Nurse Practitioners and Physician Assistants: Supply, Distribution, and Scope of Practice Considerations

Nurse Practitiners and Physician Assistants: Supply, Distributin, and Scpe f Practice Cnsideratins A resurce prvided by Staff Care, the natin s leading lcum tenens staffing firm and a cmpany f AMN Healthcare (NYSE: AHS), the largest healthcare wrkfrce slutins cmpany in the United States. www.staffcare.cm 800-685-2272 2015 Staff Care 5001 Statesman Drive Irving, Texas 75063 WE VE EARNED THE JOINT COMMISSION S GOLD SEAL OF APPROVAL CERTIFIED BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE

NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS: SUPPLY, DISTRIBUTION, AND SCOPE OF PRACTICE CONSIDERATIONS A resurce prvided by Staff Care, the natin s leading lcum tenens staffing firm and a cmpany f AMN Healthcare Intrductin Many (thugh nt all) healthcare plicy analysts agree that the United States is in the midst f a widespread and grwing physician shrtage. The dearth f dctrs has placed a grwing premium n advanced practitiners, including nurse practitiners (NPs) and physician assistants (PAs) wh can perfrm many f the duties perfrmed by physicians. NPs and PAs als fit the cncept f team-based care, in which a variety f clinicians wrk in a crdinated manner, perfrming tasks apprpriate t their training n behalf f patients. Estimates suggest that primary care physicians taking sle respnsibility fr the care f their patients wuld need t spend 18 hurs per day t prvide a full range f diagnstic and preventive services, supprting the implementatin f the team-based mdel f care ( Transfrming Primary Care: Frm Past Practice T the Practice f the Future. Health Affairs). Additinal factrs driving the use f NPs and PAs include: The fcus n primary care. The Assciatin f American Medical Clleges (AAMC) prjects a deficit f 91,000 physicians by 2025, including a deficit f 31,000 primary care physicians. Advanced practitiners are being used t make-up this deficit, particularly NPs, 87% f whm are in primary care. Scpe f practice. State legislatin has created an increasingly favrable envirnment fr PAs and NPs t practice. Over 97% f NPs can prescribe medicatins while 20 states and the District f Clumbia allw NPs t practice cmpletely independently. PAs are als benefitting frm a changing landscape, including reduced physician versight and greater prescriptive authrity. Cst. With median salaries f bth PAs and NPs ranging at arund $100,000, advanced practitiners are a relatively cst effective surce fr clinical care. Staff Care, the natin s leading physician lcum tenens staffing cmpany, has seen a significant increase in demand fr lcum tenens NPs and PAs in recent years. In 2011, we received minimal requests fr lcum tenens NPs and PAs. In 2014, by cntrast, 12% f ur ttal temprary prvider days requested were fr NPs and PAs, signaling a market-wide increase in demand fr advanced practitiners.

NPs and PAs by the Numbers Belw are sme key highlights f the PA and NP marketplace: Physician Assistants There are ver 104,000 PAs in the United States: Abut ne-third wrk in primary care, abut tw-thirds wrk in specialties PAs can prescribe in all 50 states The number f PAs has increased 100% ver the past decade PAs earn a median salary f $90,000, with annual cmpensatin ttaling $100,000 67% f PAs are wmen, 33% f PAs are men 19% f PAs are yunger than 30, 56.8% are 30 t 49 years ld, and 24.3% are 50 r lder Surce: American Academy f Physician Assistants (AAPA) Nurse Practitiners There are ver 190,000 NPs practicing in the United States: An estimated 15,000 NPs cmplete their training each year 97.2% f NPs prescribe medicatins, averaging 19 prescriptins per day NPs hld prescriptive privileges in all 50 states and Washingtn, D.C., and can prescribe cntrlled substances in 49 states 87.2% are fcused n primary care Mean base salary fr NPs is $91,310, and average full-time NP incme is $98,760 70% f NPs see 3 r mre patients per hur 96% f NPs are female The average age fr NPs is 48 years ld Surce: American Academy f Nurse Practitiners (AANP) As advanced practitiners, bth PAs and NPs prvide a specialized skill set, with different levels f training, scpe f practice, and expectatins as t hw they fit int staff-mdels. Fllwing is an examinatin f these cnsideratins, including supply f PAs and NPs by state, scpe f practice by state fr each practitiner, and hw these cnsideratins fit int the team-based mdel f care. Training and Utilizatin NPs and PAs bring a unique skillset t the team-based mdel f care, each defined by the training that they receive and the way in which they are utilized PA Training and Practice Areas A Physician Assistant is a health care prfessinal wh is licensed t practice medicine under physician supervisin. The PA s rle is t cnduct physical exams, diagnse and treat illnesses, rder and interpret tests, cunsel n preventin, assist in surgery and write prescriptins. A candidate is eligible fr a PA training prgram after receiving a Bachelr s degree with apprpriate prerequisite cursewrk in behaviral and basic sciences, alng with hands-n healthcare experience prir t matriculatin and apprpriate GRE/MCAT scres. Candidates accepted int PA training prgrams

then cmplete a 26 mnth degree prgram as accredited thrugh the Accreditatin Review Cmmissin n Educatin fr the Physician Assistant (ARC-PA) t btain a Master s degree in either Physician Assistant Studies (MPAS), Health Science (MHS) r Medical Science (MMS), alng with cmpleting mre than 2,000 hurs f clinical rtatins during educatin. Fllwing this, graduates are eligible t cmplete the PANCE (Physician Assistant Natinal Certifying Exam) administered by NCCPA (Natinal Cmmissin n Certificatin f Physician Assistants) t be certified as a PA. PAs then must btain state licensure t practice. In rder t maintain natinal certificatin, PAs must cmplete 100 hurs f cntinuing medical educatin every 2 years and pass a recertificatin exam every 10 years. Accrding t the AAPA Annual Survey Reprt fr 2013, the majrity f PAs that practice clinically chse t d s in varius specialty areas. The numbers belw shw PAs by specialty area and practice type: Specialty Area General Surgery & Surgical Subspecialties 26.0% Family Medicine 23.2% General Internal Medicine & IM Subspecialties 14.8% Emergency Medicine 10.6% General Pediatrics & Pediatric Subspecialties 3.4% OB/Gyn 2.0% Occupatinal Medicine 1.5% Other 18.4% Surce: 2013 AAPA Annual Survey Reprt NP Training and Practice Areas Practice Type Single Specialty Physician Grup Practice 18.7% Inpatient Unit f Hspital (nt ICU/CCU) 10.6% Sl Physician Practice Office 10.4% Hspital Emergency Rm 9.5% Multi-Specialty Physician Grup Practice 9.2% Outpatient Unit f a Hspital 7.3% Hspital Operating Rm 6.0% Other 28.3% Surce: 2013 AAPA Annual Survey Reprt A Nurse Practitiner is an Advanced Practice Registered Nurse (APRN) wh has cmpleted graduatelevel educatin (either a Master f Nursing r a Dctr f Nursing Practice degree). An NP treats physical and mental cnditins thrugh physical exams, cmprehensive evaluatin f medical histry, and rdering and interpreting diagnstic tests. Nurse Practitiner training invlves cmpletin f the educatin and clinical experience necessary t be a registered nurse (RN). This is fllwed by graduate-level NP prgram (either a Master s r Dctrate), and natinal bard certificatin in their area f specialty. If a Registered Nurse is trained at the assciate (tw-year) degree level, he r she must cmplete a Bachelr f Science (BSN) degree befre they can becme an NP.

Sme NPs are be able t wrk independently f physicians, while thers sign a cllabrative agreement with a supervising physician t practice. Scpe f practice regulatins, including clinical autnmy, prescribing level, respnsibilities and medical treatments and ther cnsideratins affrded t an NP vary based n state regulatins. Accrding t the AANP, the majrity f NPs practice in Primary Care (87.2%). The table belw shws NPs by practice area and average age: Practice Area Percent f NPs Average Age Acute Care 6.3% 46 Adult* 18.9% 50 Family* 48.9% 49 Gerntlgical* 3.0% 53 Nenatal 2.1% 49 Onclgy 1.0% 48 Pediatric* 8.3% 49 Psych/Mental Health 3.2% 54 Wmen's Health* 8.1% 53 *Dentes Primary Care fcus Surce: AANP Belw is a breakdwn f NPs by practice setting: Practice Setting Ambulatry setting 56.7% Private physician ffice/practice 31.6% Hspital setting 31.6% Hspital inpatient unit 13.4% Hspital utpatient clinic 10.8% Lng-Term and Elder Care 4.7% Public r Cmmunity Health 2.1% Other Settings 5.0% Surce: Natinal Sample Survey f Nurse Practitiners, Health Resurces Services Administratin (HRSA) Physician supply per state als is a functin f hw many medical residents trained in a given state the state is able t retain. Califrnia is the mst successful state in retaining its medical residents, while New Hampshire is the least successful. PA Supply and Distributin There are currently 104,337 PAs actively practicing thrughut the cuntry. A distributin by state can be seen belw, with the tp 5 mst ppulus states f New Yrk, Califrnia, Texas, Pennsylvania and Flrida cmprising 38.9% f the PA ppulatin. These 5 states cmpse 37.1% f the U.S. ppulatin, althugh a clear discrepancy is seen between the percentage f PAs versus the percentage f U.S. ppulatin in

Califrnia (9.4% cmpared t 12.2%) and Texas (6.6% cmpared t 8.5%). Number f PAs Percentage f PAs Percentage f U.S. Ppulatin New Yrk 10,866 10.4% 6.2% Califrnia 9,836 9.4% 12.2% Texas 6,898 6.6% 8.5% Pennsylvania 6,678 6.4% 4.0% Flrida 6,332 6.1% 6.2% Nrth Carlina 4,969 4.8% 3.1% Michigan 4,089 3.9% 3.1% Gergia 3,305 3.2% 3.2% Ohi 2,934 2.8% 3.6% Maryland 2,784 2.7% 1.9% Illinis 2,709 2.6% 4.0% Clrad 2,591 2.5% 1.7% Virginia 2,560 2.5% 2.6% Washingtn 2,534 2.4% 2.2% Massachusetts 2,428 2.3% 2.1% New Jersey 2,292 2.2% 2.8% Arizna 2,241 2.1% 2.1% Wiscnsin 2,034 1.9% 1.8% Minnesta 1,811 1.7% 1.7% Cnnecticut 1,774 1.7% 1.1% Tennessee 1,561 1.5% 2.1% Oklahma 1,360 1.3% 1.2% Suth Carlina 1,277 1.2% 1.5% Oregn 1,237 1.2% 1.2% Kentucky 1,212 1.2% 1.4% Kansas 1,072 1.0% 0.9% Indiana 1,055 1.0% 2.1% Iwa 1,026 1.0% 1.0% Nebraska 980 0.9% 0.6% Utah 969 0.9% 0.9% West Virginia 948 0.9% 0.6% Missuri 917 0.9% 1.9% Luisiana 862 0.8% 1.5% Maine 763 0.7% 0.4% Idah 753 0.7% 0.5% New Mexic 732 0.7% 0.7% Alabama 718 0.7% 1.5% Nevada 670 0.6% 0.9% New Hampshire 629 0.6% 0.4% Suth Dakta 515 0.5% 0.3% Mntana 511 0.5% 0.3% Alaska 465 0.4% 0.2% Nrth Dakta 346 0.3% 0.2% Vermnt 304 0.3% 0.2%

Rhde Island 303 0.3% 0.3% Arkansas 291 0.3% 0.9% Delaware 290 0.3% 0.3% Wyming 235 0.2% 0.2% Washingtn, D.C. 233 0.2% 0.2% Hawaii 225 0.2% 0.4% Mississippi 164 0.2% 0.9% Puert Ric 12 0.0% 1.1% Ttal 104,337 Surce: American Medical Assciatin Master File/MMS/U.S. Census Bureau This distributin can als be quantified n a per capita level. Natinally, there are 33 PAs per 100,000 ppulatin, with ratis varying widely by state (see belw): State PAs per 100,000 Alaska 63 Suth Dakta 60 Maine 57 New Yrk 55 Pennsylvania 52 Nebraska 52 West Virginia 51 Nrth Carlina 50 Mntana 50 Cnnecticut 49 Vermnt 49 Clrad 48 New Hampshire 47 Nrth Dakta 47 Maryland 47 Idah 46 Michigan 41 Wyming 40 Kansas 37 Massachusetts 36 Washingtn 36 Washingtn, D.C. 35 Wiscnsin 35 New Mexic 35 Oklahma 35 Arizna 33 Minnesta 33 Iwa 33 Utah 33 Gergia 33 United States 33

Flrida 32 Oregn 31 Delaware 31 Virginia 31 Rhde Island 29 Kentucky 27 Suth Carlina 26 New Jersey 26 Texas 26 Califrnia 25 Ohi 25 Tennessee 24 Nevada 24 Illinis 21 Luisiana 19 Indiana 16 Hawaii 16 Missuri 15 Alabama 15 Arkansas 10 Mississippi 5 Puert Ric 0 Surce: American Medical Assciatin Master File/MMS As these numbers indicate, the tp 5 mst ppulus states fr PAs n a per capita basis are Alaska, Suth Dakta, Maine, New Yrk and Pennsylvania. While sme large states have a crrespndingly large number f PAs, the rati f PAs per ppulatin in these states is lw. Fr example, Texas (26 PAs per 100,000 pp.), Califrnia (25 PAs per 100,000 pp.) and Flrida (32 PAs per 100,000 pp.) fall belw the natinal average f 33 PAs per 100,000 pp. NP Supply and Distributin There are currently 190,802 NPs in active patient care in the United States. The tp 5 mst ppulus states f Califrnia, Flrida, New Yrk, Texas and Pennsylvania include 33.9% f the NP wrkfrce and 37.1% f the general ppulatin. Number f NPs Percentage f NPs Percentage f U.S. Ppulatin Califrnia 17,167 9.0% 12.2% Flrida 15,338 8.0% 6.2% New Yrk 13,666 7.2% 6.2% Texas 11,074 5.8% 8.5% Pennsylvania 7,460 3.9% 4.0% Massachusetts 7,221 3.8% 2.1% Illinis 7,141 3.7% 4.0% Tennessee 6,709 3.5% 2.1%

Ohi 6,636 3.5% 3.6% New Jersey 5,650 3.0% 2.8% Gergia 5,644 3.0% 3.2% Nrth Carlina 5,365 2.8% 3.1% Virginia 5,027 2.6% 2.6% Michigan 4,678 2.5% 3.1% Arizna 4,204 2.2% 2.1% Maryland 4,028 2.1% 1.9% Missuri 3,865 2.0% 1.9% Washingtn 3,819 2.0% 2.2% Indiana 3,609 1.9% 2.1% Kentucky 3,601 1.9% 1.4% Cnnecticut 3,546 1.9% 1.1% Clrad 3,455 1.8% 1.7% Minnesta 3,212 1.7% 1.7% Wiscnsin 3,106 1.6% 1.8% Alabama 2,790 1.5% 1.5% Suth Carlina 2,564 1.3% 1.5% Oregn 2,538 1.3% 1.2% Luisiana 2,508 1.3% 1.5% Mississippi 2,447 1.3% 0.9% Kansas 2,246 1.2% 0.9% Iwa 1,921 1.0% 1.0% Arkansas 1,668 0.9% 0.9% Utah 1,514 0.8% 0.9% Oklahma 1,429 0.7% 1.2% New Mexic 1,351 0.7% 0.7% New Hampshire 1,273 0.7% 0.4% Maine 1,226 0.6% 0.4% West Virginia 1,209 0.6% 0.6% Nebraska 1,193 0.6% 0.6% Nevada 959 0.5% 0.9% Delaware 895 0.5% 0.3% Idah 851 0.4% 0.5% Rhde Island 840 0.4% 0.3% Alaska 632 0.3% 0.2% Mntana 627 0.3% 0.3% Nrth Dakta 595 0.3% 0.2% Vermnt 527 0.3% 0.2% Suth Dakta 521 0.3% 0.3% Washingtn, D.C. 479 0.3% 0.2% Hawaii 412 0.2% 0.4% Wyming 311 0.2% 0.2% Puert Ric 23 0.0% 1.1% Ttal 190,802 Surce: American Medical Assciatin Master File/MMS/U.S. Census Bureau

As with PAs, per capita distributin f NPs varies widely by state. State NPs per 100,000 Massachusetts 107 Tennessee 102 Cnnecticut 99 New Hampshire 96 Delaware 96 Maine 92 Alaska 86 Vermnt 84 Mississippi 82 Kentucky 82 Nrth Dakta 80 Rhde Island 80 Kansas 77 Flrida 77 Washingtn, D.C. 73 New Yrk 69 Maryland 67 West Virginia 65 New Mexic 65 Clrad 65 Oregn 64 Missuri 64 Nebraska 63 New Jersey 63 Arizna 62 Iwa 62 Mntana 61 Suth Dakta 61 Virginia 60 United States 60 Minnesta 59 Pennsylvania 58 Alabama 58 Ohi 57 Arkansas 56 Gergia 56 Illinis 55 Indiana 55 Washingtn 54 Nrth Carlina 54 Wiscnsin 54 Luisiana 54 Wyming 53 Suth Carlina 53

Idah 52 Utah 51 Michigan 47 Califrnia 44 Texas 41 Oklahma 37 Nevada 34 Hawaii 29 Puert Ric 1 Surce: American Medical Assciatin Master File/MMS The natinal average fr NPs per 100,000 residents is 60. Sme large states such as Texas and Califrnia have a crrespndingly large number f NPs, but trail the natinal per capita average. Scpe f Practice When assessing the rle f PAs and NPs in the team-based mdel f care, it is essential t understand the respnsibilities f each advanced practitiner in regard t scpe f practice. Cnsideratins such as autnmy f practice, prescribing level, need fr supervising physician versight and cllabratin all wrk t create a defining rle fr each practitiner, a rle that can vary frm state-t-state based n regulatry requirements. Physician Assistant Scpe f Practice Establishing Scpe f Practice Althugh PAs are licensed t practice medicine under physician supervisin, the degree t which PAs can establish this supervisin varies based n lcatin. While sme states/regins allw a PA and supervising physician t establish a written agreement utlining a PA s scpe f practice, thers require scpe f practice apprval by the State Medical Bard, r simply list the services PAs may prvide. States/regins in which PA and supervising physician may jintly establish written agreement utlining scpe f practice include: Alaska, Arizna, Arkansas, Califrnia, Clrad, Cnnecticut, Washingtn, D.C., Delaware, Hawaii, Idah, Illinis, Indiana, Kansas, Luisiana, Maine, Massachusetts, Michigan, Minnesta, Missuri, Mntana, Nebraska, Nevada, New Hampshire, New Mexic, New Yrk, Nrth Carlina, Nrth Dakta, Oregn, Rhde Island, Suth Dakta, Tennessee, Texas, Utah, Vermnt, Wyming States in which scpe f practice fr individual PAs must be apprved by State Medical Bard include: Alabama, Gergia, Kentucky, Mississippi, Suth Carlina, West Virginia States in which law determines services PA can prvide include: Flrida, Iwa, Maryland, New Jersey, Ohi, Oklahma, Pennsylvania, Virginia, Washingtn, Wiscnsin

Based n the utline abve, 34 states plus Washingtn, D.C. allw fr PAs and the supervising physician t establish a written agreement utlining PA scpe f practice; 6 states require PA scpe f practice t be apprved by the State Medical Bard; and in 10 states the law lists services PAs may prvide. Supervising Physician and Patient Recrd Oversight Anther imprtant distinctin with regard t physician supervisin f PAs is the degree and manner in which the supervising physician must mnitr the PA s cmpletin f patient medical recrds and c-sign the recrds during a clinical visit. While sme states/regins allw fr mnitring and c-signature requirements t be determined at the practice level by the supervising physician, thers pre-establish the mnitring f recrds by the supervising physician. These pre-established regulatins may include an alltted perid f time in which the supervising physician is allwed t review and c-sign medical recrds by the PA; variance in the number f recrds the physician is required t review based n established relatinship with the PA r the PA s experience; r ther factrs. States/regins in which physician c-signature requirements f patient recrds are determined at practice level by supervising physician include: Alaska, Arizna, Arkansas, Cnnecticut, Washingtn, D.C., Delaware, Flrida, Idah, Illinis, Maine, Maryland, Massachusetts, Michigan, Minnesta, New Yrk, Nrth Carlina, Nrth Dakta, Ohi, Rhde Island, Suth Dakta, Texas, Vermnt, Wiscnsin, Wyming States in which physician versight f patient recrds is pre-established. This versight varies frm statet-state, but may include alltted perid f time fr physician t review all recrds by PA, variance in the number f recrds required fr review based n PA s experience, r ther stipulatins include: Alabama, Califrnia, Clrad, Gergia, Hawaii, Indiana, Iwa, Kansas, Kentucky, Luisiana, Mississippi, Missuri, Mntana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexic, Oklahma, Oregn, Pennsylvania, Suth Carlina, Tennessee, Utah, Virginia, Washingtn, West Virginia As referenced abve, 23 states plus Washingtn, D.C. allw fr physician c-signature requirements f patient recrds t be determined at the practice level, while 27 states pre-establish cnditins fr the supervising physician t mnitr PA patient recrds. Prescriptive Authrity Physician Assistants are prvided certain privileges when establishing prescriptive authrity in a practice. Wrking hand-in-hand with the supervising physician, certain states/regins allw fr the authrity t be arranged at the practice level by the supervising physician. Other states establish restricted prescriptive authrity, where prescribing level is limited fr certain medicatins. States/regins in which the prescriptive authrity f the PA is arranged at practice by supervising physician include: Alaska, Arizna, Califrnia, Clrad, Cnnecticut, Washingtn, D.C., Delaware, Idah, Illinis, Indiana, Kansas, Maryland, Massachusetts, Michigan, Minnesta, Mississippi, Mntana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexic, New Yrk, Nrth Carlina, Nrth Dakta, Oregn, Ohi, Pennsylvania, Rhde Island, Suth Carlina, Suth Dakta, Tennessee, Texas, Utah, Vermnt, Virginia, Washingtn, Wiscnsin, Wyming States in which prescriptive authrity is restricted include: N prescriptin r administratin f scheduled drugs Kentucky Nt authrized t prescribe Schedule II depressants Iwa

Nt authrized t prescribe Schedule II medicatins Alabama, Arkansas, Gergia, Luisiana, Maine, Missuri, West Virginia May nt prescribe cntrlled substances, general anesthetics, r radigraphic cntrast materials Flrida Bard defines scpe with regards t prescriptive authrity Hawaii, Oklahma The supervising physician established the prescriptive authrity f the PA in 38 states plus Washingtn, D.C. The ther 12 states restrict PA prescriptive authrity fr the abve medicatins specified. Number f PAs Supervising Physician May Supervise When establishing practice envirnment, the makeup f practices cmpsed f PAs and supervising physicians can be influenced by the number f PAs each physician is allwed t supervise. While sme states d nt place a limit n the number f PAs a physician may supervise, thers place limitatins, including differing regulatins based n practice type. States in which there is n limit n the number f PAs a physician may supervise: Alaska, Arkansas, Maine, Massachusetts, Mntana, New Mexic, Nrth Carlina, Nrth Dakta, Rhde Island, Tennessee, Vermnt States in which physician may supervise n mre than 2 PAs: Hawaii, Indiana, Kansas, Kentucky, Luisiana, Mississippi, Nebraska*, Oklahma, Pennsylvania, Wiscnsin* *Bard may grant exceptins. Kansas: Limitatin des nt apply t medical care facility. Luisiana: A physician acting as lcum tenens supervisr may supervise mre than 4 PA s at ne time. Oklahma: Exceptins fr limitatin fr medical directr r supervising physician f a state institutin. States in which physician may supervise n mre than 3 PAs: Idah, Missuri, Nevada*, West Virginia, Wyming* *Bard may grant exceptins. Missuri: Limitatin des nt apply t hspital-emplyed PA s. West Virginia: Physician may supervise up t 4 hspital-emplyed PA s. States/regins in which physician may supervise n mre than 4 PAs: Alabama, Arizna, Califrnia, Clrad, Washingtn, D.C., Delaware, Flrida, Gergia*, Maryland, Michigan, New Hampshire, New Jersey*, New Yrk, Ohi, Oregn*, Suth Carlina*, Suth Dakta, Utah* *Bard may grant exceptins. Maryland: Limitatin des nt apply t hspitals, crrectinal facilities, detentin centers, r public health facilities. New Yrk: Physician may nt supervise mre than 6 PA s in crrectinal facility. Ohi: Limitatin des nt apply t hspital-emplyed PA s. States in which physician may supervise n mre than 5 PAs: Illinis, Iwa, Minnesta*, Washingtn* *Bard may grant exceptins. States in which physician may supervise n mre than 6 PAs: Cnnecticut, Virginia States in which physician may supervise n mre than 7 PAs: Texas In 11 states, there is n established limit t the number f PAs a physician may supervise. In the ther 39 states plus Washingtn, D.C., a limit n the number f PAs a physician may supervise is established. Surce: AAPA

Nurse Practitiner Scpe f Practice Based n prspects fr autnmus practice and independent prescribing level, the AANP has defined 20 states and the District f Clumbia in the United States where NPs enjy Full Practice scpe. Nurse Practitiners in these states/regins are allwed t evaluate patients independently, rder diagnstic tests, manage treatments and prescribe medicatin under the authrity f the State Bard f Nursing. These states include: Full Practice Scpe: Alaska, Arizna, Clrad, Cnnecticut, District f Clumbia, Hawaii, Idah, Iwa, Maine, Minnesta, Mntana, Nebraska, Nevada, New Hampshire, New Mexic, Nrth Dakta, Oregn, Rhde Island, Vermnt, Washingtn, Wyming 18 states are defined as having a Reduced Practice Scpe limit in at least ne aspect f practice, and require sme frm f cllabrative agreement, including: Reduced Practice Scpe: Alabama, Arkansas, Delaware, Illinis, Indiana, Kansas, Kentucky, Luisiana, Maryland, Mississippi, New Jersey, New Yrk, Ohi, Pennsylvania, Suth Dakta, Utah, West Virginia, Wiscnsin 12 states are defined as having a Restricted Practice Scpe restrict NPs in at least ne aspect f practice, and require supervisin, delegatin r team-management in rder t prvide care, including: Restricted Practice Scpe: Califrnia, Flrida, Gergia, Massachusetts, Michigan, Missuri, Nrth Carlina, Oklahma, Suth Carlina, Tennessee, Texas, Virginia NP Scpe f Practice Map Full Practice Reduced Practice Restricted Practice Surce: AAPA

Practice Envirnment and Distributin f Practitiners Scpe f practice fr advanced practitiners varies widely frm state-t-state, creating unique practice envirnments fr bth PAs and NPs. But hw d these differing regulatins influence distributin f practitiners? Physician Assistants Fr PAs, there are many factrs t cnsider when evaluating practice envirnment. Althugh PAs are required t be supervised by a physician in rder t practice, the degree f this supervising relatinship is wide-ranging. Based n the previus scpe f practice elements discussed, the mst pen practice envirnment fr a PA is ne in which regulatins are nt pre-established and the rle f the PA may be agreed upn with the supervising physician at the practice level, fitting these cnsideratins: The PA and supervising physician may jintly establish written agreement utlining scpe f practice Prescriptive authrity f the PA is arranged at practice by supervising physician, withut preestablished restrictins Physician c-signature requirements f PA patient recrds are determined at practice level by supervising physician There is n limit n the number f PAs a physician may supervise The 6 states listed belw match this definitin f an pen practice envirnment fr a PA: State PAs per 100,000 U.S. Rank (per capita) Alaska 63 1 Nrth Carlina 50 8 Vermnt 49 11 Nrth Dakta 47 14 Massachusetts 36 20 Rhde Island 29 36 As the numbers indicate, 5 f the 6 states that are cnsidered t have an pen practice envirnment fr PAs have greater than the natinal average f 33 PAs per 100,000 ppulatin, and rank in the tp 20 in the U.S. fr PA supply n a per capita level. This is an indicatin that an pen practice envirnment may psitively influences the supply f PAs in a given state. Nurse Practitiners Nurse Practitiners are affrded the ptential fr a greater degree f autnmy than PAs, as certain states allw fr independent practice, prescribing, and ther cnsideratins. As previusly defined by the AANP, scpe f practice fr NPs is divided int three categries: Full Practice Scpe, Reduced Practice Scpe, and Restricted Practice Scpe. The 17 States/regins that enjy Full Practice Scpe are allwed t evaluate patients independently, rder diagnstic tests, manage treatments and prescribe medicatin under the authrity f the State Bard f Nursing: State NPs per 100,000 New Hampshire 96 Maine 92 Alaska 86 Vermnt 84

Nrth Dakta 80 Rhde Island 80 Washingtn, D.C. 73 New Mexic 65 Clrad 65 Oregn 64 Arizna 62 Iwa 62 Mntana 61 Washingtn 54 Wyming 53 Idah 52 Hawaii 29 As the numbers indicate, 13 f the 17 states/regins cnsidered t have Full Practice Scpe fr NPs have greater than the natinal average f NPs per 100,000 residents (60). Cmpare this t states that fall under Restricted Practice Scpe fr NPs. These 12 states restrict NPs in at least ne aspect f practice, and require supervisin, delegatin r team-management in rder t prvide care: State NPs per 100,000 Oklahma 37 Texas 41 Califrnia 44 Michigan 47 Suth Carlina 53 Nrth Carlina 54 Gergia 56 Virginia 60 Missuri 64 Flrida 77 Tennessee 102 Massachusetts 107 Fr Restricted Practice Scpe, 8 f the 12 states have less than r equal t the natinal average fr NPs per 100,000 residents (60). This pattern indicates a crrelatin between an autnmus practice envirnment fr NPs and NP distributin. Emerging Rle f NPs and PAs in an Evlving Healthcare System In an era f physician shrtages it will be necessary fr physicians t redefine their rles. In rder t accmmdate patient demand, physicians will need t practice t the limits f their training, perfrming the mst cmplex duties f which they are capable. Specialists will fcus their effrts n technlgically advanced care fr patients with cmplex medical cnditins, using cutting edge diagnstic and surgical tls. Cntinuing medical advancements will require specialists t practice in ever narrwer but deeper sils, driving the need fr cperatin between specialists and primary care physicians wh will versee and crdinate care, in sme cases thrugh the medical hme. The Accuntable Care Organizatin (ACO) mdel als places increased emphasis n

crdinatin f care and n greater cmmunicatin between specialists. This may imprve quality, but it will absrb physician time, requiring dctrs t delegate mre duties t thers. Like specialists, primary care physicians will devte mre time t treating cmplex cases and will manage patients with multiple chrnic illnesses. Increasingly, they will manage the care f patients with cmplicated cnditins thrugh supervisin f a grwing number f nn-physician clinicians, including NPs and PAs. The Affrdable Care Act (ACA) acknwledged the grwing imprtance f NPs and PAs by increasing Medicare reimbursement by 10% fr thse practicing primary care. A number f states cntinue t increase scpe f practice f advanced practitiners t put them n clser fting with physicians. Massachusetts, fr example, passed a law requiring insurers t recgnize and reimburse NPs as primary care prviders. Insurers in the state nw list NPs with dctrs as primary care chices. It is clear that as health refrm cntinues, many patients will be less likely t see a physician and mre likely t see an NP r PA. This already is the case in many hspitals where NPs are perfrming tasks that medical residents can n lnger perfrm because f limits n their wrk hurs, as well as in rural and underserved areas. As nted abve, NPs and PAs als will play a grwing rle in the emerging medical hme and ACO mdels, and assisting in the expansin f Federally Qualified Cmmunity Health Centers (FQHCs), which received extensive funding thrugh the stimulus package and thrugh health refrm. With this in mind, it will be up t nt nly physicians, but als ther clinicians in the medical team, t absrb an increasing amunt f patient care duties. As discussed previusly, bth NPs and PAs ffer a specialized skillset, based n extensive educatinal and training backgrunds, t help augment the supply f skilled clinicians. Althugh the many PAs and NPs chse t practice in primary care, specialty areas will remain an enticing ptin fr advanced practitiners. The majrity f PAs already practice in specialty areas and therefre PAs cannt be expected t substitute fr r alleviate the shrtage f primary care physicians. Based n specific state guidelines and scpe f practice laws, the rle f NPs and PAs can vary widely frm state-t-state. Levels f autnmy, prescribing levels fr practitiners, and the need fr supervisin and/r cllabratin with a physician can create different team practice envirnments in each state. Despite these challenges, analysts cntinue t nte the quality f care NPs and PAs prvide and the patient satisfactin scres they achieve remain high. While access t care will be a key issue in the era f refrm, cst cntrl will be at least as imprtant. NPs and PAs are a relatively cst effective resurce, as they can perfrm 80% t 90% f a physician s duties while frequently earning 50% r less than physicians. With this in mind, it will cntinue t be imprtant t cnsider advanced practitiners as a realistic ptin t supplement physician services in the team-based mdel f care, particularly when taking int accunt grwing physician shrtages and verall healthcare csts.

Cnclusin As physician shrtages persist and as delivery evlves tward the team-based mdel, Physician Assistants and Nurse Practitiners will becme an increasingly imprtant part f hspital, medical grup, FQHC, and ther healthcare facility staffing plans. Practice ptins prvided t these advanced practitiners, defined by scpe f practice regulatins, varies frm state-t-state, creating many different practice envirnments. Level f autnmy, prescribing authrity, physician supervisin and ther cncerns will be imprtant t mnitr as industry leaders cntinue t find the crrect balance f clinicians in the team-based mdel f care. Fr additinal infrmatin n nurse practitiners and physician assistants, cntact: Crprate Office: Staff Care 5001 Statesman Drive Irving, Texas 75063 800-685-2272 www.staffcare.cm 800-685-2272 2015 Staff Care 5001 Statesman Drive Irving, Texas 75063