AARP Eye Center
Background
Oversight through state licensing boards is essential to ensuring that the health care workforce is properly trained and operating within the scope of their license. Continuing education is important for ensuring providers are up to date on current best practices and new developments in their practice area.
Licensing: Oversight by licensing boards ensures compliance with professional standards. To do this, state boards report medical malpractice payments and adverse fraud and abuse actions taken against licensed health care providers, practitioners, and suppliers. State and federal enforcement agencies, professional societies, and health care providers also engage in similar oversight. This is aimed at ensuring practitioners’ competence and facilitating the credentialing process. However, the data are not available to the public. Adverse actions include criminal convictions, civil judgments, program exclusions, and negative 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.
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. The problem is especially acute in delivery systems that operate in multiple states.
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 costs. However, consumers in 24 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 26 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 hurt consumers and 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, and the subsequent 2020 National Academy of Medicine report, The Future of Nursing 2020-2030: Charting a Path to Health Equity, contain many important recommendations to remove scope-of-practice barriers. More uniform regulations across the states could resolve scope-of-practice issues. The federal government can identify best practices from across the country and then create 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, 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.
To further improve access to care in rural communities and other medically underserved areas, some states have created a new license category for medical school graduates not matched in a residency to provide care in medically underserved areas under the supervision of a physician. Eight states (Missouri, Arkansas, Kansas, Utah, Arizona, Louisiana, Idaho, and Tennessee) have established a licensing category to permit individuals meeting this criterion to practice in medically underserved areas in their states. Most often referred to as assistant or associate physicians, these providers participate in a process similar to a residency program. They have the same credentials as first-year residents, and they are supervised by physicians.
Continuing education: Continuing education is critical in maintaining a well-qualified workforce. It helps clinicians and other health providers maintain and increase their knowledge and skills. It also ensures they 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.
In rural and other medically underserved communities, it can be especially challenging for providers to take the time to obtain necessary continuing education and training. As many look to innovative solutions to help support health care providers, there is growing evidence that physicians who participate in Enabled Collaborative Learning and Capability Building (ECHO) obtain the necessary skills to improve patient care and are more likely to continue to serve in health professional shortage areas (HPSAs). ECHO is a program developed by the University of New Mexico. The program offers technology-assisted collaborative learning to health care professionals, typically offering sessions on best practices in diagnosing and treating specific conditions. The benefits of ECHO are enhanced professional development, less professional isolation, and no-fee continuing education (CME). Other technology-enhanced collaborative training programs are also available.
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. They should vigorously investigate and discipline 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. They should not have duplicative and redundant licensing bodies for a single profession.
State policymakers should consider creating a new category of licensure for medical providers, typically referred to as assistant or associate physicians, to improve access to care in rural and other medically underserved communities. Such programs must engage medical school graduates with no less training than those entering their first year of residency, require supervision by a licensed physician, and include appropriation credentialing and oversight for purposes of providing primary care in medically underserved communities.
Continuing competency and continuing education
States should require all health professionals to maintain competency in their respective professions.
Policymakers should encourage providers to receive evidence-based training in best practices for treating complex health care conditions, including telehealth training programs to improve patient care in rural and other medically underserved communities.
Working with professional organizations, consumers, and other interested parties, states should 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.
Training for continuing competence, as well as initial education for students preparing for health professions, should follow best practices and evolving knowledge and understanding. It should ensure that healthcare practitioners support and advance health equity outcomes in their interactions with patients and provide high-quality care to all older adults.
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.
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 based on the evaluation.
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 this chapter’s section on 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, Advanced Practice Registered Nurses, nurses, and other key providers, based on competence in and knowledge of safety practices.
Professional societies should make a visible commitment to the delivery of quality care and 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 Practitioner 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 Patient Rights and Increasing Use of Advance Directives).
Policies and regulations on scope of practice set by the Centers for Medicare & Medicaid Services (CMS) should be updated as appropriate. APRNs and PAs should be included in the interpretation of the terms “physician” and “physician services.” They should be added 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. Medicare should also clarify that these professionals 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 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. These licensed professionals should be allowed 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 this chapter’s section on Medicare Advantage—Standards).
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 also this chapter’s section on Health Care Infrastructure and Safety-Net Providers for background and policy on state licensing and competency requirements).