How COVID reignited turf wars among doctors, nurses and other health workers

Who is allowed to care for patients? And when, where and how can they do it? Those questions have been the focus of more than 450 bills and 200 executive orders introduced in state capitols since COVID-19 hit.

“This is the wild west,” said Bianca Frogner, director of the University of Washington Center for Health Workforce Studies.

In the early days of the pandemic, lawmakers took bold measures, from calling nurses out of retirement to graduating medical students early.

“Every state was scrambling to get the people that [they needed],” Frogner said. “And they realized one way to solve this problem [was] to revisit some of these regulations.”

Those regulations, commonly known as scope of practice rules, define the limits for each health profession – the services they can provide, the licensing and oversight they require. Relaxing those rules offered lawmakers a fast lane to increasing workforce capacity.

But many of the emergency measures states enacted are now expiring. Legislators are debating which to make permanent and how else to bolster a COVID-weary workforce. Health professionals from pharmacists to physician assistants are jockeying to shape this next wave of workforce reforms.

Able to provide care, but forced to refer patients elsewhere

A recent legislative dust-up in Denver, Colorado, offers a lens into the drama playing out in state capitols across the country. Earlier this year, the Colorado House of Representatives considered HB1095, which would have enabled physician assistants, also known as physician associates or PAs, to practice more independently.

Like in many states, Colorado PAs currently have the power to diagnose, treat and prescribe — but only with oversight from a doctor. Advocates for more authority for PAs argued reducing those oversight requirements made sense in a state where 75 percent of counties are rural.

“On average, it can take anywhere from one to three years to recruit a physician to rural Colorado,” Kelly Erb of the Colorado Rural Health Center told lawmakers.

PAs like Susanna Storeng, who practices in a rural area, argued that current law overly restricts the scope of services physician assistants can provide.

“It’s crushing not to be able to do something you know you’re able to perform,” Storeng said in an interview.

Although Storeng is trained to place long-acting contraception like IUDs in patients, state law prohibits her from doing it. That’s because the physician who currently supervises her does not offer that service. Storeng estimated she refers roughly seven patients each month to other providers for contraceptive services.

Storeng worries often about one patient in particular — a young woman struggling with a methamphetamine addiction, desperate to avoid becoming pregnant. Storeng could have placed the contraceptive implant the patient wanted in under 20 minutes — as she had done at least 100 times for others under prior supervising physicians.

Instead, she had to schedule the patient an appointment with another provider. The patient never showed up.

“It just makes me feel helpless,” Storeng said.

Scope expansion efforts meet stiff resistance

Before a final House vote on HB1095, which would have allowed Storeng to provide the full scope of services she’s trained in, Colorado lawmakers engaged in nearly an hour of testy debate.

“To diminish what a PA does … is so unfair and it’s really disrespectful,” said Rep. Brianna Titone, chastising doctors who raised questions about the safety and quality of care that PAs might provide without supervision.

“There's a reason that doctors have to undergo almost 10 times as much clinical hours as a PA does,” argued Rep. Colin Larson.

That was a message echoed loudly — and with significant financial backing — by physician trade groups like the Colorado Medical Society. Researcher Frogner said the data do not support the safety concerns raised by some doctors, but they seemed to resonate nonetheless. Ultimately, HB1095 failed by seven votes.

Long-standing turf wars resurface

Nationwide, PA groups recently helped pass bills allowing their members to practice more independently in Wyoming and Utah, but they ran into resistance elsewhere — as have other professional groups. Only about one-third of the scope of practice bills introduced in the last two years have been enacted, according to a National Conference of State Legislatures database. The American Medical Association takes credit for working in 25 states this year to stop nurses, PAs and other providers from gaining more authority.

These types of turf wars among health professions have raged for decades — often between occupations with less training and lower pay and their more powerful counterparts. The controversies are resurfacing as lawmakers look for solutions to the workforce woes that COVID highlighted and, in many cases, worsened. Professional groups are essentially competing for that business, arguing their members can meet states’ needs better, faster and in some cases, more cheaply.

Even if more laws like HB1095 succeed, data suggest they may have limited impact. One study of a Massachusetts emergency order waiving supervision requirements for some nurses found that 75 percent of nurses surveyed felt the measure had not improved their work environment. Experts point to employer policies and health insurer reimbursement rules as other important levers.

A problem of national concern

Most alarming to Frogner, though, is the dizzying number of different ways states are approaching these scope of practice issues. It’s a sign, she said, of a fundamental flaw in how the U.S. regulates its health workforce.

“What health care workers can do is really decided at a state level,” she said.

The lack of overarching federal regulations and coordination, said Frogner, makes it hard to get workers where they are needed most, especially during a crisis like COVID. Inconsistent state laws, she said, also contribute to wide geographic variations in the quality and cost of care that people receive.

“We need more strategic planning happening at a national level,” Frogner said.

She said COVID could still force lawmakers to take more national action sooner than later: “The pandemic is slowing down, but it's not over.”

This story comes from the health policy podcast Tradeoffs, a partner of Side Effects Public Media. Dan Gorenstein is Tradeoffs’ executive editor, and Leslie Walker is a reporter/producer for the show, which ran this story on October 13. Tradeoffs' coverage of the impact of COVID on the U.S. health care system is supported, in part, by the National Institute for Health Care Management Foundation.

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