouri's Scope of Practice Wars: Missouri… one of the most restrictive… scope of practice for APRNs (advance practice nurses)… greatly underserved by primary care practitioners (PCPs)…. [I]t might get much worse with the addition of a further 17 million Americans moving into insured status under the Affordable Care Act. If we are stressed to provide PCP services in rural Missouri under the status quo (where an estimated 13 counties have only a CRNA -- Certified Registered Nurse Anesthetist-- to provide anesthesia services) what will happen if we expand Medicaid?  Is this a reason not to expand Medicaid?

I sometimes hear this advanced as what I call the "we can't do it, so we shouldn't even try" argument, as if provider supply were immutable…. PCP supply is so tight -- the argument goes --  the whole system might collapse of its own weight if we further expand the pool of those seeking services. This argument in favor of a rationing system based on grandfathering in the previously insured leaves me non-plussed.  Yet, it is a argument with considerable purchase in some health care reform debate circles.  It is, after all, the thinking behind widely discussed proposals to repeal the ACA but retain the provisions extending family health insurance coverage to children of insured families until the age of 26. 

The rationale--accident of birth, consanguinity or affinity as a preference for insured status--seems to me to be close to arbitrary. The rationale for favoring employer-based health insurance is in rewarding valued employees, not their 25 year old married, independent tax status, employed elsewhere offspring….

Scope of practice regimens -- including Missouri's restrictive collaborative practice requirements restricting phsycians-CRNA collaboration to a 3:1 ratio--are not accidents of nature or, even, next best systems thrown together in a world of limited resources. They are programmatically designed to restrict the provision of  PCP services by APRNs in Missouri. This they do very well…. [W]e might best start by owning the problem and owning our own role in creating the problem.

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