Background
Licensing: Oversight by licensing boards ensures compliance with professional standards. To ensure practitioners’ competence and facilitate the credentialing process, state licensing boards (as well as state and federal enforcement agencies, professional societies, and health care providers) report medical malpractice payments and adverse fraud and abuse actions taken against licensed health care providers, practitioners, and suppliers. Adverse actions include criminal convictions, civil judgments, program exclusions, and adverse licensing and certification actions. These reports are made available through two limited-access practitioner databases to federal and state government agencies, state licensure boards, Medicare contractors, health plans, and health care providers. The Affordable Care Act consolidated these two databases into the National Practitioner Data Bank. However, the data are not available to the public.
Effective workforce policy also ensures that state and federal regulations support all clinicians’ ability to provide care to the fullest extent of their education and training. Because licensure is state-based, the scope of practice varies widely across the country for all health professions other than physicians. The lack of uniformity in health professionals’ scope of practice across states creates barriers to both professional mobility and access to care, especially in delivery systems that operate in more than one state.
Specifically, practice boundaries for health care professionals are defined and enforced through professional credentialing boards, state licensing laws, and scope-of-practice laws. A “scope of practice” defines the authority given by the state to the various types of health professionals who practice there. In effect, through scope-of-practice definitions, the state creates boundaries between professions and allocates exclusive domains of control over the delivery of certain services.
For example, nurse practitioners and other types of Advanced Practice Registered Nurses (APRNs) are highly educated and qualified clinicians with the potential to ease the provider shortage. Fully utilizing APRNs would increase consumer access to health care and reduce unnecessary health care costs. However, consumers in 28 states have limited access to nurse practitioners due to state laws that prevent these clinicians from working to the full extent of their education and training. That training has fully prepared these nurses to serve consumers in the other 22 states and the District of Columbia.
These barriers often delay care to consumers, especially in rural and urban underserved areas where few clinicians are available to meet patient needs. Delays in care not only hurt consumers but also place added stress on family caregivers, who are often overwhelmed with providing and overseeing the care of a loved one. APRNs can provide consumers and their caregivers with access to convenient, cost-effective, and high-quality care. The Institute of Medicine’s October 2010 report, The Future of Nursing: Leading Change, Advancing Health, to remove scope-of-practice barriers contains many important recommendations (The Institute of Medicine changed its name to the National Academy of Medicine in 2015).
Many of the problems related to various scopes of practice result from a patchwork of state regulatory regimes. The federal government is well situated to promote effective reform by collecting and disseminating best practices from across the country and creating incentives for their adoption.
Interest in using health professionals in more flexible ways is growing as emerging models of health care delivery seek to improve coordination and efficiency. For example, evidence indicates that dental therapists in independent practice provide safe, competent care that is comparable to that provided by dentists. Allowing dental therapists to provide the full array of services for which they are qualified based on their education and training could help alleviate care gaps in areas with little or no access to oral health care.
Maine, Minnesota, and Vermont and tribal lands in Alaska, Oregon, and Washington state utilize dental therapists to provide basic dental services, such as fillings and extractions. Other states are also considering doing so. The services they provide have been rigorously evaluated and found to be safe and of a quality comparable to that of licensed dentists. Allowing these practitioners to work in areas currently underserved by dentists—particularly in geographically isolated and rural areas—will enable many people, including older adults, to obtain high-quality oral health care.
Direct-care workers such as certified nurse aides are also essential members of the health care workforce, particularly in long-term care settings. Efforts to broaden the scope of their clinical responsibilities—for example, by training them as certified medication aides—are ongoing. They can play an important role in new care models, and career mobility is needed to attract and retain more of these important providers.
It is essential to explore ways for all health professionals to provide services to the full extent of their current knowledge, training, experience, and skills. There are areas where provider shortages limit access to care and where new practitioner types can lead to better and more efficient delivery of care. Allowing the overlapping scope of practice, when appropriate, is essential to providing more coverage.
Continuing education: Continuing education plays a critical role in maintaining a well-qualified workforce. It helps clinicians and other health providers maintain and increase their knowledge and skills, as well as learn about changes in their specialty area and the health care system as a whole. Continuing education, particularly when it addresses gaps or shortcomings in skills or knowledge, can help ensure provider competence and improve quality of care for patients. However, participation in continuing education should not be equated with evidence of continuing competence.
State licensing boards and professional boards have roles to play in ensuring the ongoing competence of health professionals. A number of specialty boards oversee a Maintenance of Certification (MOC) process that allows providers to demonstrate their competence.
For example, the American Board of Medical Specialties (ABMS) oversees a MOC process for 24 medical specialties in which board-certified physicians demonstrate ongoing expertise in six core competencies. These include patient care and procedural skills, medical knowledge, interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning and improvement. The ABMS Program consists of a verification of credentials, a secure examination, and a self-evaluation of medical knowledge and practice performance.
HEALTH CARE WORKFORCE LICENSING AND CONTINUING EDUCATION: Policy
HEALTH CARE WORKFORCE LICENSING AND CONTINUING EDUCATION: Policy
Licensing
States should set strong licensing standards for all health care providers.
States should ensure that licensing boards have adequate funding and authority to carry out their responsibilities, including vigorous investigation and disciplining of substandard providers.
States should discipline incompetent health care professionals and providers and eliminate substandard care by revoking or suspending licenses to practice or imposing other sanctions, as appropriate.
Licensed providers should be regulated by their own licensing board to ensure the highest level of quality and consumer protection.
States should review and revise licensing laws for health facilities as necessary to improve the administration and operation of their provider- and physician-oversight responsibilities. Reforms should increase the range of sanctions that can be taken against poorly performing providers and practitioners.
States should have the proper professional licensure body oversee each type of health care professional and should not have duplicative and redundant licensing bodies for a single profession.
Continuing competency and continuing education
States should require all health professionals to maintain competency in their respective professions.
Working with professional organizations, consumers, and other interested parties, states should seek to phase in a mandatory continuing-competency system for all health professionals. This should include procedures to assess the continuing competence of licensees as a condition of periodic license renewal.
State licensing boards should establish standards for ensuring continued competency. They should consider granting deemed status to continuing-competency programs administered by voluntary credentialing and specialty boards or by hospitals and other health care delivery institutions when such private programs meet board-established standards.
In order to ensure providers’ continued competence, state licensing boards should go beyond mandatory continuing-education requirements to also require demonstrations of continued competence that include periodic assessment of knowledge, skills, and clinical performance, along with development, execution, and documentation of an improvement plan that is based on the assessment.
Complementary and integrative medicine
Ongoing support is needed for clinician education on complementary and integrative medicine and traditional medicine. Additionally, clinicians should communicate with their patients about its usage (see also Quality and Safety in Health Care—Medical Research for information on research funding for complementary and integrative medicine).
Information sharing and public disclosure
States should mandate public disclosure of disciplinary actions taken by health regulatory boards and make this information easily accessible to consumers.
Licensing boards should be required to share appropriate case information with peer review organizations and query the National Practitioner Data Bank before giving a clinician the right to practice.
States should encourage licensing bodies to promote patient-safety performance standards for health care professionals by implementing periodic reexaminations and relicensing of physicians, APRNs, nurses, and other key providers, based on both competence in and knowledge of safety practices.
Professional societies should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement. The committee should:
- develop a curriculum on patient safety and encourage its incorporation into training and certification requirements;
- disseminate patient-safety information to its members;
- recognize patient-safety considerations in developing practice guidelines and standards on the introduction and diffusion of new technologies, therapies, and drugs;
- work with the Center for Patient Safety to develop community-based, collaborative initiatives for error reporting and analysis; and
- collaborate with other professional societies and disciplines in a national summit on the professional’s role in patient safety.
National Practioner Data Bank
The federal government should permit public access to the data bank to assist consumers in choosing practitioners and providers.
Scope of practice
Current federal regulations and policies should be interpreted to allow Advanced Practice Registered Nurses (APRNs) and physician assistants (PAs) to fully and independently practice as defined by their education and certification.
States should allow APRNs and PAs to sign Provider Orders for Life-Sustaining Treatment forms, so consumers can more easily use these important health documents (see also this chapter’s section on Patients’ Rights and Advance Directives).
Policies and regulations on scope of practice set by the Centers for Medicare & Medicaid Services (CMS)should be updated as appropriate, to include APRNs and PAs in the interpretation of the terms “physician” and “physician services,” adding them as providers of services that are within the APRN and PA scope of practice and that would be covered if furnished by a physician. Medicare should authorize PAs and APRNs (such as nurse practitioners and clinical nurse specialists) to certify patients for services and admission to hospice, as well as clarify that they are authorized to certify admission to a skilled-nursing facility and to perform the initial admitting assessment.
Medicare hospital conditions of participation should be amended or clarified to facilitate APRNs’ eligibility for clinical privileges and membership on medical staffs.
States should update their regulations and statutes to acknowledge the authority of clinicians recognized in federal law to order services for Medicare and Medicaid patients in all locations of care, including in acute care, home health, and hospice care.
Federally mandated physician supervision of APRNs in Medicare payment policy (in cases where federal law is more restrictive than state law) should be eliminated to allow these licensed professionals to practice to the full extent of their licensure in hospitals, critical access hospitals, ambulatory surgery centers, skilled-nursing facilities, centers of excellence, and other health care facilities regulated by CMS.
Medicare Advantage plans should be encouraged to contract with APRNs, PAs, and other clinicians (as Traditional Medicare already does) so that consumers have access to their choice of providers (see also Medicare Advantage—Standards: Accessibility and network adequacy).
States should allow all professionals to provide services to the full extent of their current knowledge, training, experience, and skills where evidence indicates services can be delivered safely and effectively. States should allow and expect different professions to share overlapping scopes of practice.
States should amend current scope-of-practice laws and regulations to allow nurses, APRNs, and allied health professionals such as dental hygienists to perform duties for which they have been educated and certified. At the same time, these professionals should be monitored by the appropriate state licensing board and disciplined when they deliver inferior care or attempt to provide care that exceeds their capabilities.
States’ current nurse practice acts and accompanying rules should be interpreted—or amended where necessary—to allow APRNs to fully and independently practice as defined by their education and certification.
States should require training and demonstrated competency (in both speaking and writing) in English as a second language, as appropriate (see Health Care Infrastructure and Safety-Net Providers for background and policy on state licensing and competency requirements).