Physician Wages in States with Expanded APRN Scope of Practice

In recent years, states have looked to reforms in advanced practice nursing scope of practice (SOP) barriers as a potential means to increase access to primary care while reducing costs. Currently, 16 states and the District of Columbia permit advanced practice registered nurses to practice independently of physicians, allowing them to perform functions such as diagnosing and prescribing under their own authority within the primary care setting. Given the resistance of many physician associations to these reforms, we asked whether the economic interests of primary care physicians might be affected by reforms. Using the Bureau of Labor Statistics data on earnings, we compared primary care physicians' earnings in states that have instituted SOP reforms to those that maintain these practice barriers. We also compared surgeons' earnings as a control group. Lastly, we compared the rate of growth in the earnings of primary care physicians and surgeons over the last ten years. This preliminary analysis revealed no evidence of differences in earnings across the two groups of states. 1. Background In its 2010 report, “The future of nursing: leading change, advancing health,” the Institute of Medicine recommends the removal of scope of practice (SOP) barriers for advanced practice registered nurses (APRNs) such that they can “practice to the full extent of their education and training” (IOM, S-4). Currently, only 16 states and the District of Columbia (DC) allow APRNs to practice independently of physicians (For this study, we employ the standards of independent practice established by the Robert Wood Johnson Foundation Center to Champion Nursing in America [1], adapted from data collected for the annual Pearson Report [2]. By this standard, to be considered independent within a given state, APRNs must be permitted to diagnose and treat without physician supervision and must be permitted to prescribe medications either without physician supervision or with the signing of a one-time collaboration agreement with a physician or the state board of nursing (this may be for all prescribing or, in some states, only for prescribing of controlled substances, among which certain drugs may require case-specific consultations with a physician). In this way, our inclusion criteria for independent practice capture only states that grant APRNs complete or near-complete practice autonomy). In response to the IOM recommendation, the American Medical Association and the American Academy of Family Physicians, among others, have expressed their opposition, pointing out that