A Comparison of Changes in the Professional Practice of 

Nurse Practitioners, Physician Assistants, and Certified Nurse 

Midwives: 1992 and 2000 

This study was funded by the 
 

National Center for Health Workforce Analysis 
 

Bureau of Health Professions 
 

Health Resources and Services Administration 
 

under Contract # HRSA 230-00-0099 
 
ii
 
Preface 
 

The numbers of nurse practitioners (NPs), physician assistants (PAs), and certified nurse 

midwives (CNMs) increased dramatically in the 1990s. As of 2000 there were an estimated 

95,000 NPs1

, 40,000 PAs2, and 8,000 CNMs3 practicing in the U.S., an increase of about 160 

percent from 1992. Over this period the three professions were also becoming more widely 

accepted by physicians, patients, and the general public as key members of the health care 

delivery team. 

To document the extent to which the three professions experienced increased responsibilities 

over this period, and were helping to meet the health care needs of underserved populations, the 

Health Resources and Services Administration (HRSA) commissioned this study of the 

professional practice of NPs, PAs, and CNMs in the 50 States by the Center for Health 

Workforce Studies at the School of Public Health at the University at Albany. The study 

involved the compilation of a variety of data to explore these issues, including statutes and 

regulations from the 50 States, estimated numbers of practitioners, numbers of education 

programs and graduates, etc. These data were supplemented by field work and interviews 

conducted in seven States. This report represents a synthesis of all the components of the study. 

The Center for Health Workforce Studies is a not-for-profit research center operating under the 

auspices of the University at Albany of the State University of New York and Health Research, 

Incorporated (HRI). The views expressed in this report are those of the authors and do not 

necessarily represent the views or positions of the State University of New York, the School of 

Public Health, HRI, HRSA, or the subcontractors. 

1

 Data collected from State Boards of Nursing and/or State Regulatory Agencies by the Health Policy Institute, 
 

Medical College of Wisconsin, 2000.
 2

 American Academy of Physician Assistants, 2002 AAPA Physician Assistant Census Report, 
 

http://www.aapa.org/research/02census-intro.html. 
 3 Health Policy Institute, 2000. 
 

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iv
 
Executive Summary 
 

This chapter presents an overview of the study and this report. It includes the following sections: 

• Introduction 

• Key Findings 

• Discussion 

Introduction 
 

Physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs) play 

increasingly important roles in the health care system in the U.S. The three professions now 

combine to form a group of practitioners that is rapidly approaching 20 percent of the size of the 

physician workforce. 

Since many of the NPs, PAs, and CNMs are recent graduates of their respective education 

programs and few are near retirement age, barring a major unexpected reduction in the respective 

education programs, the supply of new practitioners is almost certain to continue to grow 

substantially relative to both population and the supply of physicians for the foreseeable future. 

A 1994 article on State practice environments of NPs, PAs, and CNMs by Sekscenski et al, 

concluded that the professional practice of NPs, PAs, and CNMs varies widely across the 50 

States, and that favorable practice environments for the three professions are strongly associated 

with larger supplies of practitioners [1]. This report revisits this situation and 

•	 documents changes in professional practice of the three professions between 1992 and 

2000; 

•	 creates new statistical professional practice indices for each of the three professions that 

more accurately reflect the respective practice environments across the 50 States in 2000; 

v 
•	 examines the nature of the relationship between the three professions, the professional 

environment in which they operate, and their physician counterparts; 

•	 identifies salient factors that are related to changes in the three professions and their 

physician counterparts; and 

•	 assesses the extent to which the three professions improved access to care for 

underserved populations in the 1990s. 

The professional practice indices described in this report were designed to quantify the 

professional practice options, structural identity, and market recognition of the three professions 

in each of the 50 States. Higher scores on a professional practice index are generally associated 

with broader sets of tasks, more autonomous practice environments (i.e., less direct oversight by 

physicians), and greater opportunities to prescribe controlled substances. 

No effort was made to develop an index that could be used to compare the professional practice 

across the three professions. Although there are similarities among the three professions, each 

has developed independently with different sets of legal, organizational, and clinical parameters, 

and it would be inappropriate to compare any single index across the three professions. 

The study included: a review of the relevant literature, a systematic review of professional 

practice statutes and regulations in the 50 States, analysis of data on the three professions and 

related practice and environmental characteristics, field work in seven States (California, Illinois, 

New York, North Carolina, Ohio, Oregon, and Texas), and interviews and discussions with a 

wide range of informants and stakeholders. 

Key Findings 

3⁄4	 The numbers of NPs, PAs, and CNMs increased significantly in virtually every State 

between 1992 and 2000. The overall increase was 160 percent over this 8 year period. 

3⁄4	 The professional practice for all three professions expanded significantly between 1992 and 

2000, that is, practitioners in each of the three professions were permitted to perform more 

procedures and were permitted to work with less direct supervision from physicians in 2000 

than they were in 1992. 

3⁄4	 None of the 50 States achieved an index score of 100 on the new professional practice 

indices for any of the three professions in 2000, indicating that even States with the most 

expansive practice environments have not yet achieved all practice options viewed as 

'optimal' by the respective professions. 

3⁄4	 While there remain differences in the scope index scores among the 50 States, the variation 

of the index scores has declined since 1992, suggesting that the 1990s was a period of 

'standardization' or 'convergence' of professional practice across the 50 States for all three of 

the professions. 

3⁄4	 The professional practice indices were significantly positively correlated with the numbers of 

practitioners per capita for the respective professions in 2000. This suggests that a more 

positive legal environment for the professions encourages both improved practice options 

and greater number of practitioners in a State. 

vi 
3⁄4	 The professional practice indices were significantly positively correlated with managed care 

penetration in the States in 2000. This suggests that managed care strategies do impact the 

regulatory environment of NPs, PAs, and CNMs. This is consistent with the significant 

increases in the numbers of graduates from professional education programs for NPs, PAs, 

and CNMs in the decade of the 90s, and the continuing success of new graduates in finding 

employment. 

3⁄4	 No other exogenous factor (e.g., aggregate health care expenditures, health insurance rates) 

was significantly correlated with the new professional practice indices for the three 

professions in the States. It may be that a study of individual practitioners would reveal 

additional relationships, but the State-level analysis in this study did not. 

3⁄4	 Despite anecdotes about tensions between physicians and the three professions, significant 

positive correlations between practitioner per capita ratios for NPs, PAs, CNMs, and 

physicians indicate that States with more physicians per capita also have more NPs, PAs, and 

CNMs per capita. This is an indication that the three professions supplement or support 

physicians rather than substitute for or supplant them. 

3⁄4	 A critical factor for the three professions related to access to care is the distribution of 

practitioners. Although the three professions do provide services in areas in which physicians 

cannot set up viable practices, the penetration of NPs, PAs, and CNMs into shortage areas is 

often limited by the practice locations of their collaborating physicians. 

3⁄4	 Although a majority of new NPs and PAs trained in US entering practice in the 1990s were 

trained in primary care specialties, many of them entered non-primary care specialties. Many 

NPs and PAs in specialty practices are assigned tasks generally considered to be 'primary 

care', e.g., histories and physicals. 

3⁄4	 Study informants reported that the attraction of NPs, PAs, and CNMs in different clinical 

settings and organizations is driven by two key factors: the salary difference between 

physicians and the three professions, and the ability of the three professions to handle 

effectively a wide range of clinical tasks. If salaries of the three professions continue to 

increase relative to those of physicians, the demand for the three professions may fall off. 

This may be the case for primary care practices as the salaries of primary care physicians in 

many parts of the U.S. are only slightly higher than those of NPs, PAs, and CNMs. 

3⁄4	 Whereas in the early 1990s the major professional practice concerns of NPs were prescriptive 

authority and legal relations with physicians, the key issue for NPs in recent years has been 

empanelment by managed care organizations and insurance carriers, that is, the ability to 

contract with and obtain their own provider numbers for reimbursement from third party 

payers. This issue is related to both access and visibility. Empanelment provides a major 

impetus for NPs to seek out patients in traditionally underserved communities and 

neighborhoods. Empanelment also permits appropriate counting of the services provided by 

NPs, which now are often reported as being provided by supervising physicians. 

3⁄4	 Although the observed increases in both numbers of practitioners and professional practice 

indices are the basis for prima facie arguments that access to services increased, reliable 

estimates of the numbers of NPs, PAs, and CNMs practicing in shortage areas are not 

available in most States. Thus, definitive statistical evidence of improved access for 

underserved populations is not available. However, qualitative research conducted as part of 

vii 
the field work in this study strongly supported the claim that the three professions do 

improve access to care for underserved populations. 

3⁄4	 The processes by which legal scopes of practice change in the 50 States are far from uniform, 

but the field work indicates that the following steps are present in most States: practice teams 

of physicians and one or more of the three professions work out ‘locally acceptable practice 

arrangements’, often based on local demonstration programs that permit innovative practices; 

then the practitioners seek changes in professional practice to permit these procedures and 

arrangements for all practitioners. If access to services is limited, public constituent groups 

and coalitions (e.g., Primary Care Agencies, advocacy groups) often lobby for changes in 

professional practice to improve access to needed services. The professional associations for 

the NPs, PAs, and CNMs also lobby actively for changes in professional practice. 

3⁄4	 Reimbursement, i.e., compensation or remuneration for different professional activities and 

procedures, is critical to the acceptance of different practice and supervision arrangements. 

There will always be some practitioners who provide pro bono services to underserved 

populations, but provision of services to broad segments of the population that are 

underserved will happen only if appropriate compensation is available. 

Discussion 
 

The analyses, interviews, and meetings conducted as part of this study identify potential followup activities that could be pursued at some point. 

1.	 Many informants suggested revisiting the professions every 4 or 5 years to track changes in 

professional practice of NPs, PAs, and CNMs, the growth in the numbers of practitioners, 

their demographic characteristics, their legal scopes of practice, their practice patterns, and 

their contributions to care, especially for underserved populations. 

2.	 A pilot study in one or two States to count/estimate the numbers of NPs, PAs, and CNMs 

who work in Health Professional Shortage Areas and Medically Underserved Areas, and 

assess their roles in providing care to underserved populations in rural communities, urban 

neighborhoods, community health centers, and institutions serving special populations would 

permit a careful assessment of the contributions of the three professions to care for the 

underserved. 

3.	 Improved financial incentives for NPs, PAs, and CNMs to practice in HPSAs and other 

shortage areas could significantly improve access to care for underserved populations. 

Options for these incentives include increased Medicare incentive payments (as with 

physicians) and educational loan forgiveness/repayment programs. 

4.	 Increased Medicare reimbursement levels for CNMs from 65 percent of physician rate to 85 

percent (as is the case for NPs and PAs) would and help to increase access to CNM services 

for populations with mental and physical disabilities who are insured by Medicare . 

5.	 Evaluation of State programs that permit practice with remote supervision in more nontraditional settings, including schools, nursing homes, home health agencies, and prisons 

could ultimately improve access to care for the people in these settings, many of whom are 

underserved. 

viii 
6.	 Practitioner data bases for NPs and CNMs comparable to those maintained by PAs and 

physicians would significantly enhance the possibilities of assessing the practice patterns of 

the professions and their contributions to access for underserved populations. 

7.	 If managed care organizations were encouraged to empanel properly qualified NPs, PAs, and 

CNMs, so that they can provide services to their patients with greater professional autonomy, 

the result would be improved access to services and reduced costs of care. Empanelment 

would also provide a basis for more accurately counting the services of the three professions, 

whose services are often now significantly underestimated because they are recorded as 

being provided by their collaborating physicians. 

ix 
x
 
TABLE OF CONTENTS 

Executive Summary.........................................................................................................................v 
 

Introduction ...................................................................................................................................v 
 

Key Findings ............................................................................................................................... vi 
 

Discussion.................................................................................................................................. viii 
 

Chapter 1. Study Overview.............................................................................................................1 
 

Introduction ...................................................................................................................................1 
 

Study Goals and Objectives...........................................................................................................3 
 

Study Components.........................................................................................................................3 
 

Remainder of the Report ...............................................................................................................4 
 

Chapter 2. Background and Context...............................................................................................7 
 

Historical Context for the Three Professions ................................................................................7 
 

Factors Related to Professional Practice Indices.........................................................................12 
 

Professionalization ......................................................................................................................13 
 

Conclusions .................................................................................................................................15 
 

Chapter 3. Professional Practice Indices.......................................................................................17 
 

Introduction .................................................................................................................................17 
 

The Original Practice Environment Indices ................................................................................18 
 

The New Professional Practice Indices .......................................................................................19 
 

The Scoring Methodology...........................................................................................................21 
 

Chapter 4. Nurse Practitioners ......................................................................................................23 
 

Introduction .................................................................................................................................23 
 

The Original Practice Environment Index for NPs .....................................................................24 
 

The New Professional Practice Index for NPs ............................................................................24 
 

Discussion....................................................................................................................................25 
 

Chapter 5. Physician Assistants ....................................................................................................27 
 

Introduction .................................................................................................................................27 
 

The Original Practice Environment Index for PAs .....................................................................28 
 

The New Professional Practice Index for PAs ............................................................................28 
 

Discussion....................................................................................................................................28 
 

Chapter 6. Certified Nurse Midwives ...........................................................................................31 
 

Introduction .................................................................................................................................31 
 

The Original Practice Environment Index for CNMs .................................................................32 
 

The New Professional Practice Index for CNMs ........................................................................32 
 

Discussion....................................................................................................................................32 
 

Chapter 7. Factors Related to Professional Practice Indices.........................................................35 
 

Introduction .................................................................................................................................35 
 

Data and Methods........................................................................................................................36 
 

Results .........................................................................................................................................38 
 

Other Patterns and Relationships.................................................................................................42 
 

Conclusions .................................................................................................................................46 
 

Chapter 8. Field Work in Seven States .........................................................................................49 
 

The Field Work Process ..............................................................................................................49 
 

Observations from the Fieldwork................................................................................................50 
 

Conclusions .................................................................................................................................52 
 

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Chapter 9. Access to Care.............................................................................................................55 
 

Concepts and Definitions ............................................................................................................55 
 

Limitations on Quantitative Assessments ...................................................................................56 
 

Professional Practice Indices and Access to Care .......................................................................57 
 

Anecdotal Evidence from Fieldwork...........................................................................................58 
 

Conclusions .................................................................................................................................65 
 

Appendix A. Project Advisory Committee...................................................................................67 
 

Appendix B. Professional Organizations......................................................................................71
 

Appendix C. Original Index Calculations.....................................................................................73
 

NPs ..............................................................................................................................................73 
 

PAs ..............................................................................................................................................79 
 

CNMs ..........................................................................................................................................85 
 

Appendix D. Professional Practice Index Calculations for PAs...................................................91 
 

Appendix E. Professional Practice Index Calculations for NPs .................................................121 
 

Appendix F. New CNM Scope Index Calculations....................................................................153 
 

Appendix G. Field Work Details ................................................................................................191 
 

Introduction ...............................................................................................................................191 
 

The Fieldwork ...........................................................................................................................192 
 

Summary of the Statutes and Regulations.................................................................................216 
 

Appendix H. References .............................................................................................................225 
 

LIST OF FIGURES 

Figure 2-1. Factors Related To Professional Practice of NPs, PAs, and CNMs .....................14 
 

Figure 7-10: General Acceptance Of Non-Physician Clinicians, 2000......................................44 
 

LIST OF TABLES 

Table 4-1:	 Professional Practice Indices for NPs in the Fifty States and 
 

District of Columbia . ............................................................................................26 
 

Table 5-1:	 Professional Practice Indices for PAs in The Fifty States and 
 

District of Columbia .............................................................................................30 
 

Table 6-1:	 Professional Practice Indices for CNMs in The Fifty States and 
 

District of Columbia .............................................................................................34 
 

Table 7-1: Variables Used to Test Study Hypotheses ............................................................37 
 

Table 7-2: 	 Original and New Professional Practice Indices for NPs, PAs & CNMs, 
 

1992 to 2000- Comparisons of Means and Standard Deviations...........................38 
 

Table 7-3: 	 Components of the Professional Practice Indices for NPs, PAs, and CNMs 
 

for the 50 States, 2000 .........................................................................................39 
 

Table 7-4: 	 Numbers of NPs, PAs, and CNMs Per 100,000 Population in the US, 
 

1992, 1996, and 2000 ............................................................................................39 
 

Table 7-5: 	 Correlations of Components of the Professional Practice Indices 
 

Across the Three Professions ................................................................................40 
 

xii
 
Table 7-6:	 Correlations Between Original Professional Practice Indices and 
 

Professionals Per Capita, 1992 and 2000 ..............................................................41 
 

Table 7-7: 	 Correlations Between NPs, PAs, and CNMs per Capita and Their Counterpart 
 

Physicians per Capita, 2000 ..................................................................................42 
 

Table 7-8: 	 Correlations of Percentages of Population in HPSAs with 
 

Other Variables of Interest ....................................................................................43 
 

Table 7-9: Correlations of HMO Penetration with Other Variables of Interest .....................43 
 

Table 7-10: Components of the New Professional Practice Indices For NPs, PAs, 
 

and CNMs for the 50 States and DC, 2000 ..........................................................45 
 

Table C-1: 	 Professional Practice Index Scoring Criteria: Original Scoring 
 

System for NPs For 2000 ......................................................................................73 
 

Table C-2: 	 Professional Practice Index Scoring Criteria: Original Scoring 
 

System for PAs For 2000 ......................................................................................78 
 

Table C-3: 	 Professional Practice Index Scoring Criteria: Original Scoring 
 

System for CNMs For 2000 ..................................................................................83 
 

Table D-1: 	 Professional Practice Index Scoring Criteria for Physician Assistants 
 

in 2000 ..................................................................................................................90 
 

Table E-1: 	 Professional Practice Index Scoring Criteria for Nurse Practitioners 
 

in 2000 ................................................................................................................120 
 

Table F-1: 	 Professional Practice Index Scoring Criteria for Certified Nurse Midwives
 

in 2000 ................................................................................................................152 
 

Table G-1: 	 Numbers of Educational Programs and Graduates for Nurse 
 

Practitioner, Physician Assistant, and Certified Nurse Midwives 
 

in the Seven Fieldwork States in 2000 ............................................................... 206 
 

Table G-2: 	 Numbers of Nurse Practitioners, Physician Assistants, and 
 

Certified Nurse Midwives in the Seven Fieldwork States ................................. 210 
 

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xiv
 
Chapter 1. Study Overview 
 

This chapter presents an overview of the study and this report. It includes the following sections: 

• Introduction 

• Study objectives 

• Study components 

• Remainder of report 

Introduction 
 

Over the last decade, the numbers of Nurse Practitioners (NPs), Physician Assistants (PAs), and 

Certified Nurse Midwives (CNMs) in the U.S. have increased substantially. So have the numbers 

of education programs, new graduates, professional practice options, location of practice, 

visibility to patient consumers, and professional standing. Many factors have contributed to these 

increases in numbers and status, some environmental and some related to the professions. 

The net result of these factors has been a decade of standardization, socialization, and 

professionalization of NPs, PAs, and CNMs. Although these processes were not the major focus 

of this study, their influences on the professions and on the environments in which they practice 

demand consideration and attention. When considering the reasons for the changes in 

professional practice experienced by the three professions, it is important to understand the 

underlying driving forces, which included: 

•	 Pervasive concerns about the rising cost of health care and a growing recognition that the 

three professions that are subjects of this study, in particular, provide cost-effective, high 

quality care; 

1
 
• Cost containment measures that have increased pressure for new economies in practice; 

•	 Consumers who are better educated about health care diagnosis and treatment through a 

combination of print media, the Internet, television, and advertising, and who as a result 

demand more of the providers and health systems from whom they seek care, including 

more time and information; 

•	 Increasing acceptance of the three professions by health care consumers and 

subsequently, wider use of them in mainstream health care settings. 

•	 The greater roles of consumers in the purchase of health services, the utilization of 

services, and choice of care providers; 

•	 The growing number of consumers willing to go beyond the traditional allopathic health 

care system to seek out homeopathic and holistic treatments to address health care 

problems; 

•	 Growing numbers of uninsured and underinsured people in need of medical care and 

increased demand for the three professions to work in underserved areas; 

•	 Increased interest and enhanced funding for women’s health care initiatives creating new 

opportunities for CNMs and NPs; and 

•	 Increasing use of the three professions instead of medical residents (i.e., physicians in 

training), particularly in primary care, in some settings that has created expanded practice 

opportunities for NPs, PAs, and CNMs. 

The regulation of health professions across the United States occurs both externally and 

internally and is intended to provide safeguards for the public, for the consumer, and for the 

professions themselves. Externally, State and Federal legislators and regulatory boards determine 

the legal parameters for professional practice and establish the rules for implementing those 

conditions. Internally, national professional organizations establish standards and core 

competencies which are to be met by the professionals within their purview and by the 

educational institutions which educate and train them. Such guidelines are intended to establish 

and maintain criteria for appropriate and competent practice. 

Regulation of NPs, PAs, and CNMs has evolved considerably over the last decade. National 

professional organizations have been refining certification and education program requirements 

and establishing standards for proficient practice. During this period, many national associations 

have become effective at lobbying for legislation that accommodates the needs of the public and 

their members on both the State and national levels. Professional associations advocate for 

regulations that contribute to the professional standing of the group. Standards elevate a 

profession to a level of skill and competence which creates uniformity and engenders respect by 

both consumers and other professions. 

State and Federal regulators have been actively engaged in altering and adjusting the legal 

environments in which these professions work to enable practice while maintaining standards to 

protect public safety. Achieving a balance in various legislative initiatives between the interests 

of the several professions is a dynamic process. Sustaining this delicate balance requires 

continual refinement and revision as health care practice, public preferences, and medical 

technologies evolve. Appropriate regulation can contribute to both efficient practice for the 

professions and effective care for patients. 

2
 
In 1994 Edward Sekscenski and colleagues reported on a study that documented the practice 

environments for NPs, PAs, and CNMs in each of the 50 States for the year 1992 [Sekscenski et 

al, 1994]. They created three statistical indices that reflected the practice environments for the 

respective professions, based on the legal status of the professions, the possibilities for direct 

reimbursement of professionals for their services, and their authority to write prescriptions. The 

three indices were applied for each State to provide a basis for comparing the practice 

environments for the three professions across the 50 States and the District of Columbia. 

Since that study, the numbers of NPs, PAs, and CNMs have increased dramatically, and their 

respective scopes of practice have expanded as well. For a variety of reasons many States began 

to look to non-physician clinicians (especially NPs, PAs, and CNMs) to address service gaps and 

shortage areas. To promote the use of non-physician clinicians in shortage areas, many State 

legislatures enacted expansions of their professional practice laws over the past decade with the 

objective of increasing the supply of medical services to the public, especially for those in 

officially designated physician shortage areas. 

Study Goals and Objectives 

The numbers of NPs, PAs, and CNMs increased dramatically in the 1990s, but questions remain: 

To what extent have the scopes of practice of the three professions increased in this period? 

Were the improvements in professional practice related to observed increases in numbers of 

practitioners? Have the overall increases in the numbers of practitioners also occurred in 

officially designated shortage areas? Has access to care increased in these areas? 

The overarching goal of this study was to answer these questions, and to assess the impact of 

changing professional practice laws for NPs, PAs, and CNMs on access to health care for the 

underserved in the U.S. This goal was supported by five specific objectives: 

1.	 Document changes in professional practice laws for NPs, PAs, and CNMs in the 50 States 

between 1992 and 2000, and assess the extent to which these scopes of practice are uniform 

across the States; 

2.	 Replicate and update the scoring system for the professional practice indices for the three 

professions developed by Sekscenski, et al; 

3.	 Compile data on the trends of the numbers of individuals licensed as NPs, PAs, and CNMs in 

each State between 1992 and 2000; 

4.	 Compare the changes in the numbers of NPs, PAs, and CNMs for States with and without a 

significant change in professional practice for each of these professions, and assess whether 

there is a relationship between change in professional practice and change in the numbers 

licensed and practicing in each State; and 

5.	 Assess the impact of changes in professional practice laws and regulations governing NPs, 

PAs, and CNMs on access to health care in underserved areas. 

Study Components 

The Center for Health Workforce Studies at the University at Albany (SUNY) in collaboration 

with the four other Centers for Health Workforce Distribution Studies (at UC San Francisco, the 

3
 
University of Washington, the University of Texas San Antonio, and the University of Illinois at 

Chicago), the North Carolina Center for Nursing, the National Conference of State Legislatures, 

and the Health Policy Institute at the Medical College of Wisconsin examined the impact of 

changing professional practice laws for three professions on access to health care for the 

underserved. The specific tasks undertaken included: 

1.	 Obtain and review previous and current professional practice statutes and regulations 

governing NPs, PAs, and CNMs in the fifty States (plus the District of Columbia) and 

document how the professional practice requirements changed between 1992 and 2000; 

2.	 Replicate and update the scoring system for professional practice for these practitioners 

developed by Sekscenski, et al for the year 2000 and assess the extent of the changes that 

took place between 1992 and 2000; 

3.	 Because the original index was shown to be insufficiently discriminating among the States 

for the year 2000, develop a new professional practice index for the three professions that 

reflected a larger number of criteria and used more detailed scoring criteria; 

4.	 Compile data on the trends of the numbers of individuals licensed as NPs, PAs, and CNMs in 

each State over the past decade to provide a statistical perspective on the changing numbers 

of practitioners in the three professions; 

5.	 Compare the changes in the number of NPs, PAs, and CNMs for States with and without a 

significant change in professional practice for each of these professions and assess whether 

there is a relationship between professional practice and the numbers licensed in each State; 

6.	 Conduct field work in seven States to gather qualitative information about the professional 

practice of the three professions and access to services in underserved areas to supplement 

the data on the professional practice indices and numbers of practitioners gathered in other 

components of the study; 

7.	 Prepare report(s) for HRSA and articles for peer-reviewed journals to disseminate the 

findings and conclusions of the study. 

Remainder of the Report 

•	 This report is presented in eight chapters, including this Study Overview. The remaining 

chapters address the following topics: 

Chapter 2: Background and Context 

Chapter 3: Professional Practice Indices 

Chapter 4: Nurse Practitioners 

Chapter 5: Physician Assistants 

Chapter 6: Certified Nurse Midwives 

Chapter 7: Factors Related to Professional Practice Indices 

Chapter 8: Field Work in Seven States 

Chapter 9: Access to Care 

4
 
•	 Providing additional detail for interested readers are eight appendices, each providing 

information about some aspect of the study, the index calculations, or the field work. 

Appendix A: Project Advisory Committee 

Appendix B: Professional Organizations Related to the Three Professions 

Appendix C: Details of the Calculations of the Original Practice Environment Indices 

Appendix D: Details of the Calculation of the New PA Professional Practice Index 

Appendix E: Details of the Calculation of the New NP Professional Practice Index 

Appendix F: Details of the Calculation of the New CNM Professional Practice Index 

Appendix G: Details About the Field Work in Seven States 

Appendix H: References 

5
 
6
 
Chapter 2. Background and Context 
 

This chapter provides a context for the subsequent discussion of professional practice indices for 

NPs, PAs, and CNMs. It includes the following subsections: 

• Historical Context for the Three Professions 

• Factors Related to Professional Practice Indices 

• Professionalization 

• Conclusions 

Historical Context for the Three Professions 
 

The concepts of non-physician providers and physician “assistants” are not new, with medical 

tradition indicating the presence of these providers across cultures for hundreds of years. These 

practitioners often worked in locations where physicians were unavailable. However, their 

presence and acceptance in the United States has increased significantly in recent years. 

Although the development of the three professions is rooted in the need for access to primary 

medical care for underserved populations, each of the three professions has an individual history 

and orientation that colors its present status. And although each has historical roots that reach 

into the past, in the United States, the professions have experienced their most rapid development 

in about the last 40 years, with considerable evolution over the last decade. Brief histories for the 

three professions are provided below. 

A Brief History of Nurse Practitioners in the US 

In the 1960s, Dr. Henry Silver and Loretta Ford, PhD (a nurse educator) at the University of 

Colorado, created a program to educate nurses to respond to the need for primary care providers 

in rural areas. Dr. Silver and Dr. Ford established a pediatric practitioner program based on the 

7
 
nursing model.4

 This was the first of the nurse practitioner programs that educated nurses to 

make medical diagnoses while providing care in a nursing model. The idea was revolutionary 

and initially not well accepted by the academic nursing profession.5 The first graduates began to 

practice in the late 1960s.6

 The program was at the master’s level requiring a nursing license and 

experience in patient care for admission. In subsequent years, several programs moved away 

from the master’s degree model to certificate programs but, more recently, the trend has again 

shifted to master’s education.7 

The nursing profession initially expressed skepticism with the educational process and the new 

identity of the nurse practitioner. Education that incorporated a medical model to create a 

physician “extender” was threatening to nursing’s roots and to its exclusive orientation to care. It 

was only as the NP profession evolved and the academic and training programs were clarified 

that the profession embraced the new roles for nurses.8 

Nurse practitioners function in a variety of roles in almost every conceivable health care setting. 

The care they provide is grounded in a nursing model which emphasizes treatment of illness in 

the context of a patient’s total well-being and encourages patient education. Nurse Practitioners 

provide well care, diagnose and treat acute illness, and monitor chronic conditions. NPs are 

permitted to order, perform, and interpret certain laboratory tests and to prescribe medications. 

In 2000, Nurse Practitioners were legally enabled to practice in every State and the District of 

Columbia. Practice varied considerably across States with different statutory and regulatory 

limitations on prescriptive authority, direct reimbursement, and the required legal relationship 

with physicians. Nurse practitioners were generally regulated by State Boards of Nursing, but in 

some States, Boards of Medicine were directly involved in regulation of the profession. In some 

States, agencies other than the Department of Health were involved in professional oversight 

activities for Nurse Practitioners. In 2000, NPs were not title protected in every State. In 49 

States and the District of Columbia, NPs were provided with some form of prescriptive authority 

which varied from the ability to prescribe only legend drugs to full prescriptive authority 

including controlled substances. The educational requirements to obtain prescriptive authority 

varied widely across States. 

Many States required a master’s degree in order to be licensed in the State. All but five States 

required national certification from a certifying body in order to qualify for licensure or 

registration as an NP. Examinations qualifying NPs for national certification were provided by 

the American Academy of Nurse Practitioners Certification Program (AANPCP), the American 

Nurse Credentialing Center (ANCC), the American Board for Pediatric Nurse Practitioners 

(PNCB), and the National Certification Corporation for the Obstetrical, Gynecologic, and 

Neonatal Nursing Specialties (NCC). 

Nurse practitioners seek some professional autonomy in practice with formal collaboration being 

the general mode of cooperation with physicians. However, in some States supervision by 

physicians is a common form of practice. 

4

 Hooker et al., p. 2.
 5 Robert Wood Johnson Foundation Anthology, Chapter 11, p.2. 
 6

 Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Maryland 1999, p. 7. 
 7

 Third Age, Nurse Practitioner Profession, http://thirdage.adam.com/ency/article/001934.htm, p. 1. 
 8 Robert Wood Johnson Foundation Anthology, Chapter 11, p. 2.
 

8
 
In 2000, there were 321 institutions offering either master’s level NP and/or post-master’s NP 

programs.9

 NP education programs were accredited by the Commission on Collegiate Nursing 

Education, the National League for Nursing Accrediting Commission, and the National 

Association of Nurse Practitioners in Women’s Health which accredits NP programs in women’s 

health.10 Seventy-two percent of the graduates of the master’s programs in 2000 were family, 

adult, or pediatric nurse practitioners11 suggesting that primary care continues to be the focus of 

the majority of NPs. 

In 2000 there were approximately 95,000 NPs12 practicing in the U.S., up from about 28,000 in 

1992. This represents an increase of more than 240 percent over the 8 year period. 

A Brief History of Physician Assistants 

The physician assistant profession is generally understood to have its roots in the military medic 

or corpsman model. Medics provided medical services teamed with physicians and nurses in 

wartime settings. In many cases these adjunct providers were highly trained members of the 

medical team who became experienced in providing care in very challenging and demanding 

circumstances. In the late 1960s during the Vietnam War, this group of trained providers became 

the focus of attention for some foresighted physicians in the United States. 

There was growing concern about a potential shortage of generalist physicians due to the 

increasing numbers of medical students who were choosing specialty training. This fact, coupled 

with increased attention to populations that were poor and/or medically underserved in the 

United States, created concern that the supply of physicians was insufficient to meet the needs of 

the public. 

As early as 1960, Dr. Charles Hudson, President of the National Board of Medical Examiners, 

spoke to a gathering of the AMA about the possibility of training these medical corpsmen to 

work with physicians in civilian medical settings.13 Several physicians, including Dr. Richard 

Smith, a Federal bureau director, and Dr. Hudson and Dr. Eugene Stead, a faculty member at 

Duke University, reiterated this suggestion in subsequent years14. Dr. Stead, Dr. Harvey Estes, 

and Dr. D. Robert Howard, all of Duke University in North Carolina, introduced the idea of 

educating a health professional who would assist physicians in the provision of primary care 

services with special emphasis on educating new providers to enhance access to care in rural 

North Carolina. In the mid-1960s, they instituted a program at Duke that provided formal 

education and training for these professionals. 

This extension of the military model into practice environments in the United States was 

conceived as a way to link underserved populations to the health care system. After the Vietnam 

9 American Association of Colleges of Nursing, 2000-2001 Enrollment and Graduations in Baccalaureate and 
 

Graduate Programs in Nursing.
 10 White Paper of the Consortium for Quality Nurse Practitioner Education,
 

http://www.aanp.org/NR/rdonlyres/e5t66jqu7scgkf3pvrlkfgrw5hiv2i7kfmhssyisrvdcetob7sz4xtkay6xrncsqcrwtk2vk
 

znylgn/White%252bPaper.pdf 
 11 American Association of Colleges of Nursing. Table 21a.
 12 Data collected from State Boards of Nursing and/or Other Regulatory Agencies by Health Policy Institute of the 
 

Medical College of Wisconsin , 2000.
 13 Hooker et al., p. 24. 
 14 Hooker et al., p. 2 and p. 17.
 

9
 
War, the recognition of the potential to use highly trained and competent medics to meet the 

needs in rural areas gained popularity. Thus the physician assistant profession was born. 

PAs traditionally practice under the supervision of physicians and this strong relationship with 

physicians has remained relatively unchanged as the profession has evolved. As the name 

suggests, Physician Assistants are closely associated with a medical model of care, one grounded 

in the diagnosis and treatment of illness. There were only 237 PAs practicing in the U.S. in 1970. 

By 2000 that number had increased to about 40,000,15 a 90 percent increase since 1992. 

As of 2000, all States and the District of Columbia had statutes or regulations governing the 

qualification of practice for PAs. All jurisdictions required PAs to pass the Physician Assistants 

National Certifying Examination, administered by the National Commission on Certification of 

Physician Assistants (NCCPA) and open only to graduates of PA educational programs 

accredited by the Accreditation Review Commission on Education for the Physician Assistant 

(ARC-PA), which is sponsored by the AMA, the American Academy of Family Physicians, the 

American College of Surgeons, the American Academy of Pediatrics, the American College of 

Physicians, the Association of Physician Assistant Programs, and the American Academy of 

Physician Assistants. Only those successfully completing the examination may use the credential 

“Physician Assistant-Certified (PA-C).” 

PAs are educated in accredited programs located in academic medical centers, teaching hospitals, 

universities, and colleges. The PA curriculum, like medical school, provides a generalist 

education that promotes the development of skills in clinical problem solving and medical 

decision-making. Their medical education makes it possible for PAs to choose any medical or 

surgical specialty after graduation, something that is facilitated by the scope of their licenses. 

In order to remain certified, PAs must complete 100 hours of continuing education every 2 years. 

Every 6 years they must pass a recertifying exam or complete an alternate program combining 

learning experiences and a take-home exam. [AAPA, 2001] 

A Brief History of Certified Nurse Midwives 

Nurse Midwives have a lengthy history when considered in an international context. The 

presence of the profession in the United States, particularly among immigrant populations, spans 

many generations. In fact, there is documentation suggesting that a nurse midwife delivered three 

babies on the voyage of the Mayflower.16 However, the formal education of nurse midwives in 

the United States began when Mary Breckenridge founded the Frontier Nursing Service in East 

Kentucky in 1925.17 This highly regarded program educates midwives to provide nursing 

services in remote areas with a focus on women and families. Nurse midwives who continue to 

be trained in this program are credited with significantly reducing infant mortality rates in the 

areas that they serve.18 This program eventually began to educate nurse practitioners as well and 

continues today to serve its mission of educating providers to work with underserved 

populations. The Frontier School of Midwifery and Family Nursing offers a distance-learning 

15 Robert Wood Johnson Foundation, Institute for the Future, Health and Health Care 2010, Chapter 6,
 

http://www.rwjf.org/app/rw_publications_and_links/publicationsPdfs/iftf/chapter_6/ch6. p. 1.
 16 Parkland School of Nurse Midwifery, p. 1. 
 17 Robert Wood Johnson Foundation Anthology, Chapter 11, p. 4.
 18 Robert Wood Johnson Foundation Anthology, Chapter 11, p. 4 
 

10
 
program that enables many students to be in their own communities working with local providers 

while being educated as midwives.19 

In 1931, a collaboration of the Lobenstine Clinic and the Maternity Center Association began 

educating nurse midwives in New York City to serve immigrant and indigent populations in the 

city. That program continues today as the SUNY Downstate Nurse Midwifery Program.20 By the 

1950’s there were seven education programs for nurse midwives in the US. In 1955, Hattie 

Hemschemeyer, a public health nurse educator who had begun the Maternity Center education 

program in New York City, incorporated the American College of Nurse Midwifery in New 

Mexico. In 2000 there were over 8,00021 nurse midwives in the U.S., educated in 40 master’s 

degree programs and 5 post baccalaureate certificate programs.22 Educational programs for the 

profession were accredited by the American College of Nurse Midwives Division of 

Accreditation. 

Midwives advocate a more homeopathic, natural approach to childbirth with less emphasis on 

the use of technological innovation.23 This approach to obstetrical care has been integrated into 

extended scopes of practice that enable nurse midwives to provide women’s well-care and other 

gynecological services to non-obstetrical patients in many States. 

Nurse midwives in the United States are generally educated in a nursing model of care. In many 

States nurse midwives are regulated in legislation as advanced practice nurses. Several States 

permit practice by non-nurse midwives who are separately licensed and regulated by the 

individual States. Many States require that non-nurse midwives pass a competency examination. 

The American College of Nurse Midwives presently offers this exam to these “direct-entry” or 

“lay” midwives. 

Nurse Midwives are governed variously in the 50 States and the District of Columbia. Statutes 

and regulations addressing practice by nurse midwives is not uniform. Nurse midwives are 

mainly governed by State Boards of Nursing. In Utah, the profession is governed by a Certified 

Nurse Midwifery Board and in New York by a Board of Midwifery that regulates both nurse 

midwives and direct entry midwives. The profession is jointly regulated by the Board of Nursing 

and the Board of Medicine in 5 States and solely by the Board of Medicine in 2 States. Illinois 

has established an Advanced Practice Nursing Board that regulates advanced practice nurses 

(APNs) including nurse midwives. The Board of Health oversees practice of nurse midwives in 3 

States. 

In 2000, certified nurse midwives had some form of prescriptive authority in 49 States and the 

District of Columbia. National certification through examination is required in 44 States and the 

District of Columbia. Since 1971, the American College of Nurse Midwives (ACNM) and 

subsequently, since 1991, the ACNM Certifcation Council (ACC) have provided competency 

19 History of Midwifery in the United States, Parkland School of Nurse Midwifery,
 20 History of Midwifery in the United States, Parkland School of Nurse Midwifery,
 21 Health Policy Institute, 2000. 
 22 American College of Nurse Midwives, Education Programs, http://www.midwife.org/edu/postbacc.cfm. 
 23 Vann MK, CNM, MSN, Professional Autonomy for Midwives, An Essential Component of Collaborative 
 

Practice, Journal of Nurse-Midwifery, Vol. 43, No. 1, January/February 1998, p. 41. 
 

11
 
testing for nurse midwives. In 1998, the ACC began providing certification for non-nurse 

midwives trained in accredited education programs.

24 

Nurse midwives operate under various practice relationships with physicians. State regulation 

requires a range of supervisory, consultative, or collaborative arrangements with physicians. In 

11 States in 2000, there was no specific language addressing a required relationship between 

nurse midwives and physicians in statute or regulation.25 

There are over 8,000 nurse midwives in the United States providing care in many settings to a 

wide variety of women. Midwives provide a significant amount of care to women whose access 

is marginal. As many as 70 percent of the women receiving care from midwives are considered 

“vulnerable” in some aspect either by their demographic characteristics, their geographic 

location, or their socioeconomic status.26 

Factors Related to Professional Practice Indices 
 

A great many factors have influenced the evolution and acceptance of the three professions in the 

U.S. Figure 2-1 presents a highly simplified schematic that suggests some of the relationships 

that have contributed to the increased status and professional practice for the three professions 

over the past several decades. The figure emphasizes factors related to the contributions to 

patient care and outcomes that can be traced back to the three professions and to their 

collaborating physicians. The discussion that follows identifies several key factors related to the 

professional practice of the three professions to suggest the richness that exists in the framework 

that defines professional practice options. 

Barbara Safriet [2002] presents a much different perspective on professional practice of 

professionals like NPs, PAs, and CNMs. She argues that current professional practice statutes 

and regulations have generally resulted in significant gaps between “the abilities of nonphysician providers and the activities government regulation allows them to perform. Dominant 

provider groups extensively lobby State legislators in order to obtain scope-of practice 

monopolies, which confer exclusive control over their areas of interest and exclude other 

equally-capable groups from performing such services. As a result, the excluded providers’ skills 

are under-used, creating a systemic inefficiency”[p. 301]. 

NPs, PAs, and CNMs have fared reasonably well in this sometimes hostile political environment. 

The net result of these and other factors has been increased acceptance of the three professions 

across the U.S. The response of the system has been dramatic with numbers of practitioners 

increasing, and the roles, responsibilities, and scopes of practice expanding. 

24 About ACC, American College of Nurse Midwifery Certification Council, 
 

http://www.accmidwife.org/misc_aboutacc.php.
 25 American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and Regulations
 

2000, Washington, DC, 2000, p. xv. 
 26 ACNM, Basic Facts 
 

12
 
Professionalization 

NPs, PAs, and CNMs have undergone a process of “professionalization” over the past 30 years, 

and especially in the 1990s. Professionalization has been described by Hodson and Sullivan as 

the “effort by an occupational group to raise its collective standing by taking on the 

characteristics of a profession.”27 The professionalism process is characterized by several steps 

including: 

• Formation of a professional organization and lobbying the government and the public for 

increased professional standing, 

• Standardization of the body of knowledge through more uniform curriculum 

requirements and training, publication of journals, engagement in research, and creation 

of examination requirements for the profession, and 

• convincing the public by creating certification requirements that the occupation possesses 

appropriate professional knowledge and by licensure through public agencies.28 

27 Hodson R and Sullivan TA, The Social Organization of Work, Belmont, California, 2002, p. 295. 28 Hodson, p. 295 

13
Figure 2-1. Factors Related to Scope of Practice of PAs, NPs, and CNMs 

More Education 

Programs and 

Graduates 

Increased 

Scope of Practice 

More Practitioners 

Greater 

Acceptance by

the Public 

Hire More 

Professionals More Patients 

Treated Cost 

Effectively 

Increased 

Interest in Entering

Profession 

More 

Lobbying 

Greater 

Political 

Stature 

Bette

Achievem

Access G

Incr

Emph

Prev

Increased Physician 

Revenues 

Statutory 

and Regulatory

Change 

More 

Self Regulation 

14
Several activities occur within a profession during this process such as creation of a code of 

ethics and encouragement of volunteer activities which expose the profession to the public, but 

also reinforce an altruistic perception of the occupation which further bolsters professional 

recognition.29 The NP, PA, and CNM professions actively engaged in these processes in the 

1990s. An interesting concomitant process that has occurred over this last decade is a general 

deprofessionalization of all medical professionals, including physicians. Hodson and Sullivan 

indicate that this process is characterized by several different processes including: the 

“demystification” of the professional body of knowledge, increased regulation of the profession, 

and increased managerial control over the professionals.30 

Several influences have contributed to this process including a public that has had increased 

access to medical information on the internet, through television and news reports, through 

advertisements, and a host of readily available resources to inform them about personal health, 

healthcare delivery and innovation, and health research. This “consumer empowerment”31 has 

increased the scrutiny of the health professions by the public, created a sharing of the body of 

knowledge that was once mainly the purview of the physician, and has subtly created a situation 

in which physicians are now being somewhat deprofessionalized. 

Regulation in healthcare has increased significantly with Federal and State governments 

increasingly establishing rules, creating oversight and audit functions, mandating reporting 

requirements, and creating payment rates and methodologies. Managerial control of the 

physician profession has also increased with managed care organizations and professional 

managers and accountants introducing their rules and restrictions on the medical profession thus 

reducing the autonomy of physicians. 

At the same time, the 1990s may rightly be called a decade of professionalization for NPs, PAs, 

and CNMs. These groups began the decade as acknowledged but loosely regulated professions. 

The growing demand for primary care providers created a climate conducive to their growth. 

Competition with physicians was not an issue in an environment with many patients unable to 

access physicians. The medical profession and professional health care managers were forced to 

employ alternate strategies in order to meet the demands on their practices. Once again, 

economics served the non-physician providers. They were less expensive than new physicians, 

and in the climate of cost containment, they were ideal alternatives. They could provide basic 

care, leaving the more difficult patients and problems to the physicians. 

Conclusions 

Many factors help to determine the acceptance of NPs, PAs, and CNMs and ultimately their 

professional practice options. Perhaps the primary determinants are the positive experiences of 

physicians working with three professions as reflected in relationships like those shown in Figure 

2-1. There are a host of other important factors that determine the professional practice of the 

three professions, several of which have been discussed in this chapter. The primary conclusion 

is that NPs, PAs, and CNMs were extraordinarily successful in finding, creating, and filling their 

respective positions in the healthcare system in the last decade. 

29 Hodson, p. 296 30 Hodson, p. 298 31 Hodson, p. 297 

15
16
Chapter 3. Professional Practice Indices 

This chapter summarizes the key concepts and scoring criteria used in the creation the 

professional practice indices for the three professions. It includes the following sections: 

• Introduction 

• The Original Practice Environment Indices 

• The New Professional Practice Indices 

The numerical index scores for NPs, PAs, and CNMs are summarized in State-by-State listings 

in Chapters 4, 5, and 6, respectively. The detailed professional practice criteria and scores for the 

original indices for each of the 50 States are provided in Appendix C. The criteria and scores for 

the new professional practice indices for NPs, PAs, and CNMs are detailed in Appendices D, E, 

and F, respectively. 

Introduction 

This chapter describes the effort in this study to replicate these three indices for the year 2000 as 

part of a larger study of the professional practice of the three professions. Comparisons of the 

indices for 1992 and 2000 reveal the extent to which the practice environment has changed for 

the three professions in each of the 50 States over the 8 year period. 

In addition to replicating the 1992 index, the current project has also developed a new index with 

different criteria and weighting schemes that better reflect the current status and roles of the three 

professions in the health workforce. The overall purpose of the new indices remains the same as 

that of the original indices, i.e., to define the professional practice options, structural identity, and 

market recognition of the three professions in each of the 50 States. 

17
The detailed calculations for all the indices presented in Appendices C, D, E, and F include an 

“optimal score” for each criterion. This optimal score represents the highest score that can be 

awarded to a State for that criterion, which occurred only when the legal environment for the 

profession is “optimal” for that criterion. Decisions about what is optimal for each profession are 

based primarily on statements, observations, and recommendations by the respective professions 

through their professional associations, and by other interested stakeholders. Input has been 

received from hundreds of stakeholders as part of this definition process. 

The three original indices assigned scores for each State ranging from 0 for “no practice 

environment” to 100 for “optimal practice environment”. The new index also uses a 0 to 100 

scoring system. The summary tables for the three professions presented in Chapters 4, 5, and 6 

also present a five-category “grading system”, which may be easier for policy makers to 

understand as they consider the possible need for changes in professional practice statutes or 

regulations in the future. 

The Original Practice Environment Indices 

In their 1994 article, Edward Sekscenski and colleagues presented three statistical indices 

representing the practice environments for NPs, PAs, and CNMs in the 50 States and the District 

of Columbia. They also examined the relationships between and among their indices for the three 

professions (NPs, PAs, and CNMs) and numbers of practitioners per capita and access to care for 

underserved populations for the 50 States. They theorized that increases in numbers of providers 

would enhance accessibility. They hypothesized that the number of practicing professionals in a 

location would be positively correlated with the legal climate within the State in which practice 

occurred. One of the hypotheses of this study is that States with more hospitable environments 

(as measured by the professional practice indices) would exhibit greater growth in the numbers 

of NPs, PAs, and CNMs. 

The statistical indices, based on the specific legal status, reimbursement, and prescriptive 

authority for the three professions in the fifty States, resulted in the assignment of values from 0 

to 100 for each State, based on practice environments in 1992. Although there was commonality 

among the three professions in their basic focus on primary care, the professions were distinct in 

professional practice, health orientation, and skills required in the different States. It was 

determined that accurate evaluation required examination of each profession on the basis of 

specific criteria relevant to that profession. 

The current study includes a replication of the scoring criteria used by Sekscenski et al to assess 

the legal practice environments in individual States in the year 2000 using the same criteria and 

weights as in the original study. This replication suffers from several limitations: 

• The original documentation was unavailable as a resource for the replication. 

• The absence of fundamental documentation from the primary study made it very difficult 

to score the more discrete criteria accurately for the year 2000. 

• Practice environments have evolved rapidly and significantly in the intervening 8 years. 

The elements of the scale which were relevant to practice in the early 1990s have shifted 

in value and importance as the legal and health care environments have advanced. In 

addition, several influential factors affect practice differently in 2000 than in 1992. 

18
• The categories are broad and do not capture important differences and nuances of current 

professional practice legislation. 

In order to complete the scoring, a number of assumptions were made about the allocation of the 

scores in 1992 in order to score for the year 2000. The final index scores for NPs, PAs, and 

CNMs are summarized in Chapters 4, 5, and 6, respectively, and the details of the scoring are 

presented in Appendix C. 

The New Professional Practice Indices 

After replication and review of the original indices, it was decided that more detailed indices of 

current practice regulations were needed to better reflect the healthcare environments of the three 

professions in the year 2000. The purpose of these new indices was to more accurately represent 

the variations across the States based on more comprehensive and detailed sets of criteria than 

were used in the original indices. In creating the new indices, some of the basic assumptions of 

the original scales were retained in order to allow some comparison between the two scales. The 

new scale incorporates the following features: 

• Since the broad categories of legal authority, reimbursement, and prescriptive authority 

remained valid, they were retained from the original indices. 

• The weights for each category were shifted to a more equitable division on the 100 point 

scale from the original scoring distribution used by Sekscenski et al (i.e., legal status = 20 

points; reimbursement = 40 points; and prescriptive authority = 40 points). 

• The weighting of each category in the new indices depended on the profession being 

scored. NPs and CNMs (legal status = 35 points, reimbursement = 35 points, and 

prescriptive authority = 30 points) were scored differently than PAs (legal status = 35 

points, reimbursement = 25 points, and prescriptive authority = 40 points). This was done 

because reimbursement impacts practice differently for CNMs or NPs practicing in a 

more independent model of practice. Since PAs are educated to practice under the 

supervision of physicians, direct reimbursement is not as important for them. Prescriptive 

authority, which is presently almost universally available to CNMs and NPs, is a major 

focus of the PAs who are more restricted in prescriptive privileges than the other two 

professions. 

• Legal status is assumed to be a driver of the other categories, although it is not considered 

a more important category. If the legal description of professional practice was 

permissive in language or privilege, it was expected that reimbursement rules and 

prescriptive privileges would be commensurately liberal. Conversely, if the language was 

restrictive, it was suspected that reimbursement and prescriptive authority would be 

limited. A total of 35 points is possible for this category for all three professions. 

• Reimbursement for services is a complex issue affected by State and Federal regulations, 

by State and Federal reimbursement and insurance law, by individual insurance company 

practice, and by employer choices. Fieldwork discussions in several States indicated that 

reimbursement was an important issue in many States for the three professions. It is the 

“new frontier” for professional practice changes for the professions in a number of States. 

Reimbursement is often predicated on limitations that dictate how, where, by whom, and 

19
under what conditions health services are provided. The scoring of this category was 

extremely challenging. 

• As presented, the reimbursement score is intended to capture the broader legislative and 

regulatory environment. The authors recognize that legislation merely enables the 

process, and may not fully reflect actual reimbursement practices. Implementation of 

statutes and regulations is interpretative and individual payers are guided by business 

principles and practices, legal exemptions, and employer prerogatives in their 

reimbursement policy. A detailed account of actual reimbursement practices in each State 

would require an exhaustive study of third party payers, which was not possible within 

the scope of this study. This category was allocated 35 points in the indices for NPs and 

CNMs, and 25 points for PAs. 

• Prescriptive Authority has changed in most States since the original index was scored, 

and many State practice environments have evolved considerably with respect to 

prescriptive privileges. A total of 30 points were allotted to this category for NPs and 

CNMs, while 40 points were allotted in the PA index. As previously indicated, 

prescriptive authority is a particularly important issue for the PAs since they have limited 

or no authority in several States. 

The Autonomy of the Three Professions 

The criteria chosen for the new scoring system were synthesized from several sources. Ideal 

legislation composed and proposed by various professional organizations which represent NPs, 

PAs, and CNMs were major resources when determining items to be scored. 

The new indices attempt to identify receptive practice environments that are conducive to 

professional autonomy. Language that adequately expresses the benchmarks for practice was 

difficult to identify. Capturing factors that contribute to an ideal practice environment within the 

confines of a scoring instrument was problematic since what is considered ideal varies by 

profession. The use of the words ‘independent’ and ‘autonomous’ generated considerable 

discussion among researchers, advisors, experts, and informants consulted by project staff. 

Autonomy is perhaps best described as “the extent to which a..[professional]...can determine 

independently the range of tasks... (s/he)... will perform.” [Chumbler, et. al. p. 2] 

Autonomy should not be confused with practice that is independent of other health care 

providers. NPs, PAs, and CNMs provide care in an interdependent healthcare delivery system 

that demands the varying expertise and competencies of a wide range of providers. The use of 

the words ‘independent’ or ‘autonomous’ in this report is not intended to suggest that these 

providers need not communicate with and seek advice or approval from other professionals when 

making clinical decisions. Rather this terminology is intended to convey the ability of the 

professional to make decisions within the limits of the particular education, skill, and 

professional competency of the provider which results in efficient use of resources unimpeded by 

restrictive regulations, rules, and oversight. 

Health care delivery requires an interconnected network of professionals that supply care within 

a spectrum of services. Effective practice and rational use of health resources is most encouraged 

by and best achieved in a system that recognizes the complementarity of various medical 

professions and encourages efficient use of providers. 

20
The three professions practice in complex environments in a medically sophisticated society in 

which there are both competing and complementary interests. There are both similarities and 

differences among and between the three professions whose roles are highly technical, very 

specialized, and narrowly focused. The proliferation of new technologies and changing 

organizational and operational structures has effected each of these professions. While there is 

sometimes overlap in functions, each possesses a discrete identity and a distinct place in the 

system. To acknowledge this diversity and to recognize their individual professional natures, a 

unique scale was developed for each profession. The characteristics of a receptive environment 

do vary depending on the profession. 

The Scoring Methodology 

Structuring and scoring the new professional practice indices required the establishment of 

certain rules: 

• Only legislative changes passed by December 31, 2000 were to be scored. This meant 

that legislation enacted in early 2001 was not considered. The need to establish a deadline 

dictated this decision. 

• Scores were determined by rules found in legislation and regulation only. Variations in 

actual practice environments were not considered. If the category was not addressed in 

statute or regulation, no score was awarded. 

• NPs were scored as a single profession. Although there are many specialties within the 

NP profession, legislation is generally focused on the broad category of NP rather than on 

the sub-specialties. 

• Scoring was generally explicit, with scores based on specific provisions found in a 

statute, regulation, or rule that were relevant to the category. There were a few cases 

where the score was implicit. If the professional practice was sufficiently broad (such as 

in Oregon where no direct physician involvement is written into the statute enabling NP 

practice), certain assumptions were made. Practice as a self-employed nurse practitioner 

implied the ability to refer or to order diagnostic tests, even if those functions were not 

explicitly enumerated in statute or regulation. These functions were implicit to providing 

a continuum of care for the patient. 

• NPs and CNMs vary greatly from PAs in their basic orientation to physicians. PAs 

“practice medicine with supervision by licensed physicians” [PAs, 8th edition p iii], and 

are inextricably linked to physician direction in a medical model of care. NPs and CNMs 

are educated in a nursing model which emphasizes patient education and management. 

These professionals tend to view their expanded roles “as nurses with a broadened 

professional practice and do not define themselves as physician-supervised 

professionals.” [Buppert, p. 11]. These orientations create differences in the desired mode 

of practice of the three professions. 

The new scoring system was designed to reveal smaller, more subtle differences and distinctions 

in professional practice across the States than was possible with the original indices developed 

by Sekscenski et al. The broad criteria used for each profession are presented in chapters 4, 5, or 

6. The detailed point allocations for each of the criteria can be found in Appendices D, E, and F. 

21
22
Chapter 4. Nurse Practitioners 

This chapter summarizes the original practice environment index for NPs developed by 

Sekscenski et al, the 2000 update of this index, and the new professional practice index 

developed in this study for NPs for the fifty States plus the District of Columbia. It includes the 

following subsections: 

• Introduction 

• The Original Practice Environment Index for NPs 

• The New Professional Practice Index for NPs 

• Discussion 

Detailed criteria and scoring sheets for the three professional practice indices for NPs for the 50 

States and the District of Columbia can be found in Appendices C and E. 

Introduction 

Nurse practitioners (NPs) are registered nurses (RNs) with advanced academic and clinical 

experience which enables them to diagnose and manage acute, episodic and chronic illness, 

either independently or as part of a health care team. NPs provide some care once offered only 

by physicians, and in most States they have the ability independently to prescribe medications. 

As of 2000, all States and the District of Columbia had statutes or regulations governing the 

qualification and professional practice for NPs. Most jurisdictions required NPs to pass one of a 

number different general or specialty-specific certifying exams. [NCSBN, 1998] Laws in most 

States allow NPs to provide patient services independently in collaboration with a physician. 

Their clinical knowledge and experience as RNs, coupled with their advanced clinical training, 

enables NPs to work with patients on a wide range of clinical tasks. NP practice blurs the 

23
discipline boundaries between nursing and medicine so their services can both substitute for and 

complement the care of physicians. This ability to work across the spectrum of care delivery sites 

and manage patients in both hospital and ambulatory care settings has found acceptance in a 

growing number of settings and specialties. On the other hand, because the number of NPs is 

much smaller than the number of physicians, they are currently used in only a fraction of the 

sites where physicians work. 

An important long-term question is whether NPs will continue their penetration of the health care 

system. If they do, they could play a dramatically larger role in the health care system of the 

future. The roles of NPs are continuing to evolve in the health care system, however, and the 

future is not entirely clear. Recommendations by the recent AHA-sponsored Commission on 

Workforce for Hospitals and Health Systems [2002] suggests that NPs could play greater roles in 

the staffing of hospital care teams. If penetration of NPs continues in different medical and 

surgical specialties, there will clearly be a significant growth of the NP profession. The current 

attention to patient safety and health care quality suggests that NPs will be integral to future 

health care delivery across the U.S. 

The Original Practice Environment Index for NPs 

The original NP practice environment index developed by Sekscenski et al for 1992 was based 

on three broad criteria and point allocations reflecting the then present practice environment for 

the profession. The broad criteria and point allocations used in creating the index were Legal 

Status (Maximum Score = 20); Reimbursement (Maximum Score = 40); and Prescriptive 

Authority (Maximum Score = 40). The detailed point allocations for the original index for NPs 

in 2000 are presented in Table C-1 in Appendix C. 

The original professional practice index scores for NPs for the 50 States based on the criteria in 

Appendix C are summarized in Table 4-1. The scores show a definite trend toward broader 

professional practice across the fifty States and the District of Columbia between 1992 and 2000. 

The increases in the index scores indicate greater professionalization, socialization, and 

standardization of professional practice for NPs over the last decade. 

The New Professional Practice Index for NPs 

To better reflect the subtle differences that often exist in professional practice across the 50 

States, a new index was developed as part of this study that incorporates more criteria and more 

variability in the scores assigned. The new professional practice index more accurately reflects 

the practice environments of NPs across the U.S. Most States scored lower on the new index than 

on the original index for 2000, indicating that the expectations/possibilities about professional 

practice for NPs had increased since 1992. 

The broad scoring criteria for the new NP Professional Practice Index are the same as for the 

original index, but the point allocations are different. The three criteria are: Legal Status 

(Maximum Score = 35); Reimbursement (Maximum Score = 35); and Prescriptive Authority 

(Maximum Score = 30). The detailed point allocations for the new index for NPs for each of the 

50 States are presented in Appendix E. 

24
The new professional practice index scores for NPs for the fifty States and the District of 

Columbia resulting from the application of these criteria are presented in Table 4-1. A qualitative 

overlay to the new professional practice index scores has been provided to identify States that 

provide Excellent, Favorable, Acceptable, Limiting, or Restrictive practice environments for 

NPs. These terms and categories are not hard-and-fast. They are provided only to help readers to 

characterize the general practice environments in different States. The terms and ratings 

generally conform to characterizations of the practice environments in States by knowledgeable 

NPs. 

Discussion 

The scores on the original NP practice environment index reveal a trend toward greater practice 

opportunities for NPs across the fifty States and the District of Columbia between 1992 and 

2000. The scores indicate the trend towards greater professionalization, socialization, and 

standardization of the NP profession over the last decade. Additional analyses of the index scores 

are described and summarized in Chapter 7. 

Table 4-1 shows that most States scored lower on the new index than on the original 2000 index. 

This is an indication of the impact of the changing health care delivery system which places 

greater demands and requirements on health professionals in both clinical practice and practice 

management. The lower scores also reflect the greater efficiency of the new index in capturing 

nuances in practice options. For example, the prescriptive authority component of the original 

index had only a three-point scale for prescriptive authority, with 40 points for “full authority”, 0 

points for no authority, and an incompletely defined 1 to 39 points for “partial authority”. The 

prescriptive authority component of the new index on the other hand has seven parts, the largest 

of which is a graduated scale for type of authority that assigns 1 point for legend drugs only, 3 

points for Schedule V drugs, 6 points for Schedule IV and V drugs, 9 points for Schedule III to V 

drugs, and 12 points for Schedule II to V drugs. Thus, the new index provides a better basis for 

identifying differences in professional practice options for NPs in different States in 2000 than 

does the original index. 

As is true with many such indices, the true differences that underlie small differences in the 

scores are generally very small. Thus, states that are close on any of the indices are not 

significantly different in their professional practice. 

Comparisons of individual NP professional practice scores on a State-by-State basis should be 

made with caution. The scores reflect general, not particular, conditions in the State regulatory 

environments. Comparing one State with another on the original practice environment index may 

not fully reflect similarities or differences in actual practice patterns. The index is a good basis 

for assessing trends toward broader practice environments, but it does not capture or reveal 

detailed variations in State environments. 

25
Table 4.1

Professional Practice Indices for NPs in the Fifty States and District of Columbia

State 

Sekscenski Index New Index Rating 1992 2000 Change 

New Mexico 

Arizona 

Iowa 

Oregon 

Montana 

Maine 

Washington 

62 99 37 

86 96 10 

73 98 25 

100 100 0 

98 98.5 0.5 

42 90 48 

90 100 10 

94 

92 

92 

92 

91.5 

91 

91 

Excellent Environment 

Idaho 

Alaska 

Colorado 

Connecticut 

Delaware 

Minnesota 

New Hampshire 

New ork Y

North arolina C

Kansas 

California 

Utah 

Rhode Island 

New Jersey 

Wyoming 

46 98.5 52.5 

93 93 0 

59 100 41 

58 100 42 

60 100 40 

68 99 31 

95 95 0 

93 93 0 

53 88 25 

52 90 38 

30 70 40 

91 100 9 

50 98 48 

65 79.5 14.5 

94 90 -4 

89.5 

88 

86 

86 

86 

86 

86 

86 

86 

84 

84 

84 

83 

82.5 

82 

Favorable Environment 

Maryland 

South Dakota 

Massachusetts 

Kentucky 

District of Columbia 

North Dakota 

Ohio 

Pennsylvania 

Michigan 

Nebraska 

Indiana 

93 93 0 

65 92 27 

68 86 18 

78 67.5 -10.5 

53 73 20 

98 98 0 

14 90 76 

66 86 20 

45 63 18 

46 78 32 

34 98.5 58.5 

78 

78 

77 

76.5 

75 

74.5 

73 

73 

72 

72 

71.5 

Acceptable Environment 

Wisconsin 

Arkansas 

Oklahoma 

West Virginia 

Texas 

Tennessee 

Florida 

Louisiana 

Hawaii 

Vermont 

Illinois 

Missouri 

Mississippi 

Nevada 

67 80 13 

48 78 30 

40 62 22 

89 89 0 

42 67 15 

27 87 60 

68 68 0 

20 62 42 

27 60.5 33.5 

68 80 12 

14 87 73 

63 70 7 

72 69 -3 

73 68 -5 

69 

67 

67 

66 

65.5 

64 

62 

62 

61.5 

61 

60 

60 

59 

58.5 

Limiting Environment 

Alabama 

Virginia 

Georgia 

South arolina C

33 43 20 

38 38 0 

32 52 20 

41 51 10 

48 

47 

45 

43 

Restrictive Environment 

26
Chapter 5. Physician Assistants 

This chapter summarizes the original practice environment index developed by Sekscenski et al, 

the 2000 update of this index and the new professional practice index developed in this study for 

Physician Assistants for the fifty States plus the District of Columbia. It includes the following 

subsections: 

• Introduction 

• The Original Practice Environment Index for PAs 

• The New Professional Practice Index for PAs 

• Discussion 

Detailed criteria and scoring sheets for the three professional practice indices for PAs for the 50 

States and the District of Columbia can be found in Appendices C and D. 

Introduction 

From the beginning, PAs have provided primary care services to patients in a wide range of 

settings including physician offices, hospitals, health clinics, correctional facilities, emergency 

centers, outpatient clinics, and a variety of military settings. PAs are recognized as providers of 

quality health services who are closely tied to physicians in medical practice. PAs work under 

varying degrees of supervision ranging from direct or personal supervision to indirect or remote 

supervision depending on the State in which practice occurs, on the setting in which care is 

offered and on the particular services which are being provided. 

In 2000 there were about 40,000 PAs in active practice32 working in both primary and specialty 

care. PAs are increasingly finding work in specialty practices including emergency medicine, 

32 AAPA, Facts At A Glance. 

27
allergy, orthopedics, cardiology, and neurosurgery. In recent years, the supply of PAs has 

expanded considerably with a variety of opportunities emerging for the profession. The practice 

environments of PAs vary significantly across States. 

The Original Practice Environment Index for PAs 

The original PA practice environment index developed by Sekscenski et al for 1992 was based 

on three broad criteria and point allocations reflecting the then present practice environment for 

the profession. The specific criteria and point allocations used in creating the index were Legal 

Status (Maximum Score = 20); Reimbursement (Maximum Score = 40); and Prescriptive 

Authority (Maximum Score = 40). The detailed point allocations for the original index for PAs 

in 2000 are presented in Table C-2 in Appendix C. 

The original practice environment index scores for PAs for the 50 States resulting from the 

criteria in Appendix C are summarized in Table 5-1. The scores show a definite trend toward 

greater professional practice opportunities across the fifty States and the District of Columbia 

between 1992 and 2000. The increases in the index scores indicate greater professionalization, 

socialization, and standardization of professional practice for PAs over the last decade. 

The New Professional Practice Index for PAs 

To better reflect the subtle differences that often exist in professional practice across the 50 

States, a new index was developed as part of this study that incorporates more criteria and more 

variability in the scores assigned. The new professional practice index more accurately reflects 

the practice environments of PAs across the U.S. Most States scored lower on the new index than 

on the original index for 2000, which reflects the greater ability of the new index to distinguish 

subtle differences in professional practice that the original index. 

The broad scoring criteria for the new PA Professional Practice Index are the same as for the 

original index, but the point allocations are different. The new PA index incorporates more 

detailed criteria than those used in the original index to more accurately reflect the practice 

environments of PAs across the U.S. The three criteria are: Legal Status (Maximum Score = 

35); Reimbursement (Maximum Score = 25); and Prescriptive Authority (Maximum Score = 

40). The detailed point allocations for each of the criteria in the new index for PAs for each of 

the 50 States are presented in Appendix D. 

The resulting professional practice index scores for PAs are presented for the 50 States in Table 

5-1. A qualitative overlay has been applied to the new index scores to identify States that provide 

Excellent, Favorable, Acceptable, Limiting, and Restrictive practice environments for PAs. 

These are not hard-and-fast terms or categories, and they are provided only to help readers to 

characterize the practice environments in the different States. The ratings do generally conform 

to characterizations of the practice environments in States by knowledgeable PAs. 

Discussion 

The scores on the original PA practice environment index reveal a trend toward greater 

professional practice options for PAs across the fifty States and the District of Columbia between 

28 
1992 and 2000. The scores indicate the trend towards greater professionalization, socialization, 

and standardization of the PA profession over the last decade. Additional analyses of the index 

scores are described and summarized in Chapter 7. 

As is true with many such indices, the true differences that underlie small differences in the 

scores are generally very small. Thus, States that are close on any of the indices are not 

significantly different in their professional practice. The authors have applied a qualitative 

overlay to the new index scores to identify States they believe provide Excellent, Favorable, 

Acceptable, Limiting, and Restrictive environments for PAs. These are not hard-and-fast terms 

or categories, and they are provided only to help readers to characterize the practice 

environments in the different States in a more qualitative way. The terms do generally conform 

to characterizations of the practice environments in States by knowledgeable PAs. 

Comparisons of individual PA professional practice scores on a State-by-State basis should be 

made with caution. The scores reflect general, not particular, conditions in the State regulatory 

environments. Comparing one State with another on the original index may not fully indicate the 

similarities or differences in actual practice patterns. The index is a good indicator of the trend 

toward broader practice environments, but it does not effectively capture the detailed variations 

in State requirements. 

29
Table 5-1

Professional Practice Indices for PAs in the Fifty States and District of Columbia

State 

Sekscenski Index New Index 

for 2000 

Rating Based on 

1992 2000 Change New Index

North Carolina 

Oregon 

Montana 

92 94 2 

99 99 0 

98 99.5 1.5 

94 

92 

91 

Excellent Environment 

Michigan 

New Hampshire 

Rhode Island 

Iowa 

Illinois 

Tennessee 

Utah 

New Mexico 

New York 

West Virginia 

California 

Connecticut 

Maine 

Wisconsin 

Arizona 

Delaware 

Massachusetts 

Vermont 

Washington 

Alaska 

South Dakota 

Minnesota 

Wyoming 

89 97 8 

95 97 2 

93 97 4 

99 99 0 

59 59 0 

42 99 57 

93 98 5 

94 98 4 

98 99 1 

96 99 3 

58 97 39 

87 97 10 

94 94 0 

95 95 0 

99 99 0 

55 68 13 

83 92 9 

86 95 9 

100 100 0 

90 96.5 6.5 

94 97 3 

83 88 5 

97 97 0 

89 

89 

88 

87 

86 

86 

85 

84 

84 

84 

83 

83 

83 

83 

82 

82 

82 

82 

82 

81.5 

81.5 

81 

81 

Favorable Environment 

Nebraska 

Hawaii 

Oklahoma 

Georgia 

Maryland 

Kansas 

Colorado 

Pennsylvania 

Idaho 

93 94 1 

38 99 61 

46 96 50 

59 96 37 

49 90 41 

87 96.5 9.5 

80 95 15 

86 86 0 

89 87.5 -1.5 

79 

78 

77.5 

77 

76 

75.5 

75 

73 

72.5 

Acceptable Environment 

North Dakota 

Arkansas 

Texas 

Nevada 

Alabama 

Florida 

Missouri 

Kentucky 

Louisiana 

South Carolina 

Indiana 

87 88 1 

54 98 44 

77 93 16 

98 95.5 -2.5 

39 89 50 

48 93 45 

39 97 58 

42 75 33 

37 60 23 

37 80 43 

37 77 40 

69.5 

69 

67 

64.5 

61 

61 

61 

54 

54 

52 

50 

Limiting Environment 

Mississippi 

New Jersey 

Virginia 

District of Columbia 

Ohio 

0 88 88 

37 42 5 

42 67 25 

92 59 -33 

51 55 4 

49 

48 

47 

45 

36.5 

Restrictive Environment 

30
Chapter 6. Certified Nurse Midwives 

This chapter summarizes the original and new professional practice indices for CNMs for the 

fifty States. It includes the following subsections: 

• Introduction 

• The Original Practice Environment Index for CNMs 

• The New Professional Practice Index for CNMs 

• Conclusions 

Detailed scoring sheets for CNMs for each of the 50 States can be found in Appendices C and F. 

Introduction 

The profession of midwifery has a history spanning both centuries and geography and is 

arguably the most publicly known of the professions that are subjects of this research. CNMs are 

healthcare providers who combine the skills of nursing with the competencies of midwifery. 

Midwives have a special focus on childbirth guided by an orientation that birth is a normal 

physiological process not an illness. 

Presently, nurse midwives provide birthing services but their practice is also augmented by skills 

obtained in advanced education to include well women health care and educational services as 

well as family planning services. Nurse midwives attend just under 10 percent of all vaginal 

births in the United States.33 Contrary to public perception, 99 percent of these births occur in a 

hospital or birthing center with less than 1 percent occurring in homes.34 

33 American College of Nurse-Midwives (ACNM), “Basic Facts About Certified Nurse-Midwives”, 

http://www.midwife.org/prof/display.cfm?id=6. 34 ACNM, Basic Facts. 

31
Nurse Midwives are currently licensed in every State. Some States regulate nurse midwifery as a 

separate profession while others regulate the profession as a special class of nurse in advance 

practice nurse legislation. In most States, the Board of Nursing governs the profession. Nurse 

Midwives are separately regulated by a Board of Midwifery in only two States, Utah and New 

York. The legal status and scope of practice of midwives varies significantly across the 50 States 

and the District of Columbia. 

The Original Practice Environment Index for CNMs 

The original CNM practice environment index developed by Sekscenski et al for 1992 was based 

on three broad criteria and point allocations reflecting the then present practice environment for 

the profession. The specific criteria and point allocations used in creating the index were Legal 

Status (Maximum Score = 20); Reimbursement (Maximum Score = 40); and Prescriptive 

Authority (Maximum Score = 40). The detailed point allocations for the original index for 

CNMs are presented in Table C-3 in Appendix C. 

The original professional practice index scores for CNMs for the 50 States resulting from the 

criteria in Table C-3 in Appendix C are summarized in Table 6-1. The scores show a definite 

trend toward greater professional practice options across the fifty States and the District of 

Columbia between 1992 and 2000. The increases in the index scores indicate greater 

professionalization, socialization, and standardization of professional practice for CNMs over the 

last decade. 

The New Professional Practice Index for CNMs 

To better reflect the subtle differences that often exist in professional practice across the 50 

States, a new index was developed as part of this study that incorporates more criteria and more 

variability in the scores assigned. The new professional practice index more accurately reflects 

the practice environments of CNMs across the U.S. in 2000. 

Table 6-1 shows that most States scored lower on the new 2000 index than on the original 2000 

index. This is an indication of the impact of the changing health care delivery system which 

places greater demands and requirements on health professionals in both clinical practice and 

practice management. For example, statutes defining Managed Care Organizations added new 

reimbursement options for CNMs between 1992 and 2000 in many States. 

Discussion 

The scores on the original CNM practice environment index reveal a trend toward more practice 

options for CNMs across the fifty States and the District of Columbia between 1992 and 2000. 

The scores indicate the trend towards greater professionalization, socialization, and 

standardization of the CNM profession over the last decade. Additional analyses of the index 

scores are described and summarized in Chapter 7. 

As is true with many such indices, the true differences that underlie small differences in the 

scores are generally very small. Thus, States that are close on any the indices are not 

significantly different in their professional practice. The authors have applied a qualitative 

32
overlay to the new index scores to identify States they believe provide Excellent, Favorable, 

Acceptable, Limiting, and Restrictive environments for CNMs. These are not hard-and-fast terms 

or categories, and they are provided only to help readers to characterize the practice 

environments in the different states in a more qualitative way. The terms do generally conform to 

characterizations of the practice environments in States by knowledgeable CNMs. 

Comparisons of individual CNM professional practice scores on a State-by-State basis should be 

made with caution. The scores reflect general, not particular, conditions in the State regulatory 

environments. Comparing one State with another on the Sekscenski index may not fully indicate 

the similarities or differences in actual practice patterns. The index is a good indicator of the 

trend toward broader practice environments, but it does not effectively capture the detailed 

variations in State requirements. 

33
Table 6-1

Professional Practice Indices for CNMs in the 50 States and District of Columbia

State 

Original Index New Index 

for 2000 

Rating Based on 

1992 2000 Change New Index

Washington 

New York 

Maine 

62 100 38 

67 90 23 

90 90 0 

92 

92 

91 

Excellent Environment 

Utah 

Rhode Island 

New Mexico 

Alaska 

Connecticut 

Oregon 

Minnesota 

Iowa 

Delaware 

Colorado 

New Hampshire 

Montana 

Idaho 

Maryland 

73 88 15 

84 90 6 

78 90 12 

84 90 6 

93 90 -3 

80 90 10 

100 100 0 

55 97 42 

60 100 40 

50 100 50 

70 95 25 

98 98 0 

54 100 46 

69 90 21 

89 

88 

88 

88 

86 

85 

84 

84 

83 

82 

82 

82 

81 

80 

Favorable Environment 

Arizona 

South Dakota 

Wyoming 

Kansas 

Massachusetts 

Indiana 

West Virginia 

North Carolina 

District of Columbia 

Ohio 

North Dakota 

Michigan 

Kentucky 

Vermont 

Arkansas 

Texas 

California 

Oklahoma 

76 96 20 

70 89 19 

60 90 30 

68 83 15 

57 90 33 

25 98 73 

80 90 10 

90 90 0 

60 80 20 

60 90 30 

55 97 42 

70 70 0 

68 68 0 

57 80 23 

35 78 43 

54 67 13 

80 70 -10 

54 60 6 

79 

78 

77 

76.5 

74 

73.5 

73 

73 

72 

71 

70.5 

69 

68.5 

64 

64 

62 

60 

60 

Acceptable Environment 

Virginia 

Tennessee 

Missouri 

Florida 

Hawaii 

Wisconsin 

Louisiana 

New Jersey 

Mississippi 

Nevada 

Pennsylvania 

47 67 20 

56 59 3 

27 60 33 

98 58 -40 

42 67 25 

62 78 16 

37 70 33 

54 47 -7 

59 59 0 

30 58.5 28.5 

34 50 16 

59 

59 

59 

58 

57.5 

57 

56 

55 

54 

52.5 

52 

Limiting Environment 

Nebraska 

Illinois 

Georgia 

South Carolina 

Alabama 

50 50 0 

31 71 40 

70 59 -11 

59 59 0 

32 50 18 

44 

43 

43 

39 

38 

Restrictive Environment 

34
Chapter 7. Factors Related to Professional Practice 

Indices 

• This chapter summarizes a series of statistical analyses performed to estimate the extent 

to which different factors and variables are related to the professional practice indices 

developed in this study. It includes the following subsections: 

• Introduction 

• Factors Related to Professional Practice Indices 

• Other Patterns and Relationships 

• Conclusions 

Introduction 

The professional practice indices presented in the preceding chapters have some limited intrinsic 

value for policy makers interested in the three professions, but much of the interest by health 

policy makers in these statistics comes from understanding how the indices are related to the 

numbers of practitioners in the three professions and, ultimately, to access to patient care, 

especially for underserved populations. 

This chapter examines several hypotheses related to the professional practice indices for NPs, 

PAs, and CNMs, the numbers of professionals per capita for the three professions in the 50 

States, and several measures related to access to and the delivery of care. Given the changes that 

have taken place in health care and the health workforce in the 1990s, three general patterns were 

hypothesized with respect to each of the three professions. 

35
• The legal scopes of practice (as measured by the indices described above) increased 

significantly between 1992 and 2000 across the 50 States, indicating increasing 

acceptance of the professions by physicians, the public, and government regulators. 

• Variations in the professional practice declined between 1992 and 2000, indicating a 

general convergence or standardization of professional practice environments across the 

States. 

• Positive relationships (i.e., correlations) exist between the professional practice indices 

and the relative supply of practitioners for the three professions (as measured by 

practitioner per capita ratios). 

In addition to these three key hypotheses, the authors performed supplementary analyses of the 

relationships between the three professions and physicians (i.e., PAs with all physicians, NPs 

with all physicians, and CNMs with ob-gyns). Of particular interest is whether or not the three 

professions and physicians have a complimentary relationship or a substitutive relationship with 

one another. 

Analyses were also performed to assess the extent of relationships between the professional 

practice indices and other measures of the health care system and the health status of the 

population. These include HMO penetration in the States and the percentages of States’ 

populations living in Health Professions Shortage Areas (HPSAs). 

Data and Methods 

The data set compiled for this study includes a number of variables summarized in Table 7-1. 

The original index for 2000 was developed by identifying specific criteria and weighting 

schemes that would permit replication of the 1992 indices, and then applying these criteria and 

weights to conditions in 2000. Because some of the historical files related to the earlier study 

were not available, it was not possible to identify criteria that permitted replication all of the1992 

scores. Several of the criteria used by Sekscenski required application of judgment about points 

assigned for certain conditions, and the authors were unable to devise a single weighting scheme 

that would successfully replicate the earlier indices for all the States. Also, the authors did not 

have complete copies of all statutes and regulations in force in the 50 States in 1992, which 

complicated the task of assigning scores for specific elements of the indices. Despite these 

limitations, it was possible to replicate the 1992 scores for 45 of the 50 States. 

The data presented in Table 7-2 summarize the original index scores as reported in their NEJM 

article, along with the results of applying the authors’ best choice of criteria uniformly for all 50 

States for 2000. Thus, State scores for 1992 are based on internally consistent criteria and 

definitions, as are the State scores for 2000. While there is some question about the validity of 

comparisons of 1992 and 2000 indices, the fact that the authors were able to replicate 90 percent 

of the State scores of 1992—and that in the cases where replication was not possible the 

differences were negative—provides a basis for confidence in the comparisons. 

The practitioner counts for 1992 were estimated from the article by Sekscenski et al. Counts for 

later years were obtained from other sources that appear to be the most reliable as indicated in 

Table 7-1. The data for PAs is believed to be generally accurate and comparable over time. The 

data for NPs and CNMs, while improving in recent years, have gaps in the early 1990s that will 

require attention before reliable year-to-year comparisons can be made for this time period. 

36
Table 7-1 

Variables Used to Test Study Hypotheses 

Variable Definition Source 

PA ’00 and ‘96 Number of PAs for 2000 and 1996 AAPA Census Report 

NP ‘00 and ‘96 Number of NPs for 2000 and 1996 National Council of State 

Boards of Nursing, Inc. 

CNM ‘00 and ‘96 Number of CNMs for 2000 and 1996 National Council of State 

Boards of Nursing, Inc. 

Population ‘00 Civilian Pop in U.S., ‘00 US Bureau of the Census 

Physicians ‘00 Non-Federal physicians, ‘00 AMA, Physician 

Characteristics & Distribution 

PA / Pop ‘00 # of PAs per 100K Pop, 2000 Computed 

NP / Pop ‘00 # of NPs per 100K Pop, 2000 Computed 

CNM / Pop ‘00 # of CNMs per 100K Pop, 2000 Computed 

PA / Pop ‘92 # of PAs per 100K Pop, 1992 Sekscenski et al [1994] 

NP / Pop ‘92 # of NPs per 100K Pop, 1992 Sekscenski et al [1994] 

CNM / Pop ‘92 # of CNMs per 100K Pop, 1992 Sekscenski et al [1994] 

PA/Phys ratio ‘00 The ratio of physician assistants to 

physicians in 2000 Computed 

NP/Phys ratio ‘00 The ratio of nurse practitioners to 

physicians in 2000 Computed 

CNM/Ob-Gyn ‘00 The ratio of certified nurse midwives to 

Ob-Gyns in 2000 Computed 

‘92 Original Index: The practice environment index 

created by Sekscenski et al (1994) Sekscenski et al [1994] 

‘00 Original Index A practice environment index for 2000 

based on Sekscenski scoring system Developed by this study 

‘00 New Index A new professional practice index for 

2000 using more detailed criteria Developed by this study 

% of Pop in HPSAs ‘00 % of State population living in 

Federally designated HPSAs in 2000 

BCHDNET, HRSA, Division of 

Shortage Designation, 2000 

HMO Penetration ‘00 % of State population enrolled in an 

HMO in 2000 

NCHS, Table 146, Health, 

United States, 2002. 

37
The primary analysis tool used in this study was Spearman’s rank order correlation. This permits 

comparisons with Sekscenski et al [1994] which also used this technique. The paired t-test was 

used to compare average values of the Sekscenski indices for 1992 and 2000. In addition, the Ftest was used to compare the variances of the Sekscenski indices in 1992 and 2000. In all cases, 

an alpha level of 0.05 was used to test statistical significance. All tests were performed using 

SPSS for Windows version 11.0. 

Results 

Trends in Professional Practice Indices from 1992 to 2000 

Table 7-2 summarizes the information in Tables 4-1, 5-1, and 6-1. It shows clearly that on 

average the 50 States experienced statistically significant increases in the original practice 

environment indices for all three professions. This is a clear indication that the professional 

practice options for all three professions expanded between 1992 and 2000. 

Table 7-2 also shows that the standard deviation of the original scores across the States was 

smaller in 2000 than in 1992 for all three professions, and that the difference was statistically 

significant for NPs and PAs. This is an indication that there has been a general convergence of 

the professional practice across the 50 States between 1992 and 2000, especially for NPs and 

PAs. 

Table 7-2 

Original and New Professional Practice Indices for NPs, PAs, and CNMs, 1992 to 2000 

Comparisons of Means and Standard Deviations 

Original Index 

Mean Standard Deviation 

New Index 

Mean 

1992 2000 Difference p-value 1992 2000 p-value 2000 

NP 60.4 82.6 22.2 <0.0005 24.0 16.5 0.009 74.7 

PA 72.8 89.1 16.3 <0.0005 25.5 13.8 <0.0005 74.1 

CNM 62.2 79.3 17.1 <0.0005 19.2 16.4 0.734 69.6 

Table 7-3 presents the three major components (legal status, reimbursement, and prescriptive 

authority) of the new professional practice indices for NPs, PAs, and CNMs for all 50 States and 

the District of Columbia for the year 2000. This reveals insights about why one State may have a 

larger or smaller index for a profession than another State. The table shows that the average 

overall new index scores for NPs, PAs, and CNMs for 2000 were 74.7, 74.1, and 69.6, 

respectively, out of a possible total of 100. These scores are significantly lower than the 

respective original index scores, reflecting the fact that additional options and criteria have been 

included in the new indices. Readers interested in more detail about the new scope calculations 

for NPs, PAs, or CNMs may refer to Appendix E, D, or F, respectively. 

Comparisons of scores across the three professions, either on average or for individual States are 

not appropriate. The three indices are based on different criteria and weighting schemes and are 

not designed to serve as a standard for comparing the professions. 

38
Table 7-3

Components of the Professional Practice Indices for NPs, PAs, and CNMs, 2000

NP PA CNM 

Legal Reimb Rx Total Legal Reimb Rx Total Legal Reimb Rx Total 

2000 Professional Practice Index 

Optimal 35 35 30 100 35 25 40 100 35 35 30 100 

Average 25.2 28.1 21.4 74.7 25.2 19.8 29.1 74.1 22.7 27.4 19.4 69.6 

Std Dev 5.6 7.1 6.1 13.6 4.6 3.7 11.5 14.3 4.7 7.2 8.6 15.0 

Original Index for 2000 

Optimal 20 40 40 100 20 40 40 100 20 40 40 100 

Average 16.9 35.4 30.3 82.6 19.1 36.7 33.3 89.1 14.9 36.0 29.0 79.9 

Std Dev 4.8 7.0 12.4 16.5 1.8 8.9 12.8 13.9 5.8 6.7 14.1 16.4 

The gaps between the “optimal” scores and the average scores reveal that opportunities for States 

to increase the index scores for the three professions are generally greatest for prescriptive 

authority and legal status, and least for reimbursement. The lower a component score for a State 

below the “optimal”, the greater the opportunity to increase the index through appropriate 

adjustment in the corresponding criteria. 

The standard deviations of the component scores for the new indices show greater variability in 

scores across the States for prescriptive authority than for legal status and reimbursement. 

Comparisons of the standard deviations for the components of the three original indices were not 

made because of difficulties in replicating the 1992 indices for five States. 

Numbers of Practitioners 

Table 7-4 shows the increases in the numbers of NPs, PAs, and CNMs per 100,000 population 

that occurred between 1992 and 2000. Despite some data limitations for the earlier years, the 

estimates show that the growth has been dramatic, with NPs per capita growing by 190 percent, 

PAs per capita growing by 70 percent, and CNMs per capita growing by 65 percent over the 8 

year period. 

Table 7-4

Numbers of NPs, PAs, and CNMs per 100,000 Population in the US, 1992, 1996, and 2000

Numbers of Practitioners per 100K Pop '92-'00 % Change 

Profession and Year Min Max Mean 

NP 1992 2.7 37.2 10.9 

NP 1996 7.7 57.1 21.8 

NP 2000 11.9 137.9 33.8 

PA 1992 0.2 24.6 7.4 

PA 1996 1.2 32.2 9.6 

PA 2000 1.3 40.3 12.8 

CNM 1992 0.1 6.4 1.7 

CNM 1996 0.4 6.1 2.0 

CNM 2000 0.3 20.6 2.9 

Mean 

} +210% 

} +73% 

} +71% 

39
Relationships Between the Professional Practice Indices and Numbers of Practitioners 

An analysis of the relationship between the three components of each index for the three 

professions (legal status, prescriptive authority, and reimbursement) across the professions 

showed positive correlations among the components professional practice indices across States 

in 2000 (Table 7-5). States with favorable prescriptive authority for PAs also had favorable 

prescriptive authority for NPs and CNMs. For legal status and reimbursement, NP scores were 

significantly correlated with CNM scores, while PA scores were not significantly correlated with 

either NP scores or CNM scores. 

Table 7-5 

Correlations of Components of the Professional Practice Indices 

Across the Three Professions 

(Coefficients are Spearman rank-order correlations across the 50 states.)

PA Legal Status NP Legal Status CNM Legal Status 

PA Legal 1.00 - -

NP Legal +0.10 1.00 -

CNM Legal +0.08 +0.61** 1.00 

PA Reimburse NP Reimburse PA Reimburse 

PA Reimburse 1.00 - -

NP Reimburse +0.26 1.00 -

CNM Reimburse +0.11 +0.73** 1.00 

PA Prescriptive NP Prescriptive CNM Prescriptive 

PA Prescriptive 1.00 - -

NP Prescriptive +0.57** 1.00 -

CNM Prescriptive +0.50** +0.84** 1.00 

* = significant at the 0.05 level 

** = significant at the 0.01 level 

Sekscenski et al found that favorable practice environments, as measured by their practice 

environment indices, were strongly positively correlated with numbers of the corresponding 

professionals. This study confirmed this relation for both 1992 and 2000 for all three professions. 

Table 7-6 shows the Spearman rank order correlations between the 1992 scope indices and 1992 

practitioners per 100,000 population, and between the 2000 scope indices and 2000 practitioners 

per 100,000 population. These correlations confirm that higher professional practice indices are 

associated with greater numbers of practitioners per capita for all three professions. 

Table 7-6 also shows that the professional practice indices are not significantly correlated with 

the numbers of physicians per 100,000 population for the corresponding years. This is an 

indication that states with relatively large (or small) numbers of physicians per capita do not 

have unusually high (or low) professional practice indices. 

40
Table 7-6 

Correlations Between Original Professional Practice Indices and 

Professionals per Capita, 1992 and 2000 

(Coefficients are Spearman rank-order correlations across states.) 

1992 

NP ‘92 Index+ PA ‘92 Index+ CNM ‘92 Index+ 

NP ‘92 / Pop +0.41** - -

PA ‘92 / Pop - +0.63** -

CNM ‘92 / Pop - - +0.50** 

Phys ’92 / Pop 0.00 -0.02 +0.16 

2000 

+ = Sekscenski index from the original study 

* = significant at the .05 level 

** = significant at the .01 level 

Relationships Between the Three Professions and Physicians 

The nature of the relationship between the three professions and their physician counterparts 

typically involves some level of dependency on the part of the three professions. PAs work under 

the supervision of physicians, and most NPs and CNMs work under some formal collaborative or 

supervisory agreement with physicians. These supervisory and collaborative working 

relationships suggest a positive correlation between the numbers of physicians and the numbers 

of the three professions. 

There are a variety of factors that influence these relationships, including organizational 

arrangements, reimbursement policies, historical trends, etc. When the changes in the professions 

are as dramatic as they have been for NPs, PAs, and CNMs, some of the usual patterns and 

relationships may be altered. Nevertheless, this preliminary analysis appears to support the 

presence of a supportive relationship between the three profession and physicians. 

If a substitutive relationship existed, one would expect a negative correlation between the 

physicians per capita and practitioners per capita for that profession, i.e., that States with 

relatively fewer physicians per capita had relatively more NPs, PAs, or CNMs per capita. Table 

7-7 shows no evidence of such a substitution effect. In fact, the data show a statistically 

significant positive correlation between NPs per capita and physicians per capita, and between 

CNMs per capita and Ob-Gyns per capita in 2000. 

NP ‘00 Index PA ‘00 Index CNM ‘00 Index 

NP ‘00 / Pop +0.38** - -

PA ‘00 / Pop - +0.39** -

CNM ‘00 / Pop - - +0.50** 

Phys ‘00 / Pop +0.06 -0.03 -

ObGyn ‘00 / Pop - - +0.14 

41
Table 7-7 

Correlations Between NPs, PAs, and CNMs per Capita and 

Their Counterpart Physicians per Capita, 2000 

(Coefficients are Spearman Rank-Order Correlations) 

NP / Pop ‘00 PA / Pop ‘00 CNM / Pop ‘00 

Phys / Pop ‘00 +0.45**+ 0.11 -

Ob-Gyn / Pop ‘00 - - +0.53** 

* = significant at the .05 level 

** = significant at the .01 level 

Other Patterns and Relationships 

Relationship of Professional Practice Indices to Access to Care 

Since one of the stated goals of the programs that originally launched both the PA and NP 

professions was to increase access to care, it is of interest to assess the extent to which these 

goals have been achieved. Unfortunately, current national data systems are not able to assign 

members of the three professions to services provided to underserved populations or to 

geographic regions identified as shortage areas. The best that can be done at present for all 50 

States is to compute correlations between the percentages of population residing in Health 

Professions Shortage Areas (HPSAs) and the scope indices and the numbers of practitioners per 

capita for the respective States. 

The results of these calculations are presented in Table 7-8, which shows no significant 

correlation between the scope indices and the percent of population in HPSAs. Since the three 

professions are not currently incorporated in the definitions of HPSAs, this is not surprising. 

The strongest correlation with percent of population in HPSAs is physicians per capita. This high 

negative correlation is expected since a region is designated a HPSA if it has especially low 

numbers of physicians. It is interesting that CNMs per capita, and not PAs per capita or NPs per 

capita, is significantly negatively correlated with the percent of population in HPSAs. 

It is also interesting that HMO penetration is significantly negatively correlated with percent of 

population in HPSAs. This suggests that HMOs have a positive impact on access to care, 

although other interpretations are possible. 

Relationship to HMO Penetration 

Table 7-9 presents correlations of HMO penetration to the chosen set of variables. Here too the 

correlations with the scope indices are not statistically significant. The correlations with 

physicians per capita, NPs per capita, and CNMs per capita are all highly significant, which 

indicates that HMO penetration is higher in states with larger numbers of these three professions. 

42
Table 7-8 

Correlations of Percentages of Population in HPSAs

with Other Variables of Interest

Spearman Rank Order Correlations

% of Pop in HPSAs '00 

New PA Scope Index '00

New NP Scope Index '00

New CNM Scope Index '00

Original NP Index Dif '92 '00

Original PA Index Dif '92 '00

Original CNM Index Dif '92 '

MD/100K Pop '00

PA/100K Pop '00

NP/100K Pop '00

CNM/100K Pop '00

HMO Penetration '00

-0.143 

-0.055 

0.021 

-0.171 

0.028 

-0.043 

-0.465 ** 

0.077 

-0.180 

-0.299 * 

-0.384 ** 

* Correlation is significant at the .05 level (2-tailed). 

** Correlation is significant at the .01 level (2-tailed). 

Table 7-9 

Correlations of HMO Penetration with Other Variables of Interest 

Spearman Rank Order Correlations 

HMO Penetration '00 

New PA Scope Index '00 0.179 

New NP Scope Index '00 0.218 

New CNM Scope Index '00 0.186 

Original NP Index Dif '92 '00 0.124 

Original PA Index Dif '92 '00 0.038 

Original CNM Index Dif '92 ' -0.111 

MD/100K Pop '00 0.611 ** 

NP/100K Pop '00 0.368 ** 

PA/100K Pop '00 -0.114 

CNM/100K Pop '00 0.461 ** 

% of Pop in HPSAs '00 -0.384 ** 

** Correlation is significant at the .01 level (2-tailed). 

General Acceptance of Non-Physician Clinicians. 

To get a sense of the extent to which different States have accepted the professions which work 

closely with physicians, a composite index (equal to the sum of the three new index numbers for 

2000) was created. This new index, which is based on all three professions, is not meant to relate 

to professional practice. It is meant solely to reflect the general acceptance of the professions by 

government regulators. Oregon had the highest score on this composite index, and South 

Carolina had the lowest. 

43
This composite index was then translated into a five point scale that rated the general acceptance 

levels of these non-physician clinicians in the 50 States and the District of Columbia from high 

acceptance to low acceptance. The results of the translation into the five point scale are displayed 

in the map in Figure 7-1. The States with the highest general acceptance for the three professions 

were scattered around the country with higher representation in the Northeast and Northwest, 

while the lowest general acceptance of the three professions was focused in the Southeast. 

CO 

AK 

AZ 

HI 

CA 

NV 

NM 

OK 

WY 

ID 

UT 

WA 

OR 

MT 

IA 

ND 

SD 

MN 

IN 

MS 

LA 

AR 

TN 

GA AL 

VA 

NC 

SC 

MD 

WV 

MI WI NY 

DC DE 

CT 

MA 

VT 

RI 

NH 

ME 

Acceptance Level 

High 

Moderately High 

Moderate 

Moderately Low 

Low 

MT 

NV 

VA 

SC 

AL GA 

LA 

TX 

NE 

MO 

IL IN 

OH 

PA NJ 

KY 

FL 

MS 

Figure 7-10. General Acceptance of Non-Physician Clinicians, 2000 

Professional Practice Component Scores 

Table 7-10 presents the scores for the three broad components of the new professional practice 

indices for the three professions in each of the fifty States and the District of Columbia. 

Interested readers can use these data to better understand the nature of the practice environments 

for the three professions in specific States. 

44
Table 7-10 

Components of the New Professional Practice Indices for NPs, PAs, and CNMs for the 50 States and DC, 2000 

NP PA CNM 

Legal Reimb Rx Total Legal Reimb Rx Total Legal Reimb Rx Total 

Optimal 35 35 30 100 35 25 40 100 35 35 30 100 

Average 25.2 28.1 21.4 74.7 25.2 19.8 29.1 74.1 22.7 27.4 19.4 69.6 

Gap 9.8 6.9 8.6 25.3 9.8 5.2 10.9 25.9 12.3 7.6 10.6 30.4 

Range 20.0 23.0 21.0 51.0 25.0 15.0 40.0 57.5 19.0 23.0 30.0 54.0 

Std Dev 5.6 7.1 6.1 13.6 4.6 3.7 11.5 14.3 4.7 7.2 8.6 15.0 

Alabama 20 20 8 48 25 25 11 61 19 13 6 38 

Alaska 32 28 28 88 25 18.5 38 81.5 25 35 28 88 

Arizona 33 31 28 92 25 20 37 82 25 26 28 79 

Arkansas 30 13 24 67 18 20 31 69 28 13 23 64 

California 26 35 23 84 25 20 38 83 23 30 7 60 

Colorado 29 30 27 86 15 20 40 75 26 30 26 82 

Connecticut 27 35 24 86 29 25 29 83 24 34 28 86 

Delaware 29 30 27 86 24 20 38 82 26 30 27 83 

District of Columbia 29 20 26 75 23 10 12 45 32 15 25 72 

Florida 22 28 12 62 27 23 11 61 21 28 9 58 

Georgia 20 14 11 45 25 19 33 77 20 15 8 43 

Hawaii 25 27.5 9 61.5 23 20 35 78 23 27.5 7 57.5 

Idaho 29 33.5 27 89.5 20 18.5 34 72.5 27 30 24 81 

Illinois 31 12 17 60 29 25 32 86 20 12 11 43 

Indiana 19 28.5 24 71.5 20 20 10 50 20 27.5 26 73.5 

Iowa 30 33 29 92 27 25 35 87 26 28 30 84 

Kansas 29 28 27 84 24 17.5 34 75.5 22 27.5 27 76.5 

Kentucky 29 32.5 15 76.5 22 20 12 54 27 27.5 14 68.5 

Louisiana 21 28 13 62 28 25 1 54 17 30 9 56 

Maine 28 35 28 91 29 20 34 83 28 35 28 91 

Maryland 20 35 23 78 18 20 38 76 19 35 26 80 

Massachusetts 18 35 24 77 25 20 37 82 20 30 24 74 

Michigan 25 30 17 72 31 25 33 89 25 30 14 69 

Minnesota 30 29 27 86 25 19 37 81 26 30 28 84 

Mississippi 20 29 10 59 27 10 12 49 16 29 9 54 

Missouri 19 30 11 60 26 20 15 61 19 30 10 59 

Montana 31 33.5 27 91.5 28 24 39 91 27 28 27 82 

Nebraska 31 15 26 72 24 20 35 79 20 15 9 44 

Nevada 19 28.5 11 58.5 30 18.5 16 64.5 17 28.5 7 52.5 

New amp H shire 32 30 24 86 34 20 35 89 26 30 26 82 

New Jersey 27 34.5 21 82.5 25 10 13 48 16 32 7 55 

New Mexico 33 34 27 94 25 20 39 84 28 35 25 88 

New York 26 35 25 86 29 20 35 84 30 35 27 92 

North Carolina 29 30 27 86 29 25 40 94 15 30 28 73 

North Dakota 21 27.5 26 74.5 21 17.5 31 69.5 17 27.5 26 70.5 

Ohio 23 30 20 73 18 18.5 0 36.5 20 30 21 71 

Oklahoma 27 20 20 67 25 17.5 35 77.5 26 15 19 60 

Oregon 33 35 24 92 33 25 34 92 29 35 21 85 

Pennsylvania 16 35 22 73 20 20 33 73 22 30 0 52 

Rhode Island 27 33 23 83 32 18 38 88 30 33 25 88 

South Carolina 15 13 15 43 9 20 23 52 13 13 13 39 

South Dakota 24 29 25 78 26 17.5 38 81.5 24 29 25 78 

Tennessee 14 35 15 64 28 20 38 86 19 29 11 59 

Texas 20 33.5 12 65.5 30 25 12 67 20 34 8 62 

Utah 27 30 27 84 30 20 35 85 29 33 27 89 

Vermont 20 15 26 61 25 19 38 82 21 15 28 64 

Virginia 13 15 19 47 24 10 13 47 16 30 13 59 

Washington 31 35 25 91 24 20 38 82 30 35 27 92 

West Virginia 16 30 20 66 29 20 35 84 18 35 20 73 

Wisconsin 31 15 23 69 26 19 38 83 19 13 25 57 

Wyoming 29 30 23 82 27 20 34 81 24 30 23 77 

45
Conclusions 

Analyses of the 1992 indices provided by Sekscenski et al and the updated indices created by the 

authors for 2000 indicates that all three professions increased their respective scopes of practice 

between 1992 and 2000. The increases observed in the professional practice indices for all three 

professions are generally associated with broader sets of tasks, more autonomous practice 

environments (i.e., less direct oversight by physicians), and greater opportunities to prescribe 

controlled substances. 

While differences remain in the professional practice index scores across the 50 States, the 

variation of the index scores declined significantly between 1992 and 2000, suggesting that the 

1990s was a period of convergence of professional practice across the 50 States for all three 

professions. A breakdown of the three components of the 2000 professional practice index 

demonstrate a convergence in both legal status and prescriptive authority for NPs, PAs, and 

CNMs across the 50 States. The reimbursement patterns for NPs, PAs, and CNMs converged 

less across the States than did the other two components of the indices. 

Relations With Physicians 

In field work conducted in seven States (California, Illinois, New York, North Carolina, Ohio, 

Oregon, and Texas) in 2001 as part of this study, more than 220 informants (representing the 

three professions, educators, provider organizations in urban and rural areas, and State and local 

planners and policy makers) were asked questions about the three professions, including some 

concerning relations between the medical profession and NPs, PAs, and CNMs. It was 

interesting that the closer that informants were to actual practice settings in hospitals, clinics, and 

physician offices, the stronger was the sense that the three professions provide valuable support 

to physicians as they serve their patients and the public. The idea is that physicians wouldn’t 

work with NPs, PAs, or CNMs in hospitals, offices, and other settings if they did not believe it 

was beneficial to their practices and their patients. 

Relationship of the Three Professions to Access to Care 

One hypothesis of the study, that greater numbers of practitioners in the three professions 

improved access to health care, especially primary care, could not be tested statistically. Reliable 

estimates of the numbers of practitioners in the three professions in the 50 States have only 

recently become available, and reliable estimates of the numbers practicing in shortage areas 

(i.e., Health Professions Shortage Areas [HPSAs] or Medically Underserved Areas [MUAs], 

both of which are based on census tracts) or serving underserved population groups are not yet 

available. Without such information, it is not possible to quantify the extent to which the three 

professions serve people with low incomes, without health insurance, or with other 

characteristics associated with lack of adequate health care. 

Although it was not possible with the data and other evidence compiled in this study to confirm 

statistically that a higher professional practice index is related to greater access to health care by 

undeserved populations, many believe that NPs, PAs, and CNMs “are providing services 

(especially primary care) to populations that otherwise would be managed by a physician or 

would not receive services” [Hooker and Berlin, 2002]. Additional information on this provided 

in Chapter 9. 

46
Further research is warranted on the extent to which greater numbers of practitioners in the three 

professions improve access to health care, particularly primary care, for underserved populations. 

Moreover, investigating the relationship between the three professions and HPSAs and MUAs is 

an important avenue for future research. 

47
48
Chapter 8. Field Work in Seven States 

This chapter summarizes the field work conducted as part of this study. It includes the following 

subsections: 

• The Field Work Process 

• Observations from the Fieldwork 

• Conclusions 

Additional details about the conduct of the fieldwork and more details from the various 

interviews and meetings are provided in Appendix G. 

The Field Work Process 

As a part of this study, fieldwork was conducted in seven States chosen for their geographic 

diversity and for the variety of legal and regulatory climates they have for the professions. The 

States chosen were California, Illinois, New York, North Carolina, Ohio, Oregon and Texas. 

These States represent variation in demographics, geography, and composition of health care 

delivery programs. Of particular interest was the impact of the three professions on delivery of 

care to underserved populations. 

The visits to California, Ohio, and New York were conducted by Albany Center. The visits in 

Oregon were conducted by the WWAMI Center for Health Workforce Studies. The visits in 

Illinois were conducted by the Illinois Center for Health Workforce Studies. The visits in Texas 

were conducted by the Center for Health Economics and Policy at the University of Texas 

Health Science Center at San Antonio. The visits in North Carolina were conducted by the North 

Carolina Center for Nursing. 

49
The field work was conducted in a variety of formats. Focus groups were convened in State 

capitals, large urban settings, and in rural locations across the fieldwork States to discuss legal 

and professional practice issues for the three professions. In some cases, one-on-one face-to-face 

or telephone interviews were conducted, and in others, written communication was involved. 

The fieldwork was structured by a list of questions generated by the cooperating research centers 

and by the Project Advisory Committee that was convened to monitor and direct the study 

process. A list of those questions is provided in Appendix H. Individual State fieldwork reports 

relied on a variety of published data for background information on the supply of the professions 

within States, the educational programs available to the professions, the numbers of recent 

graduates from those educational programs, and the demographics of the States involved. The 

findings of the fieldwork relied heavily on the observations of those who provided insights to the 

discussions about the professional experience of NPs, CNMs, and PAs in the various States. 

Those interviewed in the fieldwork included State legislators and government regulators, State 

and local policymakers, educators of the three professions, representatives of primary care 

coordinating councils and area health education centers, representatives of the physician, nurse 

practitioner, certified nurse midwife, and physician assistant professions, and the directors and 

staff of community health clinics, mobile clinics, hospital systems, long term care facilities, and 

rural health projects. Participants were identified through a variety of means including 

identification by the Project Advisory Committee, professional associations, and educational 

programs, as well as through Internet resources and literature searches, and personal referrals. 

Although the general experience of the field work staff was that the medical profession was 

underrepresented in the fieldwork process, physicians were invited to participate in all venues in 

all seven States. Participants in the focus groups and interviews represented a wide range of 

constituents and provided broad perspectives on the professions and their contributions to health 

care delivery. 

In most cases, fieldwork was conducted at defined locations through formal invitations by 

project staff. Discussions were structured to last over a morning or afternoon session and 

generally involved mixed groups of participants. However, the composition of the groups varied. 

For instance, in New York City, individual professional focus groups were hosted that included 

only nurse practitioners in one session, physician assistants in another, and certified nurse 

midwives in a third. In other locations, participants included representatives from a range of 

professional, regulatory, and organizational groups. One center found that individual physician 

interviews were the most convenient way to obtain the insights from that constituent group. 

Observations from the Fieldwork 

The following bullets summarize interesting themes that emerged in the fieldwork discussions 

across States. These ideas are discussed in detail in the ensuing pages. 

• Change in professional practice is often motivated by the practical experiences of the 

three professions and the physicians with whom they work. When a particular legal 

requirement becomes untenable in the practice environment, there is motivation by 

professional associations to advocate for change in the legislative arena. When advocates 

for patient groups feel that a situation is not acceptable, legislative initiatives are also 

50
forthcoming. Change appears to occur incrementally and often occurs through limited 

legislative mandates that sunset or expand at legislative review. 

• The three professions are seeking recognition for their professional competencies and for 

the quality of care that they provide in an environment that is striving to use resources 

effectively and efficiently. 

• The three professions resist the image of the professions as “cost-effective” providers, 

preferring instead to focus on their competencies and their contributions to healthcare for 

a variety of populations. 

• The professional status of NPs, PAs, and CNMs has been enhanced by the increase in 

their numbers throughout the United States, by their employment in a wide range of 

healthcare settings that has increased their exposure to the public, and by increased 

scopes of practice including increased prescriptive authority which has allowed them to 

practice more “autonomously”. 

• The professional scopes of practice of the three professions converged across the 50 

States in the 1990s, consistent with statistical evidence presented earlier in this report. 

• The most important professional practice issue for NPs and CNMs is reimbursement. 

• Expanded prescriptive authority is the most important professional practice issue for 

physician assistants, and it is a concern of CNMs and NPs in certain States. 

• There is a strong desire within the professions for increased visibility and acceptance by 

other providers, peers, patients, and payers. 

• It is difficult to evaluate the contributions of the three professions to access to care 

because of the business practices and organizational strategies that currently exist. 

• Although competition among the three professions was cited by some field work 

participants, there is commonality for the three professions in their positioning in the 

delivery system. Several examples of collaboration in advocacy efforts between 

professional groups in States were discussed in the fieldwork. 

• At the professional association level, the three professions struggle with the medical 

profession associations to gain desired recognition, responsibility, and autonomy within 

their individual scopes of practice. This struggle seems greatest for the advanced nursing 

professions, although physician assistants encounter many of the same roadblocks. Some 

of these differences may be attributed to the educational models in which the professions 

are trained, i.e., nursing models vs. medical models; and some may be attributed to the 

variation in how legal relationships with physicians are defined, i.e., supervisory, 

collaborative, consultative, or “independent”. 

• The struggles for professional recognition generally address more detailed aspects of 

practice, suggesting that these professions are maturing. One informant from New York 

called this period “a time for rationalization”. Whereas statutory and regulatory 

permission for any prescriptive authority was a prominent issue in the 1990’s, refinement 

of that privilege is now the focus. The same can be said for legal status and 

reimbursement. 

51
• This same maturation is occurring in educational programs where standardization of 

programs across the U.S. continues to be a goal. Growth has slowed in recent years both 

in the numbers of programs and in the numbers of graduates. 

• Another indication of the maturity of the professions is the present concern among all 

stakeholders about the supply of and demand for these providers presently and in the 

future. There are even emerging concerns about a possible oversupply of the professions 

in some States. 

• The fieldwork suggested that the three professions contributed significantly to access to 

care, but it also confirmed that it is not possible to verify statistically the contributions to 

access made by the three professions because data about their supply, places of practice, 

and the patients that they treat are inadequate. In fact, the three professions feel that the 

increased visibility gained through HMO empanelment and direct reimbursement will 

help to demonstrate their contributions to care for a variety of populations. Use of 

appropriate provider numbers in all billing for services would distinguish data about who 

is providing care to underserved populations, clarify the level and kinds of services being 

provided, and identify the settings in which services are obtained. 

• The need for new and continuing incentives to encourage the three professions to practice 

in health professional shortage areas or with underserved populations was considered 

important. Among the strategies suggested by the fieldwork participants to increase 

access to care were: educational loans with payback incentives; the opportunity for 

increased numbers of clinical rotations in areas where underserved populations are 

treated; Medicare incentives similar to those provided to physicians practicing in 

underserved areas; programs for recruitment of new professionals directly from 

underserved populations; and educational opportunities that are accessible in or near 

underserved communities 

Conclusions 

There was a broad consensus across the fieldwork states that professional practice options 

expanded in the 1990s for all three professions, and that practice is now more uniform across the 

States. Although more improvements are possible, many strides have been made for all three 

professions. 

The contributions by the three professions to access to care continue to be significant. The 

primary care orientation of NPs, PAs, and CNMs guides the professions in the provision of both 

primary and specialty services. There is significant potential for these professions to provide 

services in places where there are gaps in health care. Direct reimbursement from all payers 

would be important to achieving greater access for underserved populations. Financial incentives 

for all of the health professions should be encouraged. Physicians and the three professions work 

cooperatively and interdependently in a variety of health settings. This should be encouraged 

since the quality, quantity, and substance of services provided are enhanced by the competencies 

and skills of each of the professions working interdependently. 

Attention should be paid to a variety of factors that influence the supply and distribution of the 

professions across settings. Clinical rotations, scholarship and loan programs, and pay or tax 

52
incentives to work in health settings that provide care to medically underserved populations are 

important inducements to encourage these professionals to work in those settings. 

The three professions are important to provision of quality and cost-effective care to a range of 

consumers. The skills and competencies of the professions allow them to practice in all health 

care settings in collaboration with other medical professionals. There is still untapped potential 

within the professions that could help to resolve some of the significant access issues that exist 

across States. The paths to achieving this goal are both regulatory and financial. 

53
54
Chapter 9. Access to Care

This chapter summarizes the findings of the study relating the impact of increasing numbers of 

NPs, PAs, and CNMs and increasing professional practice options of the three professions on 

access to health care in the U.S. It includes the following subsections: 

• Concepts and Definitions 

• Limitations on Quantitative Assessments 

• Professional Practice Index and Access to Care 

• Anecdotal Evidence from Fieldwork 

• Conclusions 

Concepts and Definitions 

Access to health care is generally related to the ability of individuals in a population group to 

obtain appropriate services to diagnose and treat health problems and symptoms. A variety of 

factors influence access to health care for an individual or family, including: availability of 

health insurance or means of paying for needed services, sufficient numbers of appropriate health 

professionals to serve all those needing services, and availability of appropriate health care 

organizations within reasonable travel times. 

Access to health care in the U.S. is far from universal, despite programs like Medicaid which 

help those with limited resources obtain needed services. Many people with resources greater 

than the limits of public assistance programs like Medicaid do not have health insurance from 

their employers, and are therefore unable to obtain care. In addition, there are places in this 

country which do not have sufficient numbers of practitioners to care for all those that need 

services. 

55
An assessment of the impact of the three professions on access to care was a fundamental 

objective of this study. Although the increased numbers of practitioners and visits per capita are 

indicators of improved access, these statistics do not identify the recipients of the services. The 

initial charge to the study team called for an assessment of the impact of changes in professional 

practice and numbers of practitioners per capita on access to care for those traditionally 

underserved by the health care system, e.g., those without insurance, those who are unemployed, 

etc. 

In the discussion that follows the concern is primarily with access to care for underserved 

population groups. These groups are referred to as “underserved populations”. The term 

“underserved area” is also used in some circumstances to refer to a geographic subdivision in 

which a “large share” of the population is underserved. Because it is not possible to address the 

issue of access to care in a systematic, quantitative way, no effort has been made in this study to 

use precise definitions of these terms. 

Limitations on Quantitative Assessments 

Superficially, it is easy to conclude that the dramatic increases in the numbers of NPs, PAs, and 

CNMs in the 1990s resulted in more services to the public, and increases in professional practice 

indices resulted in additional services provided. Unfortunately, definitive measurement of the 

influence of NP, PA, and CNM professional practice on access to healthcare services for 

underserved populations remains elusive for several reasons: 

• Adequate data for NPs and CNMs are not available. Efforts to collect counts for these 

professions are confounded by the myriad licensing configurations that exist across 

States. Some State Boards of Nursing count only those licensed as nurses. In some States, 

the use of an NP or CNM credential is permitted if a nurse has obtained a national 

certification, with no additional required State certification. Recent passage of legislation 

in States addressing NP practice as a separate professional category should alleviate this 

problem. However, in many States, the census of CNMs is still embedded in NP data 

since nurse midwives are often licensed as a category of advanced practice nurse. 

• The identification of practice location of the three professions is another 

confounding issue, since no national database accurately tracks the specific locations in 

which NPs, PAs, and CNMs work. For example, in order to determine whether a 

practitioner works in a Health Professional Shortage Area (HPSA) or Medically 

Underserved Area (MUA), it is necessary to locate the practice locations of these 

professionals at the census tract or zip code level. In most States only a mailing address is 

available for identifying the geographic location of practitioners, and most mailing 

addresses are not the same as practice addresses. Files are even less likely to identify the 

location of second or third practice sites, which are more likely to be underserved areas 

than primary practice sites. 

• It is currently impossible to identify with certainty the providers of services to 

underserved populations in many settings because many NPs, PAs, and CNMs provide 

services that are tagged with the identifiers of their supervising or collaborating 

physicians in insurance claims data. Although Medicaid and Medicare carriers in many 

States are requiring that each NP, PA, and CNM providing services to eligible 

56
populations have a separate identifier, many third party payers have different claim 

requirements. In addition, many HMOs/MCOs have been unwilling to empanel NPs, 

PAs, and CNMs, requiring the three professions to bill for services through the 

participating physician(s) with whom they work. These administrative practices make 

NP, PA, and CNM services effectively ‘invisible’ to those assessing the quantity and 

quality of care. 

The new National Provider Identifier (NPI) required by the Health Insurance Portability 

and Accountability Act presents an opportunity to implement more effective tracking of 

the type of health providers, levels of care provided, and locations where services are 

offered. This will only occur if the NPIs are required by all payer organizations on billing 

documents. Such an initiative would still only identify services provided by the three 

professions to insured populations. Tracking of care provided to people without health 

insurance presents an even greater challenge. 

Professional Practice Indices and Access to Care 

One of the broad conclusions of this study drawn from the background research and fieldwork 

conducted as part of this study is that the professional practice indices for NPs, PAs, and CNMs 

are directly related to access to care. Legal requirements for practice affect both the care that is 

legally possible and the circumstances under which care is provided. There are several 

environmental and regulatory factors that inhibit or promote access by underserved populations 

to health services provided by NPs, PAs, and CNMs. 

• Supervisory arrangements for NPs, PAs, and CNMs required in law can dramatically 

affect the provision of services. Impediments to care are created when statutes or 

regulations in a State require that a physician be physically present within an office or 

facility when services are provided by a NP, PA, or CNM, or that a physician must be 

within a certain distance of the site where services are provided. Provision of care is then 

limited to locations where physicians choose to practice or to locations that are 

proximate. This study has confirmed that NPs, PAs, and CNMs, like physicians are 

concentrated in urban and suburban settings. This preference places rural populations at 

higher risk for limited access, especially in States that require the three professions to 

practice in close proximity to their collaborating/supervising physicians. 

• The specific services that may be provided may also be limited in law. Statutes and 

regulations that proscribe the tasks and services that may be provided by the three 

professions build barriers that directly affect the characteristics of practice and 

subsequently, the way in which access may be achieved. If there is a requirement that a 

new patient must see a physician prior to an encounter with a NP, PA, or CNM, access 

by the patient is limited by the availability of the physician. Similarly, requiring all 

medical orders written by a PA to be cosigned by a physician before execution limits 

access to care. Assuming that the PA is competent to provide the service without direct 

supervision, these legal limitations may unnecessarily impede the provision of care. The 

fact that such restrictions exist in some States and not in others, raises questions about 

the need for the restrictions. 

57
• Prescriptive authority is an important feature of professional practice that requires legal 

permission and enhances care, particularly for rural populations. This privilege is legally 

enabled in States at various levels by allowing NPs, PAs, or CNMs to prescribe a range 

of scheduled drugs. If permitted by the State in which practice occurs, the Federal 

government assigns the professional a DEA registration to prescribe controlled 

substances. The ability to supply a prescription to a patient without the signature of a 

physician creates important possibilities for increased access to services in locations 

physically distant from a collaborating physician. 

• Health insurance - or lack of it - is the most frequently discussed environmental 

impediment to access to health services. Those without health insurance have few 

options when seeking care and often do so only under the most serious medical 

circumstances. And when there is insurance, the reimbursement policies in States affect 

the ability of the three professions to be paid directly for services. The lack of insurance 

and the lack of available direct reimbursement for NPs, PAs, and CNMs were identified 

by study informants as significant barriers to access. The three professions are often 

limited to caring for those patients who have insurance from payer organizations with 

which the supervising/ collaborating physician has contracts to provide care. The refusal 

of many third party payers to empanel NPs, PAs, and CNMs limits access to patients. 

Physicians often act as the intermediaries between payers and NPs, CNMs, and PAs and 

also between patients and these professionals. Another dimension to the discussion about 

health insurance is that even being insured—although technically providing access—is 

not always a predictor of utilization. Other barriers such as transportation, provider 

office hours, and cultural differences can significantly affect patient utilization. 

Anecdotal Evidence from Fieldwork 

Despite the inability to assess quantitatively the impact of increased professional practice for 

NPs, PAs, and CNMs on access to care, fieldwork informants overwhelmingly supported the 

hypothesis that increases in professional practice in the 1990s improved access to care for 

underserved populations. The fieldwork in this study provides evidence of the manner in which 

these services are made available. In fact, the fieldwork suggests that demonstration projects in 

different States often provide pathways to broader scopes of practice for the three professions. 

The discussion that follows is based primarily on the fieldwork conducted as part of this study as 

summarized in Appendix G of this report and in the seven separate field study reports.35 

35 Langelier MH. “Scope of Practice of NPs, PAs, and CNMs in Ohio, Fieldwork Summary Report”. Rensselaer, 

NY: Center for Health Workforce Studies. 2001. 

Palazzo L, Hart LG, Skillman SM. “Scope of Practice Project Report, Oregon”. Seattle, WA: WWAMI Center for 

Health Workforce Studies. 2001. 

McClure C, Russinof H, and Cooksey JA. Illinois Field Report on the Scope of Practice of PAs, NPS, and CNMs”. 

Chicago, IL: Illinois Center for Health Workforce Studies. 2001. 

Gott S. “The Practice of Non-Physician Clinicians in Texas”. San Antonio, TX: Center for Health Economics and 

Policy, UT San Antonio. 2001. 

North Carolina Center for Nursing. “Examination of the Impact of Expanded Scope of Practice Laws on Improving 

Access to Health Care for the Underserved”. Chapel Hill, NC: North Carolina Center for Nursing. 2001. 

Langelier MH. “Scope of Practice of NPs, PAs, and CNMs in New York, Fieldwork Summary Report”. Rensselaer, 

NY: Center for Health Workforce Studies. 2002. 

58
General Findings 

• Statutes enabling practice by the professions across States often have preambles that 

indicate that these professions were established specifically to help meet the healthcare 

needs of underserved populations including the poor, the elderly, and the disabled. In 

fact, all three professions are rooted in the principle of serving the needy, and this 

principle continues to be central to the current values of the three professions. The 

practical application of this principle is evident in the educational curricula and clinical 

experiences provided in training programs for each of the three professions. 

• The fieldwork supports the contention that NPs, PAs, and CNMs originally practiced 

largely in areas where there was a lack of physician presence providing primary care. 

Currently, however, the health care system is drawing the three professions from their 

original focus on primary care to medical and surgical specialty practices. Since specialty 

physicians are less likely than generalist physicians to practice in underserved areas, this 

trend tends to counteract the initial positive impact on access of increasing the supply of 

NPs, PAs, and CNMs serving traditionally underserved populations. 

• In some States professional practice for the three professions is expanded under special 

circumstances to permit a broader set of services to underserved populations. In this study 

this legal condition is referred to as “dual scope of practice”. NPs, PAs, and CNMs 

practicing in “traditional” locations with physicians are governed by one set of rules, 

while NPs, PAs, and CNMs practicing in jurisdictions and settings where underserved 

populations seek health care are permitted expanded privileges for those patients. The 

experience of the three professions with needy populations in these dual scope States has 

sometimes led to legislative initiatives that broadens scope in traditional environments. A 

successful pilot project in Ohio that provided NPs with prescriptive authority to increase 

access is an example of an initiative that was initially authorized only in limited settings, 

but was eventually expanded to all settings. 

Specific Anecdotes 

The fieldwork conducted as part of this study provided many illustrations of the contributions of 

the three professions to access to care. The following examples, drawn from observations of 

fieldwork informants in the seven States (California, Illinois, New York, North Carolina, Ohio, 

Oregon, and Texas), confirm that NPs, PAs, and CNMs contribute to health care for many 

population groups. 

• In all seven States, informants reported that access to care is enhanced by the use of the 

three professions in many settings. All three professions were originally conceived 

because of national policy concerns about meeting the health care needs of underserved 

populations. In fact, informants suggested that for many years NPs, PAs, and CNMs 

worked in underserved settings in proportionately greater numbers than physicians. For 

instance, in North Carolina, NPs and PAs originally practiced only in health clinics and 

public health settings. They have subsequently moved into more mainstream practice 

environments as the professions have become more recognized. 

Langelier MH. “Scope of Practice of NPs, PAs, and CNMs in California, Fieldwork Summary Report”. Rensselaer, 

NY: Center for Health Workforce Studies. 2001. 

59 
• Initially, Federal reimbursement policies encouraged practice in underserved settings by 

permitting public reimbursement for services provided in special public health, 

institutional, and clinic settings that serve the underserved. The 1997 Balanced Budget 

Act (BBA) equalized reimbursement across all settings providing less of an incentive to 

remain in locations designated as underserved. The BBA extended a 10 percent bonus for 

physicians practicing in identified underserved locations but did not extend that same 

benefit to NPs, PAs, and CNMs practicing in the same settings. Informants suggested that 

this was counterproductive to Federal policy, which was to encourage NPs, PAs, and 

CNMs to work with populations with limited access to health services. 

• The current increase in specialization by PAs and NPs was cited by some informants as a 

reason for concern. As these professions move into specialty and sub-specialty care, their 

opportunities for practice with underserved populations are reduced. Since specialist 

physicians are not found in great numbers in HPSAs and MUAs, the NPs, PAs, and 

CNMs with whom specialist physicians collaborate are also less likely to be found in 

those settings. 

• Determining if care is being provided to the underserved by NPs, PAs, and CNMs is a 

complex task, which often has less than satisfying results. Informants suggested that 

underserved populations can be found in almost any medical setting. For example, PAs in 

New York discussed institutionally-based care in a non-HPSA certified facility. This is 

not identified as care to the underserved even though there is a significant provision of 

care to underserved individuals in such settings. There are many “needy” patients who 

would be classified as underserved who receive treatment in community hospitals, major 

medical centers, and even private physician offices. Care to patients who are uninsured or 

publicly insured is provided by medical professionals who work in settings not 

traditionally identified as serving underserved populations. However, the care provided is 

often considerable and should be identified as contributing to access. Assessing to whom, 

by whom, where, and how such care is provided is difficult and may require tracking 

patients on public assistance rather than providers. In any case, when considering the 

issue of how to increase access, traditional care settings should not be ignored. 

• Many informants reiterated that reimbursement of providers has a major impact on access 

to care. Uninsured and publicly insured populations do not always have the same access 

as privately insured patients. One informant described the Balanced Budget Act of 1997 

as “a house of cards”. Rural health was greatly affected by its implementation since 

clinics with greater than 50 beds were no longer supported. Without support, many larger 

clinics closed causing some professionals in underserved areas to leave their positions. 

• In Texas, informants indicated that reimbursement is an especially difficult issue in rural 

areas. Lack of funding for services to needy populations is a disincentive to practice in 

locations where those populations are located. Reimbursement policies impact both 

utilization by patients and recruitment of professionals since payment for services is a 

fundamental issue for all medical professionals. 

• Some informants suggested that many newer graduates are not interested in working with 

underserved populations. They are more interested in practicing where the money is. 

Students were viewed as being savvier and more aggressive than they had been in the 

60
past. This change in orientation affects the pool of providers who traditionally might have 

sought work with the underserved. 

• According to informants, public initiatives that encourage professionals to work in health 

professions shortage areas encountered difficulty because decisions about where to 

practice are often driven by personal preferences. Individuals make decisions about 

where they will practice based on personal background, individual goals, family 

obligations, and practice opportunities. Economics is an important factor for new 

graduates who have loans to repay. Educational indebtedness may cause new graduates to 

take positions based on remuneration rather than professional satisfaction. These are 

exogenous factors over which policymakers have little control. 

• Informants also noted several policy initiatives that encourage professionals to practice in 

underserved areas, including: expanded loan repayment programs, more clinical rotations 

for student professionals in underserved settings, and targeted efforts to recruit new 

professionals into underserved areas. These were considered important strategies for 

increasing the numbers of NPs, CNMs, and PAs available to provide primary care to 

underserved populations. 

• An example of a successful collaborative effort to increase the numbers of NPs, PAs, and 

CNMs in underserved settings is an educational initiative called Partnerships in Training, 

funded by the Robert Wood Johnson Foundation. The objectives of this program are “the 

development and implementation of a regional educational system for nurse practitioners, 

physician assistants, and certified nurse midwives involving a culturally competent 

interdisciplinary curriculum, distance learning modalities, and shared resources among 

the education partners.”36 The program presently operates in eight States: Arkansas, 

California, Colorado, Michigan, Minnesota, New Mexico, North Carolina, and 

Wisconsin.37 In California, the partnership consortium is operated in collaboration with 

several area health education centers as well as several college and university programs. 

Potential NPs, PAs, and CNMs are recruited from underserved communities and then 

educated in or near those same communities. The program encourages students to remain 

in their home communities after training. A survey in 2000 by the California Center for 

Health Workforce Studies, found that 39 percent of NPs, 39 percent of PAs, and 47 

percent of CNMs surveyed in the State presently practice in underserved settings.38 

Informants credit the program with encouraging new providers to locate in underserved 

areas which has increased access to care. 

• Informants were concerned about the move by various States and the Federal government 

to increase educational requirements for the professions and the concomitant impact on 

the professional workforce. New York informants suggested that a requirement for 

graduate education for the professions would change the complexion of the professional 

programs and place these professions out of the reach of some qualified candidates. 

Concern was expressed that the cost of the elevated educational requirements would 

36 Partnerships for Training, San Joaquin Valley Health Consortium, http://www.sjvhc.org/programs/pft/index.htm. 37 Partnerships for Training Projects, http://www.uchsc.edu/ahec/mapp/about/pft.htm. 38 Office of Statewide Health Planning and Development and the Center for California Health Workforce Studies at

the University of California, San Francisco, “Nurse Practitioners, Physician Assistants, & Certified Nurse Midwives 

in California”, San Francisco, California, Spring 2000. 

61
adversely affect the diversity of graduates from programs and further impede the creation 

of a culturally competent workforce. Liberal loan repayment programs or scholarship 

support for diverse students were suggested as partial remedies for this problem. 

• The environment in which the professional is educated and trained affects employment 

opportunities and prospects. Changes in educational models may also affect choice of 

work after graduation. PAs in New York indicated that current educational models affect 

practice patterns. PA education in New York was initially provided mostly in community 

college programs with clinical rotations provided in community settings. This encouraged 

graduating PAs to work in community settings by acquainting them with those 

workplaces. Many PA programs in the State have now turned to the medical training 

model in which clinical training occurs in hospitals and large medical centers. Graduates 

from these programs are not as likely to have connections to a community health provider 

and may be less inclined to return to community healthcare settings when seeking 

employment. 

• At Duke University in North Carolina, which housed the first PA training program in the 

country, the PA program uses Title VII funding to support clinical rotations in medically 

underserved areas. Several informants suggested that providing clinical rotations in a 

variety of environments was critical to the process of placing the professions in settings 

where they are exposed to needy populations. Students sometimes discover that they 

particularly enjoy working in those environments and will choose to work in them after 

graduation because of their exposure to the opportunity during training. 

• Legislation affects access to care in very direct ways. For instance, individual State 

requirements for the professions to have supervisory relationships with physicians affects 

practice in rural locations. In Ohio, a PA or NP with prescriptive authority must work 

within 60 minutes travel time of his/her supervising physician. This requirement 

significantly limits practice opportunities for PAs and NPs in the far reaches of 

Appalachia where supervising physicians are largely unavailable. PAs and NPs might 

contribute more to care for those populations if the distance limitations did not exist. 

• Special circumstances tend to influence CNMs and the locations where they choose to 

practice. CNMs are especially constrained in rural areas because of their need for backup 

physicians in case of obstetrical emergencies. In many areas of rural North Carolina there 

are no physicians to provide on-call services, so CNMs are prevented from working in 

such places. Although the relationship with physicians constrains the NPs and PAs, most 

patients of NPs and PAs are able to travel to a physician to whom they have been referred 

for more complex care, even if distance is great. However, obstetrical patients are limited 

by their emergent medical situations from traveling long distances to any provider. 

Collaborating physicians must be available to come to the obstetrical patient for delivery 

rather than having the patient come to them. CNMs, therefore, encounter very particular 

professional difficulties. 

• In Oregon, informants suggested that CNMs are rarely available in rural practice even 

though Medicaid guarantees coverage for services provided for the poor in underserved 

areas in the State. CNMs in Oregon suggested that opportunities to work in rural areas are 

scarce largely due to opposition from rural physicians who face an oversupply of 

obstetricians in the State. Some CNMs in Oregon have even chosen not to provide 

62
obstetrical services and instead provide only well-woman gynecological services in their 

practices. 

• Informants viewed provision of health care in rural environments as a special issue since 

the physical aspects of the rural environment affect practice. The example of prescriptive 

authority was provided to illustrate how location can influence practice. Expanded 

prescriptive authority for nurse practitioners is of no use in a location where there is no 

pharmacy available to fill the prescription, unless the NP also has the ability to dispense 

samples or to dispense medications. These conditions require rural providers to be 

creative and collaborative. A rural provider must establish extensive networks and 

negotiate a variety of cooperative agreements with other providers including pharmacies 

in order to operate effectively and provide all needed services. Dispensing authority for 

nurse practitioners in such locations is one possible solution. Clinics could then stock 

many needed medications to meet the needs of the served population. 

• The unique circumstances of rural communities require and inspire unique responses to 

limiting situations. In upstate New York, for instance, emergency rooms in very small, 

qualifying hospitals (under 15,000 visits per year) are staffed solely by PAs. This is 

effective in providing rural populations with access to care in emergency situations. 

• Another example of creative collaboration in rural New York State is a health care 

cooperative which involves the participation of a variety of stakeholders. A family 

physician conceived and implemented a creative model for delivery of care to small rural 

communities in the Adirondack Mountains. Town governments in a variety of locations 

participate in cooperative arrangements with a medical network, the Hudson Headwaters 

Health Network (HHHN), by providing buildings and other support services for the 

medical practices. HHHN staffs the facilities with providers on an ongoing basis. The 

resulting health consortium provides a range of physician, NP, PA, and CNM services in 

each practice location. This strategy has resulted in an effective delivery system that 

manages a broad network of providers working cooperatively in an extensive geographic 

area. Several locations are staffed strictly by one or another of the three professions with 

physicians traveling to a clinic only on particular day(s) of the week to see complicated 

cases and to review caseloads with the staff providers. A network of specialist physicians 

and local hospitals has been developed to provide referral mechanisms for more 

complicated care for patients living in these remote areas. The consortium covers a wide 

geographic area and serves a large number of patients. 

• The characteristics of rural practice dictate different responses to provider resources. In 

Oregon, informants suggested that rural practices have more difficulty predicting the 

need for providers and for assuring that they can afford them since patient caseload and 

insurance is unpredictable and the pool of potential patients is smaller. 

• In Ohio, which has particularly strict rules about the supervision of PAs, physicians in a 

rural area suggested that employing other providers creates special challenges. A 

physician must review a PA’s medical orders for patients on an ongoing basis. One rural 

physician suggested that, although hiring a PA had increased opportunities for his 

patients to see a medical provider, his caseload had effectively doubled because of record 

review requirements. He was not only required to document the records of his patients on 

a daily basis, but he was also required to review his PA’s notations on her patients. The 

63
severity of his patient caseload also increased since his PA was assigned many of the 

patients with routine illnesses. The physician’s schedule now includes a higher proportion 

of patients with complex, chronic problems. Although it is helpful that he is more 

available to these patients, the time required from him for their medical management has 

also increased. As a result, the physician was finding his practice more burdensome even 

though he had more help. When considering whether to hire another provider for his 

practice in the future, the informant felt he would give serious consideration to hiring a 

physician who would be more independent in practice and not require ongoing 

supervision. 

• Rural populations are also seen as having different characteristics. In Texas, informants 

indicated there are illegal aliens in the State afraid to seek care for fear of deportation. 

Farm and migrant workers are also unable to take time off from work to see a health care 

provider. In fact, many border workers travel to Mexico for care since medical services 

are available in that country at more convenient hours for the working poor. Getting to 

medical appointments is also an issue for people without private transportation. In Texas, 

mobile health care clinics or clinicians who can travel to the colonias in the evening to 

provide care and medications enable access. 

• Cultural competency among providers is also an issue. There are not enough providers 

and there are even fewer who are culturally diverse or culturally competent. Texas 

informants cited the shortage of physician providers in underserved areas as a reason for 

the absence of NPs, PAs, and CNMs who must be supervised in practice. If doctors are 

not available for supervised practice, then NPs, PAs, and CNMs are not able to practice. 

• Some States have implemented special statutory and regulatory provisions that create 

exceptions for professionals who wish to practice in underserved areas. For purposes of 

this study, we have identified these States as “dual scope of practice environments”. The 

legal requirements for supervision or collaboration by a physician and the parameters for 

prescriptive authority and reimbursement are expanded in defined locations to encourage 

practice with medically underserved populations or in health professional shortage areas. 

Texas and Oregon are States where such dual scope provisions exist. 

• In Oregon, PAs are permitted to apply for remote supervision by a physician, which is 

intended to extend provision of care to medically disadvantaged areas. PAs must apply 

for this privilege and must have the ability to directly communicate with a supervising 

physician in case of need. Additionally, the ratio of physician-to-physician assistants is 

expanded in the State to allow every physician in an underserved area or facility to 

supervise up to four PAs, rather than the two PAs allowed in traditional practice settings. 

• In Texas, physician assistants can practice with underserved populations under special 

circumstances that permit the PA and supervising physician more latitude. The physician 

must visit the clinic site every 10 days, perform a review of at least 10 percent of the 

medical records on a timely basis, and be available by telecommunication on a continuing 

basis. 

• Government programs dedicated to improved access are important. In rural upstate New 

York, a prenatal program which initially provided care only in the early stages of 

pregnancy was successful and has now expanded to include a full range of obstetrical 

64
services. CNMs and NPs provide much of the care to pregnant and parenting women in 

this program, which reaches some of the more remote communities of the State. 

• Increasing provider incentives to work in rural areas is also important. Oregon provides a 

$5,000 yearly income tax credit to rural providers, including NPs, PAs, and CNMs. 

Financial incentives might create an inducement to practice in underserved areas. 

Conclusions 

Many informants to this study indicated that care for underserved populations is enhanced by the 

three professions. NPs, PAs, and CNMs contribute significantly to increased access to healthcare 

in the urban and rural settings where healthcare services are provided. 

Opportunities exist to increase those contributions through increased scopes of practice which 

provide more professional autonomy, more direct access to reimbursement from a variety of 

payers, increased Federal incentives for those working with the underserved, scholarship grants 

to encourage new professionals and other initiatives to recruit a diverse workforce or train 

existing workforce to understand diversity and provide care in culturally competent practice. 

These initiatives are geared to the professions who provide care. There are also environmental 

initiatives that would permit greater access including monetary support for care to the uninsured 

and financial incentives to establish or maintain facilities that provide health services to 

populations with marginal access. 

It was clear from the fieldwork that future initiatives to increase access should not be onedimensional. All constituents—providers, payers, regulators, and patients—will be required to 

help find and create solutions to make progress towards a goal of universal access to healthcare. 

65
66
Appendix A. Project Advisory Committee 

Richard A. Cooper, MD 

Director, Health Policy Institute 

Medical College of Wisconsin 

8701 Watertown Plank Road 

Milwaukee, WI 53226 

Antonio Furino, PhD 

Professor of Economic and Director 

Center for Health Economics and Policy 

University of Texas, HSC at San Antonio

7703 Floyd Curl Drive, Mail Code 7907

San Antonio, TX 78229-3900 

Tim Henderson 

Director, Primary Care Resource Center

National Conference of State Legislatures

444 North Capitol Street, Suite 515 

Washington, DC 20001 

L. Gary Hart, PhD 

Director, WWAMI Health Workforce Center 

Roosevelt Way, NE Suite 308 

University of Washington 

Seattle, WA 98195-4795 

Thomas R. Konrad, PhD 

Director, Program on Health Professions 

Sheps Center for Health Services 

725 Airport Road, CB 7590, Suite 210

Chapel Hill, NC 27599-7165 

Linda Lacey

Associate Director 

North Carolina Center for Nursing 

222 North Person Street 

Raleigh, NC 27601 

Kevin Marvelle 

VP, Data Systems and Analysis 

American Academy of Physician Assistants 

950 North Washington Street 

Alexandria, VA 22314-1552 

Eileen T. O’Grady, PhD, RN, NP 

Policy Liaison 

American College of Nurse Practitioners 

503 Capitol Court, NE, #300 

Washington, DC 20002 

Joyce Roberts, CNM, PhD 

President 

American College of Nurse-Midwives (ACNM) 

818 Connecticut Avenue, NW Suite 900 

Washington, DC 20006 

Hollis Russinof, MUPP 

Center Manager and Policy Analyst 

Illinois Center for Health Workforce Studies 

850 West Jackson Blvd, Suite 400 

Chicago, IL 60607 

67
Edward Sekscenski 

Health Care Financing Administration 

Susan Skillman 

Deputy Director, WWAMI Health 

Workforce Center 

Roosevelt Way, NE Suite 308 

University of Washington 

Seattle, WA 98195-4795 

Joanne Spetz 

Research Fellow 

Center for the Health Professions 

545 Edinburgh Street 

San Mateo, CA 94402 

Staff 

Edward S. Salsberg 

Executive Director 

Center for Health Workforce Studies 

School of Public Health, University at Albany

One University Place, Suite 200 

Rensselaer, NY 12144-3456 

Paul Wing 

Deputy Director 

Center for Health Workforce Studies 

School of Public Health, University at Albany

One University Place, Suite 200 

Rensselaer, NY 12144-3456 

Margaret Langelier 

Senior Research Associate 

Center for Health Workforce Studies 

School of Public Health, University at Albany

One University Place, Suite 200 

Rensselaer, NY 12144-3456 

Emily Slocum 

Graduate Research Assistant 

Center for Health Workforce Studies 

School of Public Health, University at Albany

One University Place, Suite 200 

Rensselaer, NY 12144-3456 

HRSA Project Officer 

Louis A. Kuta 

Economist and Project Officer 

National Center for Health Workforce Analysis 

Health Resources and Services Administration 

5600 Fishers Lane, Suite 8-55 

Rockville, MD 20857 

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Appendix B. Professional Organizations 

This appendix lists the professional organizations related to NPs, PAs, and CNMs contacted as 

part of this study. 

Professional Organizations 

The professional organizations that credential and represent Nurse Practitioners, Certified Nurse 

Midwives and Physician Assistants are: 

Nurse Practitioners 

• American Academy of Nurse Practitioners 

• American College of Nurse Practitioners 

• National Association of Pediatric Nurses Practitioners 

• National Organization of Nurse Practitioner Faculties 

• Association of Women’s Health Obstetric and Neonatal Nurses 

• National Association of NPs in Women's Health 

• National Conference of Gerontological Nurse Practitioners 

• National Council of State Boards of Nursing, Inc. 

• American Nurses Credentialing Center 

• National Certification Corporation for the Obstetric, Gynecologic, and Neonatal Nursing 

Services 

• American Academy of Nurse Practitioners Certification Program 

69
• National Certification Board of Pediatric Nurse Practitioners 

Nurse Midwives 

• American College of Nurse Midwives 

• American College of Nurse Midwives (ACNM) Certification Council Inc. (ACC) 

• ACNM Division of Accreditation for CNMs and CMs 

• North American Registry of Midwives (NARM) for CPMs 

• American College of Nurse-Midwives Certification Council 

Physician Assistants 

• American Academy of Physician Assistants 

70
Appendix C. Original Index Calculations 

This appendix contains a table that documents the detailed calculations used to compute the 

practice environment indices for the three professions for each of the 50 States plus the District 

of Columbia. It includes the following subsections: 

• NPs 

• PAs 

• CNMs 

NPs 

The original practice environment index developed by Sekscenski et al for 1992 was based on a 

number of specific criteria and point allocations reflecting the then current practice environment 

for the profession. The specific criteria and point allocations used in creating the index are 

presented below. 

Legal Status (Maximum = 20) 

License or Title Recognition = 6. 

Practice Defined by the Board of Nursing = 7. 

No Supervision by Physician = 7. 

Reimbursement (Maximum = 40) 

Mandated Payment = 20. [This was understood to mean any required payment to 

Nurse Practitioners by Medicare, Medicaid, Workers Compensation, or private 

payer.] 

71
Services Covered = 0 – 10. [Particularly favorable environments were awarded 10 

points, while somewhat favorable environments were awarded 5 points] 

Medicaid % Pay = 0 – 10. [This was computed by multiplying the percent of 

physician reimbursement rate x 10. Thus NP reimbursement at 80 percent of 

physician rate received a score of 8.] 

Prescriptive Authority (Maximum = 40) 

Full Authority = 40. [This was defined as prescriptive authority for Schedule II-V 

controlled substances and legend drugs.] 

Partial Authority = 10 – 30. [Schedule III-V and legend drugs was valued at 30 

points. Schedule IV-V and legend drugs was valued at 20 points. Legend drugs 

only was awarded 10 points.] 

No Authority = 0. 

The details of the point allocations for each of the fifty States and the District of Columbia can 

be found below. 

72
Table C-1

Professional Practice Index Scoring Criteria

Original Scoring System for NPs for 2000

Scoring Category Score Optimal Score AL AK AZ AR CA CO CT DE DC FL 

Legal Status 

License or Title Recognition 

Practice Defined by Board of Nursing 

No Supervision by Physician 

6 6 6 6 6 6 6 6 6 6 6 6 

7 7 7 7 7 7 7 7 7 7 

7 7 7 7 7 7 7 7 7 7 7 7 

Subtotals Legal 20 13 20 20 20 20 20 20 20 13 20 

Reimbursement 

Mandate Payment 

Services Covered 

Medicaid % Pay x 10 

20 20 20 20 20 20 20 20 20 20 

0-10 10 10 5 10 10 10 10 10 10 

10 10 10 8 6 8 10 10 10 10 8 

Subtotals e R imbursement 40 20 33 36 28 20 40 40 40 20 38 Prescriptive Authority 

Full Authority 

Partial Authority 

No Authority 

40 40 40 40 40 40 40 40 

1-39 10 30 30 10 

0 

Subtotals Prescriptive Authority 40 10 40 40 30 30 40 40 40 40 10 

TOTAL 100 43 93 96 78 70 100 100 100 73 68 

continued 

73
Table C-1, continued 

Professional Practice Index Scoring Criteria 

Original Scoring System for NPs for 2000 

Scoring Category Score Optimal Score IA KS KY LA ME MD MA MI MN MS 

Legal Status 

License or Title Recognition 

Practice Defined by Board of Nursing 

No Supervision by Physician 

6 6 6 6 6 6 6 6 6 6 6 

7 7 7 7 7 7 7 7 7 7 

7 7 7 7 7 7 7 7 7 7 

Subtotals Legal 20 20 20 20 14 20 13 6 13 20 20 Reimbursement 

Mandate Payment 

Services Covered 

Medicaid % Pay x 10 

20 20 20 20 20 20 20 20 20 20 20 20 

0-10 10 10 7 10 10 10 10 10 10 10 10 

10 10 8 8 7.5 8 10 10 10 10 9 9 

Subtotals e R imbursement 40 38 35 37.5 38 40 40 40 40 39 39 Prescriptive Authority 

Full Authority 

Partial Authority 

No Authority 

40 40 40 40 40 40 

1-39 35 10 10 30 10 10 

0 

Subtotals Prescriptive Authority 40 40 35 10 10 30 40 40 10 40 10 

TOTAL 100 98 90 67.5 62 90 93 86 63 99 69 

continued 

74
Table C-1, continued 

Professional Practice Index Scoring Criteria 

Original Scoring System for NPs for 2000 

Scoring Category Score Optimal Score NJ NM NY NC ND OH OK OR PA RI 

Legal Status 

License or Title Recognition 

Practice defined by Board of Nursing 

No Supervision by Physician 

6 6 6 6 6 6 6 6 6 6 6 6 

7 7 7 7 7 7 7 7 7 

7 7 7 7 7 7 7 7 7 7 

Subtotals Legal 20 20 20 13 13 20 20 13 20 6 20 Reimbursement 

Mandate Payment 

Services Covered 

Medicaid % Pay x 10 

20 20 20 20 20 20 20 20 20 20 20 

0-10 10 10 10 10 10 10 10 10 10 10 10 

10 10 9.5 9 10 10 8 10 9 10 10 8 

Subtotals e R imbursement 40 39.5 39 40 40 38 40 19 40 40 38 Prescriptive Authority 

Full Authority 

Partial Authority 

No Authority 

40 40 40 40 40 40 40 40 

1-39 20 35 30 30 

0 

Subtotals Prescriptive Authority 40 20 40 40 35 40 30 30 40 40 40 

TOTAL 100 79.5 99 93 88 98 90 62 100 86 98 

continued 

75
Table C-1, continued

Professional Practice Index Scoring Criteria

Original Scoring System for NPs for 2000 

Scoring Category Score Optimal Score VT VA WA WV WI WY 

Legal Status 

License or Title Recognition 

Practice Defined by Board of Nursing 

No Supervision by Physician 

6 6 6 6 6 6 

7 7 7 7 7 7 7 

7 7 7 7 7 7 7 

Subtotals Legal 20 20 20 14 20 20 Reimbursement 

Mandate Payment 20 20 20 20 20 

Services Covered 0-10 10 10 10 10 10 10 10 

Medicaid % Pay x 10 10 10 10 10 10 10 10 10 

Subtotals Reimbursement 40 20 20 40 40 20 40 Prescriptive Authority 

Full Authority 40 40 40 40 40 Partial Authority 1-39 18 35 No Authority 0 

Subtotals Prescriptive Authority 40 40 18 40 35 40 30 TOTAL 100 80 38 100 89 80 90 

76

30 
PAs 

The original practice environment index developed by Sekscenski et al for 1992 was based on a 

number of specific criteria and point allocations reflecting the then present practice environment 

for the profession. The criteria and point allocations used in creating the index are presented 

below. The detailed point allocations for the 50 States can be found below. 

Legal Status (Maximum = 20) 

License or Title Recognition = 5. 

Professional Practice Regulations = 5. 

Practice Under Indirect Physician Supervision = 0 – 10. [On-site supervision = 0; 

Distance limitations in the regulations = 5; and Indirect supervision with electronic 

communication = 10.] 

Reimbursement (Maximum = 40) 

Mandated Payment = 30. [This was assumed to mean any required payment by Medicare, 

Workers Compensations, Medicaid or third party payer.] 

Payment for Services Under Indirect Supervision = 10. [This was determined to be the 

Medicaid percent times ten.] 

Prescriptive Authority (Maximum = 40) 

Any authority to Write Prescriptions = 20. 

Limited Authority to Order Medications in Inpatient Settings = 0 – 10. This was a 

subjective category scored according to the variation across the states in the privilege to 

write scripts in hospitals. If orders for medication must be signed by a physician before 

execution, for instance, fewer point were awarded. If PAs could write orders for 

immediate implementation with post review of records, 10 points were awarded.] 

Absence of Specific Restrictions = 0 – 10. [This was scored by a review of all restrictions 

on prescriptive authority. A point was discounted from the full value of 10 for each 

restriction found.] 

77
Table C-2

Professional Practice Index Scoring Criteria

Original Scoring System for PAs for 2000

Optimal 

Scoring Category Score Score AL AK AZ AR CA CO CT DE DC FL 

Legal Status 

License or Title Recognition 5 5 5 5 5 5 5 

Scope of Practice Regulations 5 5 5 5 5 5 5 

Practice Under Physicians Indirect Supervision 0-10 10 10 10 10 10 10 10 9 10 10 8 

Subtotals e L gal 20 20 20 20 0 0 5 9 0 0 8 

5 0 5 5 5 

5 5 5 5 5 

2 2 1 1 2 2 1 

Reimbursement 

Mandate Payment Payment for Services Under Indirect Supervision 

(if less than physician then %x10) 

30 30 30 30 30 30 30 30 30 0 0 30 

10 10 10 8.5 10 10 10 10 10 10 0 8 

Subtotals Reimbursement 40 40 38.5 40 40 40 40 40 10 0 38 Prescriptive Authority 

Any Authority to Write Prescriptions Limited Authority to Order Medications in 

Inpatient settings Absence of Specific Restrictions 

20 20 20 20 20 20 20 20 20 20 20 20 

0-10 10 7 10 10 10 10 10 10 10 10 10 

0-10 10 2 8 9 8 7 10 8 8 9 7 

Subtotals re P scriptive u A thority 40 29 38 39 38 37 40 38 38 39 37 TOTAL 100 89 96.5 99 98 97 95 97 68 59 93 

continued 

78
Table C-2, continued 

Professional Practice Index Scoring Criteria 

Original Scoring System for PAs for 2000 

Optimal 

Scoring Category Score Score IA KS KY LA ME MD MA MI MN MS 

Legal Status 

License or Title Recognition 5 5 5 5 5 5 

Scope of Practice Regulations 5 5 5 5 5 5 5 

Practice Under Physicians Indirect Supervision 0-10 10 10 10 10 10 10 10 10 10 10 10 

20 20 20 15 0 0 0 0 0 0 0 

5 5 5 5 5 

5 5 5 5 5 

Subtotals e L gal 2 2 2 2 2 2 2 Reimbursement 

Mandate Payment Payment for Services Under Indirect Supervision 

(if less than physician then %x10) 

30 30 30 30 30 30 30 30 30 30 30 30 

10 10 10 7.5 10 10 10 10 10 10 9 

Subtotals Reimbursement 40 40 37.5 40 40 40 40 40 40 39 30 Prescriptive Authority 

Any Authority to Write Prescriptions Limited Authority to Order Medications in 

Inpatient settings Absence of Specific Restrictions 

20 20 20 20 20 20 20 20 20 20 20 

0-10 10 10 10 0 10 10 10 10 10 

0-10 10 9 9 4 2 7 9 8 

Subtotals re P scriptive u A thority 40 39 39 20 0 34 30 32 37 29 38 TOTAL 100 99 96.5 75 60 94 90 92 97 88 88 

continued 

79
Table C-2, continued

Professional Practice Index Scoring Criteria

Original Scoring System for PAs for 2000

Optimal 

Scoring Category Score Score NJ NM NY NC ND OH OK OR PA R

Legal Status 

License or Title Recognition 5 5 5 5 5 5 5 5 5 5 

Scope of Practice Regulations 5 5 5 5 5 5 5 5 5 5 5 

Practice Under Physicians Indirect Supervision 0-10 10 7 10 10 10 10 10 10 10 10 10 

20 17 20 20 20 20 20 20 20 20 20 

5 5 

5 

Subtotals Legal Reimbursement 

Mandate Payment 30 30 30 30 30 30 30 30 30 30 30 

Payment for Services Under Indirect Supervision 10 10 10 10 10 8 8 10 10 10 

(if less than physician then %x10) 

Subtotals Reimbursement 40 0 40 40 40 38 30 38 40 40 40 

Prescriptive Authority 

Any Authority to Write Prescriptions 20 20 20 20 20 20 20 20 20 20 20 

Limited Authority to Order Medications in 0-10 10 5 0 0 10 0 5 10 10 0 10 

Inpatient settings 

Absence of Specific Restrictions 0-10 10 8 9 4 10 8 9 6 7 

40 25 38 39 34 30 5 38 39 26 37 

1 1

Subtotals Prescriptive Authority TOTAL 100 42 98 99 94 88 55 96 99 86 97 

continued 

80
Table C-2, continued

Professional Practice Index Scoring Criteria

Original Scoring System for PAs for 2000

Optimal 

Scoring Category Score Score VT VA WA WV WI WY 

Legal Status 

License or Title Recognition 5 5 5 5 5 5 

Scope of Practice Regulations 5 5 5 5 5 5 

0-10 10 10 2 10 10 10 10

5 5 5 5 

Practice Under Physicians Indirect Supervision 

Subtotals Legal 20 20 12 20 20 20 20Reimbursement 

Mandate Payment 

Payment for Services Under Indirect Supervision 

(if less than physician then %x10) 

30 30 30 30 30 30 30 30 

10 10 9 10 10 10 10 

Subtotals Reimbursement 40 39 30 40 40 40 40 Prescriptive Authority 

Any Authority to Write Prescriptions 

Limited Authority to Order Medications in 

Inpatient settings 

Absence of Specific Restrictions 

20 20 20 20 20 20 20 20 

0-10 10 10 5 10 10 10 10 

0-10 10 6 10 9 5 7 

Subtotals Prescriptive Authority 40 36 25 40 39 35 37 TOTAL 100 95 67 100 99 95 97 

81
82
CNMs 

The scores on the Sekscenski CNM professional practice index indicate a trend toward greater 

autonomy in State practice environments for CNMs across the fifty States and the District of 

Columbia between 1992 and 2000. The scores indicate the trend towards greater 

professionalization, socialization, and standardization of the CNM profession over the last 

decade. These trends are discussed more fully at the end of this chapter. 

Legal Status (Maximum = 20) 

License or Tile Recognition = 10. 

Regulation by Board of Nursing Alone = 10. [These points were allocated only if the 

Board of Nursing had sole regulatory authority. If another agency or board had any 

influence on some aspect of professional practice, such as prescriptive privilege, no 

points were awarded.] 

Reimbursement (Maximum = 40) 

Mandated Payment = 20. [This was interpreted to mean that reimbursement is required by 

Medicare, Medicaid, Workers Compensation, or third party payers.] 

Services Covered = 0 – 20. [This was a subjective award with 20 points given to very 

favorable payment environments, 10 points awarded for somewhat favorable 

environments, and fewer points given as determined by the reimbursement environment 

in a particular State. Incorporated in this category was Medicaid percentage payment 

times ten (as found in the CNM scale).] 

Prescriptive Authority (Maximum = 40) 

Full Authority = 40. [This was defined as prescriptive authority for Schedule II-V 

controlled substances and legend drugs. Schedule III-V and legend drugs was valued at 

30 points. Schedule IV-V and legend drugs was valued at 20 points, while legend drugs 

only was awarded 10 points.] 

The detailed point allocations for CNMs for the 50 States are presented below. 

83
Table C-3

Professional Practice Index Scoring Criteria

Original Scoring System for CNMs for 2000

Scoring Category Score Optimal Score AL AK AZ AR CA CO CT DE DC FL 

Legal Status 

License or Title Recognition 10 10 10 10 10 10 10 10 10 10 10 

Regulation by Board of Nursing Alone 10 10 10 10 10 10 10 10 10 

Subtotals e L gal 20 10 10 20 20 20 20 10 20 20 10 

Reimbursement 

Mandate Payment Services Covered 

20 20 20 20 20 20 20 20 20 20 

0-20 20 20 20 16 8 20 20 20 20 20 18 

Subtotals e R imbursement 40 20 40 36 28 40 40 40 40 20 38 Prescriptive Authority 

Full Authority 

Limited or Restricted Authority 

No Authority 

40 40 40 40 40 40 40 40 

30 

20 

10 10 

0 10 

Subtotals r P escriptive u A thority 40 10 40 40 30 10 40 40 40 40 10 TOTAL 100 40 90 96 78 70 100 90 100 80 58 

continued 

84
Table C-3, continued 

Professional Practice Index Scoring Criteria 

Original Scoring System for CNMs for 2000 

Scoring Category Score Optimal Score IA KS KY LA ME MD MA MI MN MS 

Legal Status 

License or Title Recognition 

Regulation by Board of Nursing Alone 

10 10 10 10 10 10 10 10 10 10 10 

10 10 10 10 10 10 10 10 

Subtotals e L gal 20 20 10 20 20 10 10 10 20 20 10 Reimbursement 

Mandate Payment Services Covered 

20 20 20 20 20 20 20 20 20 20 20 20 

0-20 20 17 18 18 20 20 20 20 20 20 19 

Subtotals e R imbursement 40 37 38 38 40 40 40 40 40 40 39 Prescriptive Authority 

Full Authority 

Limited or Restricted Authority 

No Authority 

40 40 40 40 40 40 40 

35 

20 

10 10 10 10 

0 

Subtotals r P escriptive u A thority 40 40 35 10 10 40 40 40 10 40 10 TOTAL 100 97 83 68 70 90 90 90 70 100 59 

continued 

85
Table C-3, continued

Professional Practice Index Scoring Criteria

Original Scoring System for CNMs for 2000

Scoring Category Score Optimal Score NJ NM NY NC ND OH OK OR PA RI 

Legal Status 

License or Title Recognition 10 10 10 10 10 10 10 10 10 10 10 

Regulation by Board of Nursing Alone 10 10 0 0 10 10 10 

Subtotals e L gal 20 10 10 10 20 20 10 20 10 10 

Reimbursement 

Mandate Payment Services Covered 

20 20 20 20 20 20 20 20 20 20 20 20 

0-20 20 17 20 20 20 17 20 20 20 20 

Subtotals e R imbursement 20 37 40 40 40 37 40 20 40 40 40 Prescriptive Authority 

Full Authority 

Limited or Restricted Authority 

No Authority 

40 40 40 40 40 40 40 

30 30 30 

20 

10 

0 0 

Subtotals Prescriptive Authority 40 10 40 40 40 40 30 30 30 0 40 TOTAL 100 47 90 90 90 97 90 60 90 50 90 

continued 

86
Table C-3, continued 

Professional Practice Index Scoring Criteria

Original Scoring System for CNMs for 2000

Scoring Category Score Optimal Score VT VA WA WV WI WY 

Legal Status 

License or Title Recognition 10 10 10 10 10 10 10 10 

Regulation by Board of Nursing Alone 10 10 10 10 10 10 10 

Subtotals e L gal 20 20 10 20 20 20 20 Reimbursement 

Mandate Payment 20 20 20 20 20 20 20 

Services Covered 0-20 20 17 20 20 18 20 

Subtotals e R imbursement 40 20 37 40 40 18 40 Prescriptive Authority 

Full Authority Limited or Restricted Authority 

No Authority 

40 40 40 40 40 

30 30 

20 20 

0 

Subtotals Prescriptive Authority 40 40 20 40 30 40 30 TOTAL 100 80 67 100 90 78 90 

87
88
Appendix D. Professional Practice Index 

Calculations for PAs 

This appendix contains a table that documents the detailed calculations used to compute the new 

professional practice index for PAs for each of the 50 States plus the District of Columbia. The 

criteria used in the new index include: 

Legal Authority (Maximum = 35) 

Title protection prevents those not qualified or certified by the State from practicing 

as a professional. Title protection provides safeguards to the public and to the 

professional. 

Licensure implies approval of credentials and granting of professional status. 

Licensing of PAs occurs in many States, but certification and registration is used in 

other States. States vary on the qualifications for licensure which may include the 

passing of a national certification examination and in some States, an employment 

agreement with a physician. 

Although having a supervising physician is fundamental to PA practice, the 

professional association for PAs suggests that employment agreements should be 

independent of licensure. PAs should not be required to have an employment contract 

to remain licensed [PAs 8th edition, p. v]. 

Professional Practice should be “dependent on what the supervising Physician wishes 

to delegate” [PAs 8th edition, p. xi] and not be finely detailed in law. 

Supervision should be the least restrictive mode that permits appropriately supervised 

practice. “Continuous” [PAs, 8th edition, p. xvi] supervision which may be indirect, 

but which permits contact with the supervising physician as needed is most desirable. 

89
Regulation by a PA Committee of the Board of Medicine is the optimal regulatory 

mechanism. Input by PAs is important to the profession. 

Fees for supervisory agreements can create disincentives for association with a 

professional. High costs may limit the number of agreements between a physician and 

PAs. 

The conditions and timing of review of records, although an implicit part of practice 

between a physician and a PA, is best determined by the agreement between the two 

professionals rather than by specific delineation in legislation. 

Limiting the number of PAs with whom a physician may associate through legislated 

ratios may be unduly restrictive. Leaving that number to the discretion of the 

physician and PAs suggests confidence in the abilities of both professions to 

adequately provide care within the skill and competencies of each and “according to 

the tenets of good patient care, adequate supervision, and legal responsibility.” [PAs, 

8th edition, p. vi] 

Locum Tenens means “the temporary provision of services by a substitute provider.” 

[PAs, 8th edition, p xx]. Allowance for substitution in law provides legal means for a 

physician or a PA to continue to practice in the temporary absence or inaccessibility of 

the other. 

Temporary License permits a PA to practice prior to taking the certification 

examination. 

Supervising Physician Liability in law reinforces the legal relationship that exists 

between a physician and PA. 

The ability to act independently in a declared emergency allows a PA to respond 

appropriately to emergency needs in a disaster. It provides legal protection for services 

provided by the PA in those circumstances. 

Reimbursement (Maximum = 25) 

Any mandated payment reflects the evolution of payment over the decade. Payment 

to PAs was changed after passage of the Balanced Budget Act in 1997 which extended 

payment for services rendered by PAs to all locations where they are employed. 

Medicaid payment percentage varies by State and this category reflects that 

fluctuation. 

Any language that permits reimbursement to “any qualified provider” is intended 

to describe the legal obligation to pay for services supplied by a PA. PAs are generally 

in employment situations in which the physician or the facility is billing for and 

receiving reimbursement for health services. Legislation that protects the right to 

payment is enabling to care. 

Prescriptive Authority (Maximum = 40) 

Prescriptive authority as delegated to PAs “can improve patient access to 

comprehensive care and provide for increased efficiency and cost effectiveness.” [PAs, 

8th edition, p. vii]. It may be defined in law or by the supervisory agreement. The 

more extensive privilege allows the PA more latitude in patient care. DEA numbers are 

90
required when prescribing scheduled drugs. Points are allotted for a DEA number to 

emphasize the importance of the prescriptive privilege. 

Accepting and distributing samples, having the PA name on the prescription pad 

and signing prescriptions are indicative of latitude in practice provided to the PA in 

law. 

The actual point allocations for PAs for the 50 States are presented below. 

91
Table D-1

Professional Practice Index Scoring Criteria For Physician Assistants in 2000

New Index for AL, AK, AZ, AR, CA, and CO 

Scoring Category Points 

Optimal 

Score fn 

State 

AL AK AZ AR CA CO 

Legal authority 

Title protection 3 3 a 3 3 3 3 3 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 b 5 5 

3 3 3 

1 1 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 

2 

2 

1 1 

0 0 0 c 0 0 0 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 5 

3 3 3 3 3 

1 

National certification required for initial licensing 1 1 e 1 1 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 5 5 5 5 5 f 

3 

0 

Regulated by: 

PA Board or committee appt by ext agency resp to med bd 

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 5 

5 

5 5 

0 0 0 g 0 

No fees for supervisory agreements 1 1 h 1 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I 

1 1 1 I 1 1 I 1 

0 I 0 I 

Ratios > 2 in outpatient settings, or not legislated 2 2 j 2 2 j j 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k 

1 1 1 

1 

Temporary License 1 1 l 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 1 1 1 

Subtotals Legal 35 25 25 25 18 25 15 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 10 8.5 10 10 10 10 

Any legislated mandate for coverage of PA services 5 5 5 0 0 0 0 0 

Subtotals Reimbursement 25 25 18.5 20 20 20 20 

continued 

92
Table D-1, continued 

Scope of Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for AL, AK, AZ, AR, CA, and CO, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

AL AK AZ AR CA CO 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30 p 30 30 p 30 

30 

25 25 p 

20 

15 

10 10 

0 

0 

Sign for samples 1 1 q 1 1 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 1 1 

PA's name on pad 1 1 s 1 1 1 1 1 1 

PA's signature only 2 2 t 2 t 2 

Own DEA number 5 5 u 5 5 5 5 5 

Subtotals x u R th A ority 40 11 38 37 31 38 40 

TOTAL 100 61 81.5 82 69 83 75 

FOOT NOTES 

Alabama h) Physician must review PA prescribing practices weekly by a review of 10% of 

patient charts 

Alaska b) Lose authority to practice if lose collaborative agreement 

c) Board approves "method for periodic assessment" and plan for delegation of prescriptive authority 

p) Schedule ll allowed with approval of physician 

Arizona I) PA must meet with physician once a week but review of records is not defined 

Arkansas g) Board "may" appoint an Advisory Committee 

j) No more than 2 PA's at onetime 

p) Statute says pharmacists authorized to fill scripts from PA's but rules say physician must sign all 

scripts . 1999 statutory change not yet reflected in rules 

California I) Countersignature and dating of 10% of medical records within 30 days but review of records of 

patients receiving prescription within 7 days 

p) Practice specific formulary and protocols that list specific criteria for prescribing. Controlled 

substance prescriptive authority is patient specific 

Colorado I) In statute, review of records every 2 days in HPSA. In regulations, chart notes of PA's reviewed and 

signed by physician within 7 days 

j) No more than 2 "specific individual" PA's 

f) PA practices "under personal and responsible direction and supervision of licensed physician" 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

Alabama State of Alabama Medicaid, http://www.medicaid.state.al.us 

Alabama Society of Physician Assistants, http://www.alabamapasociety.org 

Alaska Alaska Academy of Physician Assistants, http://www.akapa.org 

Arizona The Arizona State Association of Physician Assistants, http://www.asapa.org 

Arkansas Arkansas General Assembly, http://www.arkleg.state.ar.us 

Arkansas Academy of Physician Assistants, http://www.aapa.org/states/arapa 

California Physician Assistant Committee, Medical Board of California, http://www.physicianassistant.ca.gov 

Colorado Colorado State Board of Medical Examiners, http://www.dora.state.co.us 

Colorado Academy of Physician Assistants, http://www.corloradopas.org 

93
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for CT, DE, DC, FL, GA, and HI 

Scoring Category Points 

Optimal 

Score fn 

State 

CT DE DC FL GA HI 

Legal authority 

Title protection 3 3 a 3 3 3 3 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 5 5 5 5 

3 3 

1 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 3 3 

2 2 

2 

1 1 

0 0 0 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 5 d 

3 3 3 3 3 

1 

National certification required for initial licensing 1 1 e 1 1 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 5 

3 3 f 3 f 3 f 3 f 

0 

Regulated by: 

PA Board or committee appt by ext agency resp to med bd 

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 

5 5 

5 5 5 5 5 

0 

No fees for supervisory agreements 1 1 h 1 1 1 1 1 h 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I 

1 1 1 I 1 I 

0 0 I 0 I 0 I 0 I 

Ratios > 2 in outpatient settings, or not legislated 2 2 j 2 2 j j j 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k k k 

1 1 

1 

Temporary License 1 1 l 1 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 1 

Subtotals Legal 35 29 24 23 27 25 23 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 10 10 0 8 9 10 

Any legislated mandate for coverage of PA services 5 5 5 0 0 5 o 0 0 

Subtotals eim R bursement 25 25 20 10 23 19 20 

continued 

94
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for CT, DE, DC, FL, GA, and HI, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

CT DE DC FL GA HI 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30

30 

25 25 p 25 p 

20 20 p 

15 

10 10 10 

0 

0 

Sign for samples 1 1 q 1 q 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 1 1 1 1 r 

PA's name on pad 1 1 s 1 1 1 1 

PA's signature only 2 2 t 2 2 2 2 

Own DEA number 5 5 u 5 5 5 5 

Subtotals Rx Authority 40 29 38 12 11 33 35 

TOTAL 75 83 82 45 61 77 78 

FOOT NOTES 

Connecticut I) Regular review of records 

p)Schedule II, III inpatients only, co-signature by physician within 24 hours 

Delaware f) Not more than 30 minutes distant 

I) In regulation every 3 months (not merely up to physician and physician assistant team) 

k) Maximum number of PA's is 2 

DC f) Present within a 15 mile radius of District 

I) Countersign all medical orders and progress notes within 48 hours 

k) No more than 2 PA's at one time 

Florida f) Reasonable physical proximity 

I) Review and sign records within 7 days 

j) No more than 4 at anyone time 

o) Insurance must provide payment for PA first assist if coverage would have been provided 

to physician first assist 

Georgia d) But board must approve scope job description 

f) Physician readily available for personal supervision 

I) Physician to sign medical record entry for script within 7 days, review patient records 

daily in remote site 

j) No more than 2 PA's at any onetime 

p) Schedule II in emergency only 

Hawaii h) No agreement 

I) Review of charts within 7 days 

j) No more than 2 at one time 

p) Administer, Prescribe, Dispense Schedule ll inpatient only 

q,r) May request, receive or sign for professional samples, not controlled substances 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

Connecticut Connecticut Academy of Physician Assistants, http://www.connapa.org 

Delaware Delaware Academy of Physician Assistants, http://www.delawarepas.org 

DC District of Columbia Code, dccode.westgroup.com 

Office of Documents and Administrative Issuances, os.doc.gov/info 

continued 

95
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for CT, DE, DC, FL, GA, and HI, continued 

Florida Nova Southeastern University, http://www.nova.edu/pa 

Florida Academy of Physician Assistants, http://www.fapaonline.org 

Georgia Georgia Association of Physician Assistants, http://www.gapaonline.org 

Hawaii State of Hawaii, Office of the Auditor, http://www.state.hi.us/auditor 

Hawaii Academy of Physician Assistants, http://www.aapa.org/states/hapa.htm. 

96
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for ID, IL, IN, IA, KS, and KY 

Scoring Category Points 

Optimal 

Score fn 

State 

ID IL IN IA KS KY 

Legal authority 

Title protection 3 3 a 3 3 3 3 a 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 5

3 3 b 

1 1 b 1 b 1 b 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 3 

2 2 c 

2 2 

1 1 c 1 

0 0 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 5 5 5 

3 3 3 

1 

National certification required for initial licensing 1 1 e 1 e 1 1 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 5 f 5 f 5 f 5 f 

3 3 f 

0 

Regulated by: 

PA Board or committee appt by ext agency resp to med bd 

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 g 5 g 5 g 5 g 

5 

5 5 g 

0 0 

No fees for supervisory agreements 1 1 h 1 h 1 h h 1 1 h 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I 

1 1 1 i 1 I 0 I 1 I 

0 0 I 0 I 

Ratios > 2 in outpatient settings, or not legislated 2 2 j j j j j j j 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k 

1 1 1 

1 

Temporary License 1 1 l 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 1 1 

Subtotals Legal 35 20 29 20 27 24 22 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 8.5 10 10 10 7.5 10 

Any legislated mandate for coverage of PA services 5 5 5 o 5 o o 

Subtotals Reimbursement 25 18.5 25 20 25 17.5 20 

continued 

97
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for ID, IL, IN, IA, KS, and KY, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

ID IL IN IA KS KY 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

30 30 

30 

25 25 p 25 p 25 p 25 p 

20 

15 

10 10 p 10 

0 q 

0 r 

Sign for samples 1 1 s 1 1 q 1 q 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 t 1 1 1 1 

PA's name on pad 1 1 u 1 1 

PA's signature only 2 2 2 2 2 2 

Own DEA number 5 5 5 5 5 5 

Subtotals x u R th A ority 40 34 32 10 35 34 12 

TOTAL 100 72.5 86 50 87 75.5 54 

FOOT NOTES 

Idaho e) National certification and baccalaureate degree required 

h) Agreement not filed with the board 

I) Periodic review of representative sample 

j) No more than 2 

p) Prescribe only 

Illinois c) Required to file notice of delegation of prescriptive authority and notice of supervisory 

control 

f) Physician within reasonable distance 

g) PA Advisory Committee - 7 members 

h) No agreement filed 

I) Review on a timely basis 

j) No more than 2 

o) PA not allowed to bill patients for services but employer can bill. Payment must be made 

if services rendered would have been paid if rendered by a physician 

p) Prescribe, Dispense and Administer if delegated by supervising physician 

Indiana b) Certificate 

f) Physically present or immediately available 

g) 5 member PA committee appointed by governor 

h) $ 20 fee for changing physician 

I) Within 24 hours 

j) No more than 2 in statute, 1 in regulations 

p) Use or dispense drugsif approved by supervising physician 

Iowa b) Licensure and registration 

f) PA may function in remote medical clinic if approved by board 

g) 7 member PA committee appointed by governor 

I) Charts signed at least once per week in remote clinic 

j) No more than 2 at one time 

o) 3rd party payer to pay for PA care if same care provided by MD would be paid 

p) Schedule ll depressants and stimulants excluded 

Kansas b) Registered 

f) PA may work at a different practice location under certain conditions 

g) PA council, 5 members appointed by governor 

I) Review and sign patient records biweekly 

j) No more than 2 

p) Schedule ll in emergency situation only 

q) Request, receive, sign for and distribute samples 

continued 

98
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for ID, IL, IN, IA, KS, and KY, continued 

Kentucky a) No protection 

b) Certification 

c) Physician applies for approval to supervise PA 

f) May practice in separate clinic or office with board approval 

g) member of PA Advisory Committee 

h) $ 100 fee 

I) Sign all records in timely manner 

j) No more than 2 at any time 

o) Prohibited from directly billing any patient or payer 

q) Request, receive, sign for, and distribute samples 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

Idaho Idaho Statutes and Constitution Internet Home Page, http://www3.state.id.us 

Illinois Association Management Partners, http://ampka.com/iapa 

Illinois General Assembly, http://www.legis.state.il.us/legisnet 

Illinois Academy of PAs, http://www.ampka.com/iapa 

Indiana Indiana Academy of Physician Assistants, www.aapa.org/iapa.htm 

Iowa Iowa Physician Assistant Society, http://showcase.netins.net/web/ipas 

Kansas Kansas Academy of Physician Assistants, http://www.kansaspa.com 

Kentucky Kentucky Academy of Physician Assistants, http://www.kyapa.org 

99
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for LA, ME, MD, MA, MI, and MN 

Scoring Category Points 

Optimal 

Score fn 

State 

LA ME MD MA MI MN 

Legal authority 

Title protection 3 3 a 3 3 3 3 3 3 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 5 

3 3 b 

1 1 1 b 1 b 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 3 c 

2 2 2 c 

2 2 c 2 c 

1 

0 0 c 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 5 d 

3 3 d 3 3 

1 1 

National certification required for initial licensing 1 1 e 1 1 1 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 5 5 5 5 5 f 

3 

0 

Regulated by: 

PA Board or committee appt by ext agency resp to med bd 

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 5 5 5 g 

5 

5 5 5 g 

0 

No fees for supervisory agreements 1 1 h h h h 1 1 1 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I 

1 1 1 1 I 

0 0 I 0 I 0 I 0 I 

Ratios > 2 in outpatient settings, or not legislated 2 2 j j 2 j j j j j 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k 

1 1 1 k k 1 

1 

Temporary License 1 1 l 1 1 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 1 n 1 1 1 n 

Subtotals Legal 35 28 29 18 25 31 25 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 10 10 10 10 10 9 

Any legislated mandate for coverage of PA services 5 5 5 o o 5 o 

Subtotals eim R bursement 25 25 20 20 20 25 19 

continued 

100
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for LA, ME, MD, MA, MI, and MN, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

LA ME MD MA MI MN 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30 p 30 30 

30 

25 25 25 p 

20 

15 

10 

0 

0 0 p 

Sign for samples 1 1 q 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 1 

PA's name on pad 1 1 s 1 1 1 

PA's signature only 2 2 t 2 2 2 2 2 

Own DEA number 5 5 u 5 5 5 5 5 

Subtotals Rx Authority 40 1 34 38 37 33 37 

TOTAL 100 54 83 76 82 89 81 

FOOT NOTES

Louisiana d) Legislation states list is "intended to be illustrative not limiting"

h) $ 75 fee 

I) Inpatient records 24 hours, Nursing Home 48 hrs, all others 72 hrs 

j) Not more than 2 

k) Physician may supervise up to 4 PA's on a locum tenens basis 

n) Under supervision of physician who is present (not supervising physician) 

o) "Nothing shall prohibit" charges from being submitted to any government or private payer 

for services rendered by PA 

p) May orally transmit physician prescription, may administer, may transmit physician 

order into medical record 

Maine b) Certificate of registration and license 

c) Physician notifies board 

h) $ 100 Fee 

j) No limitation 

Maryland b) Delegation agreement 

h) $ 200 Fee 

I) Certificate of registration and license 

j) No more than 2 in a hospital setting 

p) PA may not dispense 

Massachuset b) Registration 

c) Written guidelines 

i) Prescriptive orders for Schedule ll must be reviewed within 96 hours. Physician reviews 

diagnosis and treatment information in a timely manner 

j) No more than 2 

o) PA's may not bill separately for services rendered -services are considered those of 

supervising physician 

Michigan c) Written authorization for prescriptive authority maintained in each practice location 

d) Separate statute and rules for osteopathic PA's 

g) Joint Task Force for PA's and Osteopathic PA's - 9 members, PA member of Medical 

Board as well 

I) Regular review of records 

j) No more than 2 at one practice site 

o) 3rd party payer may not deny payment for services by PA, under special conditions of practice 

p) Schedule ll only in facility where PA and supervising physician practice and only for 

patient being discharged 

continued 

101
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for LA, ME, MD, MA, MI, and MN, continued 

Minnesota b) Registered 

c) Physician PA agreement details practice arrangement and delegated prescriptive 

authority 

f) PA may provide services in geographically remote location 

g) PA Advisory Council (7 members) to Board 

I) Daily reviews of prescriptions 

j) Not more than 2 simultaneously 

n) May provide care during an emergency under direction of Emergency Medical 

Director 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

Louisiana Louisiana Board of Medical Examiners, http://www.lsbme.org 

Louisiana State Legislature, http://www.legis.state.la.us 

Maine State of Maine, Bill Status, 120th Legislature, http://janus.state.me.us 

Maryland Maryland General Assembly, http://mlis.state.md.us 

Massachuset Massachusetts Association of Physician Assistants, http://www.mass-pa.com 

Michigan The Michigan Academy of Physician Assistants, http://www.michiganpa.org 

Minnesota Minnesota Statutes, http://www.revisor.leg.state.mn.us 

Minnesota Medical Association, http://www.mnmed.org/mapa

Minnesota Academy of Physician Assistants, http://www.mnmed.org/mapa

102
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for MS, MO, MT, NE, NV, and NH 

Scoring Category Points 

Optimal 

Score fn 

State 

MS MO MT NE NV NH 

Legal authority 

Title protection 3 3 a 3 3 3 3 3 3 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 5 5 b 5 

3 3 3 b 

1 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 

2 

2 2 2 

1 

0 0 c 0 0 0 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 5 d 5 5 d 5 d 

3 3 

1 

National certification required for initial licensing 1 1 e 1 e 1 1 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 5 f 5 5 

3 3 f 3 f 

0 

Regulated by: 

PA Board or committee appt by ext agency rasp to med bd 

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 5 5 

5 5 5 g 

5 5 5 

0 

No fees for supervisory agreements 1 1 h 1 h 1 h 1 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I 

1 1 1 I 1 I 1 I 1 I 1 I 

0 0 

Ratios > 2 in outpatient settings, or not legislated 2 2 j j 2 j j 2 j j 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k 

1 1 1 

1 

Temporary License 1 1 l 1 1 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 1 

Subtotals Legal 35 27 26 28 24 30 34 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 10 9 10 8.5 o 10 

Any legislated mandate for coverage of PA services 5 5 0 5 o 0 0 0 

Subtotals Reimbursement 25 10 20 24 20 18.5 20 

continued 

103
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for MS, MO, MT, NE, NV, and NH, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

MS MO MT NE NV NH 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30 p 30 p 30 p 

30 

25 

20 

15 

10 10 p 10 10 p 

0 

0 

Sign for samples 1 1 q 1 1 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 1 r 1 1 r 

PA's name on pad 1 1 s 1 1 s 

PA's signature only 2 2 t 2 2 

Own DEA number 25 5 u 5 5 5 u 5 

Subtotals Rx Authority 40 12 15 39 35 16 35 

TOTAL 100 49 61 91 79 64.5 89 

FOOT NOTES

Mississippi c) Board approved protocol

e) A bachelor's degree is also required until 12/31/04 at which time a master's is required 

f) Continuous but not requiring on-site presence - practice confined to same community 

as physician 

h) Not defined 

I) On at least a monthly basis, 10% of charts 

j) No more than 2 at any one time, if supervising 2 NPs, no supervision of PA allowed 

p) Administering, ordering, prescribing, dispensing as delegated( no controlled substances) 

Missouri f) Limit on distance (no more than 30 miles by road, 50 miles in HPSA) also, doctor must 

be on-site 20% of time 

I) Must jointly review records at least once every two weeks 

r) 72 hr dose only on sample 

Montana d) PA may not maintain or manage an office separate from supervising physician 

but can practice in remote site with physician visits every 30 days 

g) PA is a non-voting liaison member of board, governor also appoints 1 PA 

to Medical Board 

h) $ 50 fee for new plan 

I) Not described 

j) No more than one PA but board can make exceptions 

o) 3rd party payers to consider services of PA's to be Medical Assistance 

p) Prescribe, dispense, administer. Schedule ll limited to 34 day supply 

s) And on medical container 

Nebraska b) Statute indicates licensed, regulations indicate certification 

f) Must be together 20% of time 

j) No more than 2 PA's 

p) Schedule ll limited to 72 hour supply 

Nevada b) License valid only as long as a physician employs the PA 

d) But board authorizes the supervision and the scope 

I) Regular "review of records" 

j) May not supervise more than 3 PA's 

o) Reimbursement based on PA assigned relative value unit 

p) May prescribe and dispense legend drugs, only dispense controlled substances 

r,u) DEA # for dispensing only 

New Hampsh d) Supervising physician develops a "specific written job description" 

I) Records review determined by physician andPA 

j) May not supervise more than 2 PA's 

P) May prescribe, dispense and administer "to the extent delegated by physician" 

continued 

104
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for MS, MO, MT, NE, NV, and NH, continued 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

Mississippi Mississippi State Board of Medical Licensure, http://www.msbml.state.ms.us 

Mississippi Academy of Physician Assistants, http://www.aapa.org/msapa.htm 

Missouri Missouri Revised Statutes, www.moga.state.mo.us/statutes 

Missouri Academy of Physician Assistants, http://moapa.org 

Missouri Board of Registration for the Healing Arts, www.ccodev.state.mo.us 

Secretary of State, State of Missouri, www.mosl.sos.state.mo.us/csr 

Montana Montana Academy of Physician Assistants, www.aapa.org/mapa.htm 

Nebraska Nebrasksa Academy of Physician Assistants, http://members.aol.com/neacdpas 

Nebraska Medical Association, http://nebmea.org 

Nevada Nevada Medical Association, www.state.nv.us/medical 

Nevada Administrative Code, www.leg.state.nv.us 

New Hampshire 

New Hampshire Board of Medicine, http://www.state.nh.us/medicine 

105
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for NJ, NM, NY, NC, ND, and OH 

Scoring Category Points 

Optimal 

Score fn 

State 

NJ NM NY NC ND OH 

Legal authority 

Title protection 3 3 a 3 3 3 3 3 3 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 5

3 3 b 3 b 3 b 3 b 

1 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 3 

2 2 2 

2 2 c 

1 1 c 

0 0 c 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 d 5 5 

3 3 

1 1 

National certification required for initial licensing 1 1 e 1 1 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 f 5 5 5 

3 3 3 f 

0 

Regulated by: 

PA Board or committee appt by ext agency resp to med bd 

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 

5 5 

5 5 5 5 

0 0 

No fees for supervisory agreements 1 1 h 1 1 1 1 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I I 

1 1 1 I 1 1 I 1 

0 0 I I 

Ratios > 2 in outpatient settings, or not legislated 2 2 j j j j 2 j j j 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k 

1 1 

1 1 

Temporary License 1 1 l 1 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 

Subtotals Legal 35 25 25 29 29 21 18 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 0 10 10 10 7.5 8.5 

Any legislated mandate for coverage of PA services 5 5 0 0 5 o 0 0 

Subtotals Reimbursement 25 10 20 20 25 17.5 18.5 

continued 

106
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for NJ, NM, NY, NC, ND, and OH, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

NJ NM NY NC ND OH 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30 p 

30 30 p 

25 25 p 25 p 

20 

15 

10 10 p 

0 0 p 

0 

Sign for samples 1 1 q 1 1 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 1 1 1 r 

PA's name on pad 1 1 s 1 1 1 1 

PA's signature only 2 2 t 2 2 2 2 

Own DEA number 5 5 u 5 5 5 5 

Subtotals Rx Authority 40 13 39 35 40 31 0 

TOTAL 100 48 84 84 94 69.5 36.5 

FOOT NOTES 

NEW JERSEY 

f) Physician continuously or intermittently present on-site with constant availability through 

electronic communication in inpatient setting 

I) Personal review by physician of all charts and records within 7 days in outpatient setting 

j) No more than 2 PA's 

p) only when "delegated to do so by physician", may not prescribe controlled substances 

NEW MEXICO 

c) Written utilization plan 

I) When practicing in remote areas, 20% must be reviewed every two weeks 

j) May not supervise more than 2 PA's 

p) Board approved formulary 

NEW YORK 

b) "Registered" as PA but issued a license 

d) Duties assigned by physician 

j) No more than 2 PA's in private practice 

p) May not write scripts for Schedule ll 

NORTH CAROLINA 

b) "Licensed by" and "registered with" 

I) "Physician countersigns outpatient charts within 7 days" 

j) Not legislated 

o) Payment for service within PA scope of practice shall not be denied when performed by PA 

p) PA may, under certain conditions, compound and dispense drugs. Schedule ll and lll 

for 30 days supply only 

NORTH DAKOTA 

b) Certificate of qualification 

c) Contract between physician and PA must be filed for approval 

I) "It is the responsibility of the supervising physician to review records" 

j) No more than 2 PA's 

r) Dispensing pre-packaged medicines limited to schedules IV and V and legend drugs 

p) Prescriptive authority delegated by supervising physician 

OHIO 

b) Certificate of registration (license) 

c) Standard utilization plan must be approved as well as supplemental utilization plan for any 

services beyond those included in standard plan 

f) Not more than 60 minutes travel time away 

i) $ 75 for approval of utilization plan 

j) No more than 2 PA's 

p) PA may not prescribe, dispense or order medication but may carry out physician order for 

medication 

continued 

107
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for NJ, NM, NY, NC, ND, and OH, continued 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

New Jersey New Jersey State Society of Physician Assistants, http://www.njsspa.org 

New Mexico New Mexico Academy of Physician Assistants, http://www.nmapa.com 

New York New York State Society of Physician Assistants, http://www.nysspanet.org 

North Carolin North Carolina Academy of Physician Assistants, http://www.ncapa.org 

North Dakota North Dakota State Board Of Medical Examiners, http://www.ndbomex.com/Default.htm 

Ohio Ohio Association of Physician Assistants,http://www.ohiopa.com 

108
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for OK, OR, PA, RI, SC, and SD 

Scoring Category Points 

Optimal 

Score fn 

State 

OK OR PA RI SC SD 

Legal authority 

Title protection 3 3 a 3 3 a 3 3 3 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 5 5 b 

3 3 b 

1 1 b 1 b 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 

2 2 

2 

1 

0 0 0 c 0 c 0 0 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 5 

3 3 3 3 3 

1 

National certification required for initial licensing 1 1 e 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 f 5 5 5 

3 3 3 f 

0 

Regulated by: 

PA Board or committee appt by ext agency resp to med bd 

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 5 

5 5 g 5 g 

5 5 5 5 

0 0 

No fees for supervisory agreements 1 1 h 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I 

1 1 1 j 1 j j 1 1 j 

0 0 0 j 

Ratios > 2 in outpatient settings, or not legislated 2 2 j k k k k k 2 k 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k 

1 1 1 l 1 1 

1 

Temporary License 1 1 l 1 1 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 1 

Subtotals Legal 35 25 33 20 32 9 26 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 7.5 10 10 8 10 7.5 

Any legislated mandate for coverage of PA services 5 5 5 0 

Subtotals Reimbursement 25 17.5 25 20 18 20 17.5 

continued 

109
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

OK OR PA RI SC SD 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30 p 

30 30 p 

25 25 p 25 25 p 

20 

15 15 p 

10 

0 

0 

Sign for samples 1 1 q 1 q 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 r 1 r 

PA's name on pad 1 1 s 1 1 1 1 1 1 

PA's signature only 2 2 t 2 2 2 2 2 2 

Own DEA number 5 5 u 5 5 5 5 5 5 

Subtotals Rx Authority 40 35 34 33 38 23 38 

TOTAL 100 77.5 92 73 88 52 81.5 

FOOT NOTES 

OKLAHOMA 

f) Physician must be on-site half day per week 

j) "Regularly review health care services" of PA 

k) No more than 2 PA's at any time 

l) In locum tenens, all charts must be signed within 24 hours 

p) Board formulary but authority delegated by physician, restrictions on supply of controlled 

substances 

q,r) May request, receive sign and distribute professional samples 

OREGON 

a) Must register as a PA if employed as a PA 

c) Tasks to be delegated approved by Board 

h) "Physician may have 2 PA's, PA may have 4 supervising physicians" 

j) Medical services of PA reviewed by MD on regularly scheduled basis 

r) May "dispense" pre packaged medications 

PENNSYLVANIA 

b) Certified 

c) PA may not practice without written agreement with a physician 

g) Once in every 8 years PA sits on board (4 year terms alternate with NPs/CNMs ) 

j) Personal and at least weekly review of patient records 

k) May not have responsibility for more than 2 PA's 

p) Board of approved formulary 

RHODE ISLAND 

b) Licensed 

g) 2 PA's on board 

k) Not more than 2 PA's at any time 

o) Rate not available but reimbursement allowed, 80% chosen as reasonable score 

p) Statutory change 1999, rules not yet written 

SOUTH CAROLINA 

b) On front 

f) 45 miles or 60 minutes 

j) Physician must review charts within 72 hours 

k) No more than 2 PA's 

p) Schedule V if in the "approved written protocol" 

SOUTH DAKOTA 

b) License in statute, certificate in regulations 

j) Responsibility of the physician to review work 

k) Up to 4 PA's 

p) Schedule ll for not more than 48 hours 

continued 

110
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

Oklahoma Oklahoma Academy of Physician Assistants, http://www.chickasaw.com 

Oregon Oregon Health Division, http://www.ohd.hr.state.or.us 

Oregon State Legislature, http://www.leg.state.or.us 

Oregon Board of Medical Examiners, http://www.bme.state.or.us 

Pennsylvania Pennsylvania Society of Physicians Assistants, http://www.pspa.net. 

Pennsylvania Code, http://www.pacode.com 

Rhode Island Rhode Island Department of Health, http://www.health.state.ri.us 

South Caroli South Carolina Academy of Physician Assistants, http://www.scapapartners.org 

South Dakota South Dakota Department of Health, http://www.state.sd.us/doh 

South Dakota Academy of Physician Assistants, http://www.sdapa.net 

111
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for TN, TX, UT, VT, VA, and WA 

Scoring Category Points 

Optimal 

Score fn 

State 

TN TX UT VT VA WA 

Legal authority 

Title protection 3 3 a 3 3 3 3 3 3 

How Licensed 

Licensure language only 

Licensure w/Registration ( i.e. reg. w/employment papers) 

Certification or Registration language only 

b 

5 5 5 5 5 

3 3 3 b 

1 1 b 

Agreement 

No notification required, agreement exists btw phys & PA 

Notification only of employment/agreement btw phys & PA 

Written agreement available 

File practice agreement w/board 

File for approval of board 

c 

3 3 

2 2 2 c 

2 2 

1 

0 0 c 0 0 

Definition of Scope 

Scope defined by supervising physician & PA 

Scope loosely defined in law (may include but not limited to...) 

Scope clearly delineated in law (list of permissible tasks) 

d 

5 5 5 d 5 5 

3 3 3 3 d 

1 

National certification required for initial licensing 1 1 e 1 1 1 1 1 1 

Supervision: 

Indirect-physical presence not required 

Limited Indirect (limit on distance, time, travel, etc) 

Direct-physical presence required (on site) 

f 

5 5 5 5 5 f 5 5 

3 3 f 

0 

Regulated by: 

PA o B ard r o committee p a pt y b x e t g a ency es r p o t e m d d b

Medical Board with PA representation 

PA Committee appt by medical board 

Medical Board with no PA representation 

g 

5 5 5 5 g 5 g 5 

5 5 5 

5 

0 

No fees for supervisory agreements 1 1 h 1 1 1 1 

Review of Records by Physician: 

> 7 days/not described/determined by phys-PA team 

< 7 days 

I 

1 1 1 1 

0 0 I 0 I 0 I 

Ratios > 2 in outpatient settings, or not legislated 2 2 j j 2 j j 2 j 2 j 

Locum Tenens 

Legislated 

When no practice agreement, locum tenens inherent 

k 

1 1 1 1 1 

1 

Temporary License 1 1 l 1 1 1 1 1 

Supervising physician liability 1 1 m 1 1 1 1 1 1 

Disaster relief legislation 1 1 n 1 

Subtotals Legal 35 28 30 30 25 24 24 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 10 10 10 

Medicaid % x 10 10 10 10 10 10 9 0 10 

Any legislated mandate for coverage of PA services 5 5 0 5 0 0 

Subtotals eim R bursement 25 20 25 20 19 10 20 

continued 

112
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

TN TX UT VT VA WA 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30 p 30 p 

30 30 p 30 p 

25 

20 

15 

10 10 p 10 p 

0 

0 

Sign for samples 1 1 q 1 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 1 r 1 1 1 

PA's name on pad 1 1 s 1 1 

PA's signature only 2 2 t 2 2 t 2 

Own DEA number 5 5 u 5 5 5 5 

Subtotals x u R tho A rity 40 38 12 35 38 13 38 

TOTAL 100 86 67 85 82 47 82 

FOOT NOTES 

TENNESSEE 

d) Protocol jointly determined by physician and PA 

j) No more than 2 PA's 

p) Regulations regarding prescriptive authority in statutory change from1999 

not yet written 

TEXAS 

c) Notification includes name, address, licenses and phone numbers of PA 

and physicians 

g) Texas State Board of PA Examiners 

j) 3 PA's or their FTE equivalent 

p) Authorization through standing medical orders, delegation orders etc. At 

site in a MUA or primary practice site 

r) In public health clinics may supply one or more doses in properly labeled 

containers 

UTAH 

f) Must provide direct supervision at least 50% of the time, prior approval for "off-site 

practice" is required 

g) PA Licensing Board 

I,p) Doctor must co-sign all charts where Schedule ll or lll drugs are prescribed, 

PA may prescribe and administer 

j) No more than 2 PA's but an exception may be granted 

VERMONT 

b) Certification 

c) "Written scope of practice submitted to board for approval" 

p) Prescribe, dispense and administer drugs and devices 

t) Script signed by PA but must indicate the name of physician who has delegated 

privilege 

VIRGINIA 

b) Virginia allows volunteer PA license with no remuneration in clinical settings 

f) Must obtain board approval if services are to be rendered away from supervising 

physician, PA not to establish separate office 

I) Review and sign records within 72 hours 

j) No more than 2 "assistants" at any one time 

p) PA may administer but not dispense 

continued 

113
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

WASHINGTON 

b) License in statute, certified in regulations 

d) PA functions outlined in "standardized procedures" established by commission 

I) "Every written entry reviewed within 2 working days" 

j) No more than 3 

p) May dispense medication from office supplies, must have specific approval from 

commission for prescriptive authority 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

Tennessee Tennessee Academy of Physician Assistants, www.tnpa.com. 

Tennessee Medical Association, www.medwire.org. 

Tennessee Rules and Regulations, www.state.tn.us/sos 

Texas Texas State Board of Medical Examiners, http://www.tsbme.state.tx.us/rules 

Texas Legislature, http://www.capitol.state.tx.us 

Texas Academy of Physician Assistants, http://www.tapa.org 

Utah Utah Academy of Physician Assistants, http://www.utahapa.org 

Vermont Vermont Board of Medical Practice, www.dacboard.org/vt/pa. 

Virginia Virginia Department of Health Professions, http://www.dhp.state.va.us 

Virginia Academy of Physician Assistants, http://www.vapa.org 

Washington Washington State Department of Health, Washington Medical Quality Assurance Commission, 

http://www.doh.wa.gov/Medical/rcws.htm 

Washington Academy of Physician Assistants, http://www.wapa.com 

114
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for WV, WI, and WY 

Scoring Category Points 

Optimal 

Score fn 

State 

WV WI WY 

Title protection 3 a 3 3 

How Licensed b 5 

Licensure language only 5 5 b 

Licensure w/Registration ( i.e. reg. w/employment papers) 3 3 

Certification or Registration language only 1 

Agreement c 

No notification required, agreement exists btw phys & PA 3 3 

Notification only of employment/agreement btw phys & PA 2 

Written agreement available 2 2 

File practice agreement w/board 1 1 

File for approval of board 0 c 

Definition of Scope d 

Scope defined by supervising physician & PA 5 5 5 d 

Scope loosely defined in law (may include but not limited to...) 3 3 

Scope clearly delineated in law (list of permissible tasks) 1 1 

National certification required for initial licensing 1 e 1 e 1 

Supervision: f 

Indirect-physical presence not required 5 5 f 5 f 5 

Limited Indirect (limit on distance, time, travel, etc) 3 

Direct-physical presence required (on site) 0 

Regulated by: g 

PA Board or committee appt by ext agency resp to med bd 5 5 5 g 

Medical Board with PA representation 5 5 

PA Committee appt by medical board 5 5 

Medical Board with no PA representation 0 

No fees for supervisory agreements 1 h 1 1 

Review of Records by Physician: I 

> 7 days/not described/determined by phys-PA team 1 1 I 1 I 

< 7 days 0 

Ratios > 2 in outpatient settings, or not legislated 2 j 2 j j 

Locum Tenens k 

Legislated 1 1 1 1 

When no practice agreement, locum tenens inherent 1 1 

Temporary License 1 l 1 1 

Supervising physician liability 1 m 1 

Disaster relief legislation 1 n 

Subtotals Legal 35 29 26 27 

Legal authority 

3 3 

5 

0 

1 1 

5 

1 1 

1 I 

2 j 

1 1 

1 1 

1 

Reimbursement o 

Any mandated payment- Medicare, Champus, et al. 10 10 10 10 10 

Medicaid % x 10 10 10 10 9 10 

Any legislated mandate for coverage of PA services 5 5 

Subtotals Reimbursement 25 20 19 20 

continued 

115
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for WV, WI, and WY, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

WV WI WY 

Prescriptive Authority 

How defined 

Defined by Supervisory Agreement 

Defined in Law--allows controlled substances--II-V 

III-V 

IV-V 

V only 

no controlled 

Defined in Law--formulary, no controlled substances 

No Rx Authority 

p 

30 30 30 p 

30 

25 25 p 25 

20 

15 

10 

0 

0 

Sign for samples 1 1 q 1 q 

Dispense/distribute samples--implies prepackaged w/ inst 1 1 r 1 r 1 r 

PA's name on pad 1 1 s 1 1 1 

PA's signature only 2 2 t 2 2 2 

Own DEA number 5 5 u 5 5 5 

Subtotals Rx Authority 40 35 38 34 

TOTAL 100 84 83 81 

FOOT NOTES 

WEST VIRGINIA 

a) Statute recognizes PA midwives 

c) Physician applies to board for approval to supervise PA, must include 

description of services to be performed 

e) Requires bachelor's or master's degree (7/1/94) 

f) Special provisions for rural areas 

I) Supervising physician responsible for records of each PA 

j) No more than 3 PA's at any one time 

p) Exclusion of schedule ll anti-coagulants, anti-neoplastics, etc 

Schedule lll limited to 72 hour supply 

q,r) May accept and distribute professional samples 

WISCONSIN 

f) Electronic communication within 15 minutes 

g) Council on PA's 

I) If PA prescribing, script or patient record must be reviewed and countersigned 

within one day 

j) No more than 2 PA's but requests for more are possible 

p) Physician must countersign script or patient record within one day 

WYOMING 

d) "PA may perform those duties and responsibilities are provided under the 

supervision of a board-approved physician" 

I) Not legislated 

j) Physician may supervise 2 PA's and be back up for 2 PA's but may not supervise 

more than 2 at any one time 

r) Dispensing of pre-packaged medications permitted in rural clinics only 

continued 

116
Table D-1, continued 

Professional Practice Index Scoring Criteria For Physician Assistants in 2000 

New Index for WV, WI, and WY, continued 

REFERENCES 

Main Resources 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, 

Alexandria, Virginia 1992. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, 

Alexandria, Virginia 1998. 

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, 

Alexandria, Virginia 2000. 

American Academy of Physician Assistants, http://www.aapa.org 

Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service. 

U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners 

Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html 

Washburn Law School, www.washlaw.edu 

West Virginia West Virginia Department of Health and Human Resources, http://www.wvdhhr.org 

West Virginia Legislature, http://www.leg.is.state.wv.us 

West Virginia Association of Physician Assistants, http://www.wvapa.com 

Wisconsin Wisconsin Academy of Physician Assistants, http://www.wapa.org 

Wyoming Wyoming Association of Physician Assistants, http://www.wapa.net 

117
118
Appendix E. Professional Practice Index 

Calculations for NPs 

This appendix contains a table that documents the detailed calculations used to compute the new 

professional practice index for NPs for each of the 50 States plus the District of Columbia. The 

criteria used in the new index include: 

Legal Status (Maximum = 35) 

Title Protection suggests acceptance and acknowledgement of the skills required to 

practice as a professional. Legal protection provides a safeguard for both the public 

and the professional.] 

Licensure as NP indicates full recognition as a professional. Licensure as an RN and 

certification or registration as NP is the second best situation. RN license only is the 

minimum. Requirements for recognition to practice in an advanced nursing role vary 

by State and may include the passing of a national certification examination, the 

obtaining of an advanced degree (at the master or doctoral level), as well as various 

levels of pharmacology education for prescriptive authority. Licensure to practice may 

occur independently of certification to prescribe. In some States, the renewals of 

licensure and prescriptive authority occur in tandem. In others, licensure and 

prescriptive authority require separate applications and separate criteria. 

Autonomous practice possible provides the most expansive practice options. 

Legal relationship with physicians indicates the degree of autonomy in practice for 

the advanced practice nurse. Statutes vary considerably in their requirements for 

physician involvement in NP practice. In some laws, physician relationship is not 

mentioned; in some, collaboration with other health professionals is a requirement; in 

others, laws demand supervision by a physician for the NP. More independent 

119
environments are considered the ideal practice situation for NPs to exercise their 

professional practice. However, NPs function well in all of these configurations. 

Regulation by the State Board of Nursing is the most appropriate design for NP 

management. Control of various aspects of practice by Boards of Medicine, Boards of 

Pharmacy, Boards of Consumer Affairs, etc. occurs across the States with regularity, 

but these insert the interests of other professions into the practice arena. Self-regulation 

is the goal of most professions. 

The requirement to have practice agreements approved or legislated review of 

records at particular intervals removes the autonomy of the nurse and/or physician 

with whom s/he practices to exercise discretion over practice conditions. Professionals 

recognize and seek appropriate safeguards to the suitable and safe delivery of care to 

patients. The ideal would be to have that standard determined on an individual basis by 

the nurse and collaborating health professional at the practice level. 

Hospital privileges, referrals, and the ability to order testing suggest recognition of 

the skills of the NP. In order to practice as a true primary care provider, these things 

are necessary to care adequately for the patient. 

Reimbursement (Maximum = 35) 

In 1997, the Balanced Budget Act, expanded the locations at which Nurse Practitioners 

could be reimbursed for services. Since this represented a progression in 

reimbursement from 1992, a score was awarded to every State for direct Medicare 

payment. 

State reimbursement policy for payment of services rendered to Medicaid-eligible 

patients varies considerably by State and by profession. 

The legal right to be included on the provider panels of health maintenance 

organizations allows NPs to fully provide patient care within their professional 

practice. Since NPs are trained with a primary care orientation, this is a desirable 

privilege. 

The legal right to be reimbursed for services provided is critical to the autonomy of 

the NP. Although services might potentially be provided totally by the NP, the inability 

to bill third parties for payment as an identified provider could preclude that from 

happening. This could be a barrier to the provision of care. 

Prescriptive Authority (Maximum = 30) 

When prescriptive authority is granted as part of the licensure process for advanced 

practice, it implies recognition of NP skill and education. Separate application suggests 

special requirements for the privilege that are not fundamental to the educational and 

clinical preparation of the NP. 

Although DEA numbers are a requirement for prescribing controlled substances, a 

separate score was allotted to emphasize the importance of the privilege of prescribing 

scheduled drugs. 

120
Definition of the prescriptive privilege in law rather than by individual physicians 

suggests full recognition of the abilities of the professional. Dependence on physician 

delegation for prescriptive authority limits the nurse practitioner and creates barriers to 

efficient practice. Review by another health professional of patient needs and the 

ordering of appropriate medications is certainly a necessary part of practice as a NP; 

however, the circumstances under which that consultation occurs may best be 

determined by the advanced practice professional and collaborator and need not be 

detailed in law. 

The ability to receive and distribute sample medications, to independently sign a 

prescription and to prescribe medical devices indicate recognition of the 

competencies of NPs. 

Continuing education requirements are important for maintaining the skills and 

updating the competencies of the NP. 

The actual point allocations for NPs for the 50 States are presented below. 

121
Table E-1

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000

New Index for AL, AK, AZ, AR, CA, and CO 

Optimal 

Points Score fn 

Title protection 3 a 3 3 3 3 3 

How Licensed b 

Lic as Nurse Practitioner 3 3 3 

Lic as Nurse & Cert, Reg or Approved as NP 2 2 b 2 b 2 b 2 b 2 b 

RN license only 1 

Autonomous practice possible 7 c 7 7 7 c 7 

Relationship with Physicians: d 

No mention of physician in legislation 5 5 5 

Collaborative language 4 4 4 4 d 4 d 

Supervisory Language 2 2 

Electronic communication permitted/Indirect sup. 1 1 

Regulated by: e 

State Board of Nursing Alone/or Board of APN 3 3 3 3 3 3 

Regulation by State BON with another entity 2 2 e 2 e 

Regulation by Board of Medicine or other 1 

National certification required 1 f 1 1 1 1 

Master's degree required for licensure 1 g 1 1 g 

Practice Agreements: h 

No written practice agreement required 3 3 3 3 3 h 

Written practice agreement avail on site 2 2 h 

Written practice agreement filed with reg agency 1 1 1 

Ratios > 2 in outpatient settings, or not legislated 1 I 1 1 I 1 I 1 

Review of Records by Physician: j 

No legislated time requirement for review 3 3 3 j 3 j 3 j 3 j 

Periodic/Regular Reviews 2 2 

Strict/Daily 1 

Hospital Privileges protected in legislation 1 k 1 

Can refer directly for health/medical services 2 l 2 2 2 l 2 

Can order or perform diagnostic or lab tests 2 m 2 2 2 

Subtotals Legal 35 20 32 33 30 26 29 

Scoring Category 

State 

AL AK AZ AR CA CO 

Legal Authority 

3 3 

7 7 

1 1 

1 1 

1 1 

3 

1 

2 2 2 

2 2 

5 n 5 5 5 5 5 

Legal right to be listed on panels as PCP 5 o 5 5 o 

Medicaid % x 10 10 10 p 10 8 6 p 8 0 p 10 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 q 15 15 

Subtotals Reimbursement 35 20 28 31 13 35 30 

Medicare 

Reimbursement 

5 5 

5 5 

1

continued 

122
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for AL, AK, AZ, AR, CA, and CO, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

AL AK AZ AR CA CO 

Prescriptive Authority 

How Received: 

Automatic 

Application or Approval Required 

4 4 r 

2 2 2 2 2 2 2 

Uses Own DEA number 3 3 s 3 3 3 3 3 

How defined 

Defined by Legislation/Phys.agmt.doesn't determine 

Collaborative agreement defines 

Supervisory agreement defines 

Defined Formulary (inclusive or exclusive) 

t 

5 5 5 t 5 t 5 5 

4 

3 3 

1 1 

Type of Authority 

Full authority within Scope (II-V and Legend) 

Extensive authority (III-V and Legend) 

Limited authority (IV-V and Legend) 

Restricted (V and Legend) 

Legends only 

u 

12 12 12 12 u 12 

9 9 u 9 u 

6 

3 

1 1 u 

Durable medical equipment 1 1 1 1 1 1 

Sign for samples 1 1 w 1 1 1 1 1 

Distribute samples 1 1 x 1 x 1 1 1 1 

NP signs prescription 2 2 y 2 2 2 2 2 y 2 

Continuing Ed requirements 1 1 z 1 1 1 1 1 1 

Subtotals Prescriptive Authority 30 8 28 28 24 23 27 

TOTAL 100 48 88 92 67 84 86 

FOOTNOTES 

ALABAMA 

b) Certificate of Qualification 

e) BOM 

x) NP allowed to provide(dispense) drugs within formulary 

ALASKA 

b) Authorized 

j) Not required 

t) No involvement 

u) NPs can dispense drugs 

ARIZONA 

b) Certificate to practice 

p) NPs may contract with Health Cost Containment System as PCPs 

t) Not defined 

u) NPs can dispense drugs 

ARKANSAS 

d) Collaborative agreement for prescriptive privilege 

I) For prescriptive authority 

j) Not defined 

l) Determined by hospital 

q) Any Willing Disallowed Provider Law disallowed 1997 

u)1000, hours of practice as APN required, 300 hrs Preceptorship training for privilege 

continued 

123
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for AL, AK, AZ, AR, CA, and CO, continued 

CALIFORNIA 

b) Scope is RN scope 

c) May not order drugs in solo practice 

e) Board of Nursing is a part of State and Consumer Service Agency 

Standardized procedures developed with BOM 

h) Standardized procedures guide practice 

I) Four 

j) Not defined 

o) Medi-CAL-cal lists as PCPs 

p) Medicaid reimbursement limited to FNP and PNP 

u) Dispensing Authority 

y) Drs name must appear on drug container label, Effective 2001, NP name as well 

COLORADO 

b) Registered 

d) RN viewed as independent practitioner 

g) Master's degree required for prescriptive authority and after 7/1/08, for everyone 

h) Collaborative agreement for prescriptive authority must notify BON the name 

of physician 

j) Not defined 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

ALABAMA 

Alabama Board of Nursing, http://www.abn.state.al.us 

ALASKA 

http://www.legis.state.ak.us

Alaska Division of Occupational Licensing: Board of Nursing, http://www.dced.state.ak.us/occ

ARIZONA 

Arizona Health Care Cost Containment System, http://www.ahccs.state.az.us 

Arizona State Board of Nursing, http://www.azboard of nursing.org 

ARKANSAS 

Arkansas State Board of Nursing , http://www.accessarkansas.org/nurse 

CALIFORNIA 

State of California-State and Consumer Services Agency, Board of Registered Nursingwww.rn.ca.gov 

National Council of State Boards of Nursing, http://www.ncsbn.org 

American College of Nurse Midwives, http://www.acnm.org 

COLORADO 

Colorado Department of Regulatory Agencies, http://www.dora.state.co.us/Nursing 

124
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for CT, DE, DC, FL, GA, and HI 

Scoring Category Points 

Optimal 

Score fn 

State 

CT DE DC FL GA HI 

Legal Authority 

Title protection 3 3 a 3 a 3 3 3 a 3 

How Licensed 

Lic as Nurse Practitioner 

Lic as Nurse & Cert, Reg or Approved as NP 

RN license only 

b 

3 3 3 

2 2 2 b 2 2 b 2 b 

1 

Autonomous practice possible 7 7 c 7 c 7 7 7 

Relationship with Physicians: 

No mention of physician in legislation 

Collaborative language 

Supervisory Language 

Electronic communication permitted/Indirect sup. 

d 

5 5 

4 4 4 4 4 d 4 d 

2 2 

1 1 

Regulated by: 

State Board of Nursing Alone/or Board of APN 

Regulation by State BON with another entity 

Regulation by Board of Medicine or other 

e 

3 3 3 

2 2 e 2 e 2 e 2 e 

1 1 e 

National certification required 1 1 f 1 1 f 1 1 f 1 1 

Master's degree required for licensure 1 1 g 1 1 1 1 g 

Practice Agreements: 

No written practice agreement required 

Written practice agreement avail on site 

Written practice agreement filed with reg agency 

h 

3 3 3 h 

2 2 2 

1 1 h 1 h 1 h 

Ratios > 2 in outpatient settings, or not legislated 1 1 I 1 1 1 1 1 1 

Review of Records by Physician: 

No legislated time requirement for review 

Periodic/Regular Reviews 

Strict/Daily 

j 

3 3 3 j 3 j 3 3 j 

2 2 2 j 

1 

Hospital Privileges protected in legislation 1 1 k 1 1 1 

Can refer directly for health/medical services 2 2 l 2 2 2 

Can order or perform diagnostic or lab tests 2 2 m 2 2 2 2 2 

Subtotals Legal 35 27 29 29 22 20 25 

5 n 5 5 5 5 5 

Legal right to be listed on panels as PCP 5 o 5 o 

Medicaid % x 10 10 10 p 10 10 10 p 8 7.5 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 15 q 15 

Subtotals Reimbursement 35 35 30 20 28 14 27.5 

Reimbursement 

Medicare 5 5 

5 5 

9 

continued 

125
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for CT, DE, DC, FL, GA, and HI, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

CT DE DC FL GA HI 

How Received: 

Automatic 4 4 r 4 4 r 

Application or Approval Required 2 2 2 2 

Uses Own DEA number 3 s 3 3 

How defined t 

Defined by Legislation/Phys.agmt.doesn't determine 5 5 5 

Collaborative agreement defines 4 4 4 

Supervisory agreement defines 3 3 3 

Defined Formulary (inclusive or exclusive) 1 1 

Type of Authority u 

Full authority within Scope (II-V and Legend) 12 12 12 12 12 u 

Extensive authority (III-V and Legend) 9 

Limited authority (IV-V and Legend) 6 

Restricted (V and Legend) 3 

Legends only 1 1 1 u 

Durable medical equipment/devices 1 1 1 

Sign for samples 1 w 1 

Distribute samples 1 x 1 1 1 x 1 

NP signs prescription 2 y 2 2 2 2 y 2 

Continuing Ed requirements 1 z 1 1 1 

Subtotals Prescriptive Authority 30 24 27 26 12 11 9 

Prescriptive Authority 

4 

3 3 

1 

1 

1 1 

2 2 

1 1 

TOTAL 100 86 86 75 62 45 61.5 

FOOTNOTES 

CONNECTICUT 

a) APRN for Prescriptive privilege only 

c) Prescribe "under direction" of physician in statute 

e) BON is located in the Department of Public Health 

DELAWARE 

e) If NP practices under guidelines or protocols governed by BON, if NP practices 

and prescribes independently governed by Joint Practice Committee (BON and BOM) 

f) Master's required if no national certifying exam is available 

h) Submit collaborative agreement for prescriptive authority 

j) Not defined 

DISTRICT OF COLUMBIA 

b) Certificate to practice 

e) BON and Department of Consumer and Regulatory Affairs 

h) Not required 

j) Not defined 

o) Redesignated PCPs 

p) Medicaid managed care, NPs excluded 

u) Non refillable prescriptions for controlled substances 

FLORIDA 

e) BON and BOM joint committee approves protocols 

f) National certification for initial certificate only 

h) Filed for prescriptive privilege 

q) Any Willing Provider Law 

GEORGIA 

a) RN only 

b) Authorization to practice 

d) Scope of practice is collaborative, prescriptive authority is supervisory and delegatory 

j) Not defined 

x,y) Written protocols define privilege on delegated medical authority of physician in 

restricted locations 

r) May administer, order or dispense but may not prescribe 

continued 

126
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for CT, DE, DC, FL, GA, and HI, continued 

HAWAII 

b) Recognition 

d) For prescriptive authority 

e) BON , BOME and Department of Commerce and Consumer Affairs define 

prescriptive authority 

g) Master's required for prescriptive authority only 

h) For prescriptive authority 

j) Joint and periodic evaluation of services 

u) APRNs can prescribe legend drugs independently and controlled substances under 

physician direction only 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

CONNECTICUT 

Connecticut Department of Public Health, http://www.state.ct.us/dph 

DELAWARE 

State of Delaware, Delaware Administrative Code, http://www.state.de.us 

DISTRICT OF COLUMBIA 

Lexis Nexis, 198.187.128.12/dc 

FLORIDA 

Online Sunshine, State of Florida, http://www.leg.state.fl.us 

GEORGIA 

State Government of Georgia, http://www.ganet.org 

HAWAII 

Hawaii State Legislature, http://www.capitol.hawaii.gov

Hawaii State Government, Department of Commerce and Consumer Affairs, http://www.state.hi.us

127
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for ID, IL, IN, IA, KS, and KY 

Scoring Category Points 

Optimal 

Score fn 

State 

ID IL IN IA KS KY 

Legal Authority 

Title protection 3 3 a 3 3 3 3 3 3 

How Licensed 

Lic as Nurse Practitioner 

Lic as Nurse & Cert, Reg or Approved as NP 

RN license only 

b 

3 3 3 b 3 

2 2 b 2 b 2 b 2 b 

1 

Autonomous practice possible 7 7 c 7 c 7 c c 7 7 7 

Relationship with Physicians: 

No mention of physician in legislation 

Collaborative language 

Supervisory Language 

Electronic. communication permitted/Indirect sup. 

d 

5 5 

4 4 4 4 4 d 4 

2 2 d 

1 

Regulated by: 

State Board of Nursing Alone/or Board of APN 

Regulation by State BON with another entity 

Regulation by Board of Medicine or other 

e 

3 3 3 3 e 3 3 3 3 e 

2 

1 

National certification required 1 1 f 1 1 1 1 1 

Master's degree required for licensure 1 1 g 1 g g g 1 g 

Practice Agreements: 

No written practice agreement required 

Written practice agreement avail on site 

Written practice agreement filed with reg agency 

h 

3 3 3 2 3 

2 2 h 

1 1 h 1 h 

Ratios > 2 in outpatient settings, or not legislated 1 1 I 1 1 I 1 1 1 1 I 

Review of Records by Physician: 

No legislated time requirement for review 

Periodic/Regular Reviews 

Strict/Daily 

j 

3 3 3 3 j 

2 2 j 2 j 2 j 2 j 

1 

Hospital Privileges protected in legislation 1 1 k 1 k 

Can refer directly for health/medical services 2 2 l 2 2 2 2 2 2 

Can order or perform diagnostic or lab tests 2 2 m 2 2 2 2 

Subtotals Legal 35 29 31 19 30 29 29 

5 n 5 5 5 5 5 

Legal right to be listed on panels as PCP 5 o 5 o 5 

Medicaid % x 10 10 10 p 8.5 7 8.5 8 8 7.5 

Language permits reimb by 3rd party or HMO 15 15 q 15 q 15 q 15 15 15 q 

Subtotals Reimbursement 35 33.5 12 28.5 33 28 32.5 

Medicare 

Reimbursement 

5 5 

5 5 

continued 

128
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for ID, IL, IN, IA, KS, and KY, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

ID IL IN IA KS KY 

How Received: 

Automatic 4 4 r 4 4 

Application or Approval Required 2 2 2 2 

Uses Own DEA number 3 s 3 3 3 3 

How defined t 

Defined by Legislation/Phys. agmt. doesn't determine 5 5 5 5 

Collaborative agreement defines 4 4 4 4 

Supervisory agreement defines 3 3 t 

Defined Formulary (inclusive or exclusive) 1 

Type of Authority u 

Full authority within Scope (II-V and Legend) 12 12 12 12 12 12 

Extensive authority (III-V and Legend) 9 

Limited authority (IV-V and Legend) 6 

Restricted (V and Legend) 3 3 u 

Legends only 1 1 

Durable medical equipment/devices 1 1 1 1 

Sign for samples 1 w 1 1 w 

Distribute samples 1 x 1 1 1 1 x 

NP signs prescription 2 y 2 2 2 2 

Continuing Ed requirements 1 z 1 1 1 1 

Subtotals Prescriptive Authority 30 27 17 24 29 27 15 

Prescriptive Authority 

4 

3 3 

1 

1 1 

1 1 

2 2 2 

1 1 1 

TOTAL 100 89.5 60 71.5 92 84 76.5 

FOOTNOTES 

IDAHO 

b) Licensed as an NP, authorized as an NP prescriber 

c) "May perform ...direct management of acute and chronic illness 

d) Supervisory, collaborative and consultative language. Supervision "means 

designation of a course of action or provision of guidance" 

j) BOM rules for physicians require periodic review of a sample of records 

o) Blue Cross has NPs on preferred provider list 

q) Any Willing Provider Law(CNM confirms) 

ILLINOIS 

c) Not practice without direction from physician but no employment relationship 

is required 

e) Advanced Practice Nursing Board 

g) Legislated in 1998, effective from 2001 

I) No specific number but not "excessive" number 

j) Periodic 

u) Schedule lll-V but delegated authority only-- may prescribe, dispense and 

administer 

INDIANA 

b) APN recognition, only necessary for prescriptive authority(CNMs different) 

c) Collaboration with licensed practioner required, other APNs do not qualify 

as collaborators 

g) Complete a "graduate program or a certificate program" 

h) Only if applying for prescriptive authority 

j) Review of a sample of charts when prescriptions are written 

must occur within 7 days 

q) Any Willing Provider Law 

continued 

129
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for ID, IL, IN, IA, KS, and KY, continued 

IOWA 

b) Registration for prescriptive authority only 

g) Masters not required, may be one of qualifications fulfilled 

k) Hospital Fairness Act, 1999-2000 

I) Not legislated 

p) Amendment to medical program, telemedicine pilot project pays 

for ARNP services 

KANSAS 

b) Certificate of Qualification issued 

d) Collegial 

g) Law passed in 2000, effective from 2002 

h) Written protocol defines prescriptive authority 

j) Periodic 

t) Written protocol between physicians and NP defines classes of drugs Dispensing, 

except for samples is prohibited 

KENTUCKY 

b) Registration and designation 

e) Advanced Registered Nurse Practice Council and BON 

h) Effective from 1997 for prescriptive authority 

I) Not legislated 

j) Not defined 

q) Any Willing Provider Law 

w,x) Non scheduled legend drugs 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997,

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

IDAHO 

Idaho State Board of Nursing, http://www2.state.id.us/adm 

ILLINOIS 

Illinois General Assembly, http://www.legis.state.il.us

Illinois Bar Journal, http://www.illinoisbar.org

National Council of State Boards of Nursing, http://www.ncsbn.or/files/npa/wholenpas/ilnpa.asp

INDIANA 

Indiana Health Professions Bureau, http://www.IN.gov/hpb/boards 

Indiana State Board of Nursing, http://www.state.in.us/hpb/boards 

IOWA 

Iowa Board of Nursing, http://www.state.ia.us/nursing 

KANSAS 

Kansas Legislative Services, http://www.accesskansas.org/legislative 

KENTUCKY 

Kentucky Legislature, http://www.lrc.state.ky.us/kar 

Kentucky Board of Nursing, http://www.kbn.state.ky.us 

130
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for LA, ME, MD, MA, MI, and MN 

Scoring Category Points 

Optimal 

Score fn 

State 

LA ME MD MA MI MN 

Legal Authority 

Title protection 3 3 a 3 a 3 3 3 3 3 

How Licensed 

Lic as Nurse Practitioner 

Lic as Nurse & Cert, Reg or Approved as NP 

RN license only 

b 

3 3 3 b 

2 2 b 2 b 2 b 2 b 2 b 

1 

Autonomous practice possible 7 7 c 7 c 7 7 

Relationship with Physicians: 

No mention of physician in legislation 

Collaborative language 

Supervisory Language 

Electronic communication permitted/Indirect sup. 

d 

5 5 5 4 

4 4 4 

2 2 d 2 d 

1 

Regulated by: 

State Board of Nursing Alone/or Board of APN 

Regulation by State BON with another entity 

Regulation by Board of Medicine or other 

e 

3 3 3 e 3 

2 2 e 2 e 2 e 2 e 

1 

National certification required 1 1 f 1 1 1 1 1 1 

Master's degree required for licensure 1 1 g 1 1 g 

Practice Agreements: 

No written practice agreement required 

Written practice agreement avail on site 

Written practice agreement filed with reg agency 

h 

3 3 3 h 

2 2 2 

1 1 1 

Ratios > 2 in outpatient settings, or not legislated 1 1 I I 1 I 1 I 1 I 

Review of Records by Physician: 

No legislated time requirement for review 

Periodic/Regular Reviews 

Strict/Daily 

j 

3 3 3 j 3 j 3 j 

2 2 j 2 2 j 

1 

Hospital Privileges protected in legislation 1 1 k 

Can refer directly for health/medical services 2 2 l 2 2 2 l 2 2 

Can order or perform diagnostic or lab tests 2 2 m 2 2 2 m 2 2 

Subtotals Legal 35 21 28 20 18 25 30 

Reimbursement 

Medicare 5 5 n 5 5 5 5 5 5 

Legal right to be listed on panels as PCP 5 5 o 5 5 5 o 

Medicaid % x 10 10 10 p 8 10 10 10 10 9 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 q 15 15 15 q 15 

Subtotals Reimbursement 35 28 35 35 35 30 29 

continued 

131
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for LA, ME, MD, MA, MI, and MN, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

LA ME MD MA MI MN 

How Received: 

Automatic 4 4 r 4 

Application or Approval Required 2 2 2 2 2 r 

Uses Own DEA number 3 s 3 3 3 3 

How defined t 

Defined by Legislation/Phys.agmt.doesn't determine 5 5 5 5 

Collaborative agreement defines 4 4 4 

Supervisory agreement defines 3 3 

Defined Formulary (inclusive or exclusive) 1 1 

Type of Authority u 

Full authority within Scope (II-V and Legend) 12 12 12 12 12 12 

Extensive authority (III-V and Legend) 9 

Limited authority (IV-V and Legend) 6 

Restricted (V and Legend) 3 3 u 

Legends only 1 1 

Durable medical equipment/devices 1 1 1 1 

Sign for samples 1 w 1 1 

Distribute samples 1 x 1 1 

NP signs prescription 2 y 2 2 2 2 

Continuing Ed requirements 1 z 1 1 

Subtotals Prescriptive Authority 30 13 28 23 24 17 27 

Prescriptive Authority 

4 

3 3 

1 

1 1 1 

1 1 1 1 

2 2 2 

1 1 

TOTAL 100 62 91 78 77 72 86 

FOOTNOTES 

LOUISIANA 

a) Under violations in law 

b) Licensed as an Advanced Practice Registered Nurse 

e) BON with BOME for prescriptive authority 

I) No more than two 

j) Frequency determined by APRN and collaborating physician 

q) Any Willing Provider Law 

MAINE 

b) Licensed as RN, approved APRN 

c) At initial certification must practice for 24 months under supervising physician then 

allowed independence and prescriptive authority 

e) APRN Committee and BON 

g) Passed in 2000, effective from 2006 

j) Not defined 

MARYLAND 

b) Certified 

e) Joint Committee appointed by BON and BOM 

I) Not defined

l,m) Determined by collaborative agreement

MASSACHUSETTS 

b) Licensed RN, Authorized in Expanded role 

d) Direction, Supervision, Collaboration and Consultation 

e) Prescriptive authority regulated by BON with Board of Regulations in Medicine 

and Board of Regulations in Pharmacy, also Advisory Committee of APNs 

j) Every three months, if schedule ll drugs are prescribed, record must be reviewed 

in 96 hours 

o) Mass. Medicaid PCP 

continued 

132
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for LA, ME, MD, MA, MI, and MN, continued 

MICHIGAN 

b) Speciality certification 

d) No requirement for physician supervision or collaboration but a physician 

may delegate at their discretion( Beauport) 

e) Department of Commerce licenses 

h) Not required 

I) Not legislated 

j) Not defined 

q) Attorney General's opinion 

u) Schedule lll-V and legend but "delegated medical task" 

MINNESOTA 

b) Certification 

I) Not legislated 

j) Not defined 

r) 1999 law requires fee and proof that criteria for prescriptive authority are met 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

LOUISIANA 

Louisiana State Board of Nursing, http://www.lsbn.state.la.us 

MAINE 

Maine Legislature, http://janus.state.me.us/legis 

MARYLAND 

Maryland General Assembly, http://mlis.state.md.us 

Maryland Board of Nursing, http://dhmh.state.md.us 

MASSACHUSETTS 

Commonwealth of Massachusetts, http://www.state.ma.us/legis 

MICHIGAN 

National Council of State Boards of Nursing, http:// 

www.michiganlegislature.org/law 

Michigan Legislature, http://www.michiganlegislature.org/law 

MINNESOTA 

State of Minnesota Board of Nursing , http://www.nursingboard.state.mn.us 

Minnesota Office of the Revisor of Statutes, 

http://www.revisor.leg.state.mn.us 

133
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for MS, MO, MT, NE, NV, and NH 

Scoring Category Points 

Optimal 

Score fn 

State 

MS MO MT NE NV NH 

Legal Authority 

Title protection 3 3 a 3 3 3 3 3 a 3 a 

How Licensed 

Lic as Nurse Practitioner 

Lic as Nurse & Cert, Reg or Approved as NP 

RN license only 

b 

3 3 3 3 

2 2 b 2 b 2 b 2 b 

1 

Autonomous practice possible 7 7 c 7 7 c 7 

Relationship with Physicians: 

No mention of physician in legislation 

Collaborative language 

Supervisory Language 

Electronic communication permitted/Indirect sup. 

d 

5 5 5 5 

4 4 d 4 d 4 4 d 

2 

1 

Regulated by: 

State Board of Nursing Alone/or Board of APN 

Regulation by State BON with another entity 

Regulation by Board of Medicine or other 

e 

3 3 3 e 

2 2 e 2 e 2 e 2 e 2 e 

1 

National certification required 1 1 f 1 1 1 1 1 1 

Master's degree required for licensure 1 1 g 1 g 1 g 1 1 g 1 g 

Practice Agreements: 

No written practice agreement required 

Written practice agreement avail on site 

Written practice agreement filed with reg agency 

h 

3 3 3 3 

2 2 

1 1 1 h 1 

Ratios > 2 in outpatient settings, or not legislated 1 1 I 1 I 1 I 1 1 1 I 1 

Review of Records by Physician: 

No legislated time requirement for review 

Periodic/Regular Reviews 

Strict/Daily 

j 

3 3 3 j 3 j 3 

2 2 j 2 j 

1 1 j 

Hospital Privileges protected in legislation 1 1 k 

Can refer directly for health/medical services 2 2 l 2 2 2 2 2 2 

Can order or perform diagnostic or lab tests 2 2 m 2 2 2 

Subtotals Legal 35 20 19 31 31 19 32 

5 n 5 5 5 5 5 

Legal right to be listed on panels as PCP 5 o 5 o 

Medicaid % x 10 10 10 p 9 10 8.5 10 8.5 10 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 q 15 15 15 

Subtotals Reimbursement 35 29 30 33.5 15 28.5 30 

Reimbursement 

Medicare 5 5 

5 

continued 

134
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for MS, MO, MT, NE, NV, and NH, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

MS MO MT NE NV NH 

How Received: 

Automatic 4 4 r 4 4 

Application or Approval Required 2 2 2 2 

Uses Own DEA number 3 s 3 s 3 

How defined t 

Defined by Legislation/Phys.agmt.doesn't determine 5 5 5 5 

Collaborative agreement defines 4 4 t 

Supervisory agreement defines 3 3 t 3 t 

Defined Formulary (inclusive or exclusive) 1 1 

Type of Authority u 

Full authority within Scope (II-V and Legend) 12 12 12 u 12 u 12 u 

Extensive authority (III-V and Legend) 9 

Limited authority (IV-V and Legend) 6 

Restricted (V and Legend) 3 

Legends only 1 1 1 1 u 

Durable medical equipment/devices 1 1 

Sign for samples 1 w 1 

Distribute samples 1 x 1 x 1 x 1 1 1 

NP signs prescription 2 y 2 2 2 

Continuing Ed requirements 1 z 1 1 1 1 

Subtotals Prescriptive Authority 30 10 11 27 26 11 24 

Prescriptive Authority 

4 

3 3 

1 

1 

1 1 

2 2 

1 1 1 

TOTAL 100 59 60 91.5 72 58.5 86 

FOOTNOTES 

MISSISSIPPI 

b) Certified / registered 

d) Collaboration, consultative language but "supervising" physician in reimbursement 

statute 

e) Rules jointly promulgated by BON and BOM 

g) Effective from 1998 " a graduate program" 

I) Not legislated 

j) Not defined 

t) Protocol defines 

x) "Dispense" in regulations 

MISSOURI 

b) Document of Recognition 

d) Can not be geographically distant ( 30 miles by road or 50 miles in HPSA) 

e) Regulations by BON and Board of Healing Arts and Board of Pharmacy 

g) 1998 

I) No more than three 

j) Review every two weeks 

q) BC/BS statutory non discriminatory policy 

t) Protocol 

x) Limited to 72hr supply 

MONTANA 

b) Certificate 

e) Department of Commerce administers licenses, prescriptive authority 

administered by BON, BOME and BOP 

j) Quarterly by peers or physicians 

o) 1997 Bill 519 workers COMP, PCP 

u) Quality assurance process for prescriptive authority 

continued 

135
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for MS, MO, MT, NE, NV, and NH, continued 

NEBRASKA 

b,h) Integrated practice agreement may be waived if nurse will practice in a 

Geographic Health Shortage Area 

d) Board of Advanced Practice 

g) For prescriptive authority 

j) Not defined 

u) Schedule ll, 72 hour prescription only 

NEVADA 

a) APN 

b) Certificate of Recognition 

d) Nursing regulations, collaborative language 

e) BON, BOM, BOP 

g) Required after 6/1/05 

I) No more than 3 

j) Periodic/ monthly(BOM) review 

s) DEA for dispensing and administering only, if privilege approved 

t) Pharmacy regulations supervisory in language 

u) APNs may dispense controlled substances under certain circumstances 

when a pharmacy exam has been passed 

NEW HAMPSHIRE 

a) ARNP 

e) APRN committee on BON, Joint Committee of BON, BOM and BOP for 

prescriptive authority, formulary 

u) Plenary authority from a formulary established by Joint Health Council of BON 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

MISSISSIPPI 

Lexis Nexis, 198.187.128.12/mississippi 

Mississippi State Board of Nursing, http://www.msbn.state.ms.us/laws 

MISSOURI 

Missouri General Assembly, http://www.moga.state.mo.us/statutes

Missouri Department of Economic Development, Board of Nursing, http://www.ecodev.state.mo.us/pr/nurising

MONTANA 

Montana Department of Commerce, Board of Nursing, http://www.com.state.mt.us/License 

Montana State Documents Online, http://statedocs.msl.state.mt.us 

NEBRASKA 

National Council of State Boards of Nursing, http://www.ncsbn.org/serach/documents 

NEVADA 

Nevada Legislature, www.leg.state.nv. us/NRS

Nevada Legislature, www.leg.state.nv.us/nac

National Council of State Boards of Nursing, www.ncsbn.org/search/documents/actsand regs/nv

NEW HAMPSHIRE 

New Hampshire Board of Nursing, www.state.nh.us/nursing

National Council of State Boards of Nursing, www.ncsbn.org/search/documents/actsand regs/nh

136
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for NJ, NM, NY, NC, ND, and OH 

Scoring Category Points 

Optimal 

Score fn 

State 

NJ NM NY NC ND OH 

Legal Authority 

Title protection 3 3 a 3 3 3 3 3 3 

How Licensed 

Lic as Nurse Practitioner 

Lic as Nurse & Cert, Reg or Approved as NP 

RN license only 

b 

3 3 3 3 

2 2 b 2 b 2 2 b 

1 

Autonomous practice possible 7 7 c 7 7 7 c 7 c 

Relationship with Physicians: 

No mention of physician in legislation 

Collaborative language 

Supervisory Language 

Electronic communication permitted/Indirect sup. 

d 

5 5 5 

4 4 d 4 4 d 4 4 

2 

1 

Regulated by: 

State Board of Nursing Alone/or Board of APN 

Regulation by State BON with another entity 

Regulation by Board of Medicine or other 

e 

3 3 3 3 e 3 

2 2 e 2 e 

1 1 e 

National certification required 1 1 f 1 f 1 f 1 f 1 1 

Master's degree required for licensure 1 1 g 1 1 1 g 1 g 1 

Practice Agreements: 

No written practice agreement required 

Written practice agreement avail on site 

Written practice agreement filed with reg agency 

h 

3 3 3 

2 2 h 2 2 h 

1 1 1 h 

Ratios > 2 in outpatient settings, or not legislated 1 1 I 1 1 1 1 I 1 

Review of Records by Physician: 

No legislated time requirement for review 

Periodic/Regular Reviews 

Strict/Daily 

j 

3 3 3 

2 2 2 j 2 j 2 2 j 

1 

Hospital Privileges protected in legislation 1 1 k 1 

Can refer directly for health/medical services 2 2 l 2 l 2 2 2 2 

Can order or perform diagnostic or lab tests 2 2 m 2 2 m 2 2 2 

Subtotals Legal 35 27 33 26 29 21 23 

5 n 5 5 5 5 

Legal right to be listed on panels as PCP 5 o 5 o 5 o 

Medicaid % x 10 10 10 p 9.5 9 10 10 7.5 10 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 15 15 15 15 

Subtotals Reimbursement 35 34.5 34 35 30 27.5 30 

Reimbursement 

Medicare 5 5 5 

5 5 

continued 

137
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for NJ, NM, NY, NC, ND, and OH, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

NJ NM NY NC ND OH 

How Received: 

Automatic 4 4 r 4 r 

Application or Approval Required 2 2 2 2 r 2 

Uses Own DEA number 3 s 3 s 3 3 3 3 

How defined t 

Defined by Legislation/Phys.agmt.doesn't determine 5 5 5 5 

Collaborative agreement defines 4 4 4 

Supervisory agreement defines 3 3 

Defined Formulary (inclusive or exclusive) 1 1 

Type of Authority u 

Full authority within Scope (II-V and Legend) 12 12 12 u 12 12 u 12 

Extensive authority (III-V and Legend) 9 9 

Limited authority (IV-V and Legend) 6 6 u 

Restricted (V and Legend) 3 

Legends only 1 

Durable medical equipment/devices 1 1 1 1 1 1 

Sign for samples 1 w 1 w 1 

Distribute samples 1 x 1 1 1 1 

NP signs prescription 2 y 2 2 2 2 

Continuing Ed requirements 1 z 1 1 

Subtotals Prescriptive Authority 30 21 27 25 27 26 20 

Prescriptive Authority 

2 

3 3 

1 

1 1 1 

1 1 

2 2 2 

1 1 

TOTAL 100 82.5 94 86 86 74.5 73 

FOOT NOTES 

NEW JERSEY 

b) Certification

d,h) Collaborative agreement (joint protocol) required only for prescriptive privilege

e) Division of Consumer Affairs of Department of Law and Public Safety approves 

standards for joint protocols developed by BON with BOME 

f) Highest level exam in specialty approved by board 

s) Only if prescribing controlled substances in limited circumstances 

u) Allowed to prescribe Schedules ll-IV, in an inpatient or outpatient setting 

as a continuation or "reissuing of an order for a controlled substance" 

previously issued by a physician or at end of life (Pearson) 

NEW MEXICO 

l,m) Implied by independent practice 

o) Defined as PCP in rules and regulations 

u) CNP must maintain a self-determined formulary relevant to specialty with BON 

w) Implied by independent practice 

NEW YORK 

b) Certification 

c) NPs considered independent practitioners 

e) Department of Education and BON 

f) National certification is an option 

j) Not less than every three months 

o) NPs qualified as primary gatekeepers under Medicaid Managed Care Law 

r) Required to obtain a certificate after completing a program with a pharmacology 

component 

continued 

138
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for NJ, NM, NY, NC, ND, and OH, continued 

NORTH CAROLINA 

b) Approval 

c) Effective in 2000, independent practice allowed as long as there is a contract with 

and MD (Pearson) 

d) Collaborative language but supervising physician 

e) Joint Committee of BON and MB 

f,g) 2000 

j) Periodic and joint review 

r) Given with NP approval 

u) Schedule ll-lll for 30 days only, NP may procure, prescribe, order. Compound and 

dispense 

NORTH DAKOTA 

h) Collaborative agreement for prescriptive authority only (1999) 

e) Rules for prescriptive authority promulgated by BON and BOME 

g) 2001 

I) Not legislated 

OHIO 

b) Authorization 

h) On-site standard care arrangement 

j) Regular review of care outcomes 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

NEW JERSEY 

New Jersey State Legislature, www.njleg.state.nj.us 

New Jersey.the online state www.state.nj.us 

New Jersey State Nurses Association, http://www.nurse.org/nj/njsna 

NEW MEXICO 

Lexis Nexis, http://198.187.128.12/newmexico

i Bienvenidos a Nuevo Mexico! – Welcome to New Mexico!, www.state.nm.us/clients/nursing

NEW YORK 

New York State Coalition of Nurse Practitioners, www.nysconp.org/gvtaffairs 

New York State Assembly-Consolidated Laws – Education, http://assembly.state.ny.us 

New York State Education Department, Office of the Professions, http://www.op.nysed.gov/rap.htm 

NORTH CAROLINA 

North Carolina Board of Nursing, http://www.ncbon.com

National Council of State Boards of Nursing, http://ncsbn.org/files/npa/wholenpas/ncnpa.asp

North Carolina General Assembly, http:www.ncga.state.nc.us

NORTH DAKOTA 

North Dakota Board of Nursing, http://www.ndbon.org 

OHIO 

National Council of State Boards of Nursing, http://www.ncsbn.org/files/npa/wholenpas/ohnpa.asp

State of Ohio Government Info and Services, http:// www.state.oh.us/nur

Anderson’s Online Documentation, http://onlinedocs.andersonpublishi

Session Law from the 124th General Assembly of the State of Ohio, http://ohioacts.avv.com

139
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for OK, OR, PA, RI, SC, and SD 

Scoring Category Points 

Optimal 

Score fn 

State 

OK OR PA RI SC SD 

Legal Authority 

Title protection 3 3 a 3 3 3 3 a 3 

How Licensed 

Lic as Nurse Practitioner 

Lic as Nurse & Cert, Reg or Approved as NP 

RN license only 

b 

3 3 3 b 3 

2 2 b 2 b 2 b 2 b 

1 

Autonomous practice possible 7 7 c 7 c 7 c 7 c 7 c 

Relationship with Physicians: 

No mention of physician in legislation 

Collaborative language 

Supervisory Language 

Electronic communication permitted/Indirect sup. 

d 

5 5 5 

4 4 4 

2 2 d 2 d 2 

1 1 1 1 

Regulated by: 

State Board of Nursing Alone/or Board of APN 

Regulation by State BON with another entity 

Regulation by Board of Medicine or other 

e 

3 3 3 

2 2 e 2 e 2 e 2 e 2 e 

1 

National certification required 1 1 f 1 1 1 1 f 

Master's degree required for licensure 1 1 g 1 g 1 1 

Practice Agreements: 

No written practice agreement required 

Written practice agreement avail on site 

Written practice agreement filed with reg agency 

h 

3 3 3 h 3 h 3 

2 2 h 

1 1 h 1 h 

Ratios > 2 in outpatient settings, or not legislated 1 1 I I 1 1 I 1 1 I 

Review of Records by Physician: 

No legislated time requirement for review 

Periodic/Regular Reviews 

Strict/Daily 

j 

3 3 3 j 3 j 3 j 3 j 3 j 

2 2 

1 

Hospital Privileges protected in legislation 1 1 k k 1 k 

Can refer directly for health/medical services 2 2 l 2 2 2 

Can order or perform diagnostic or lab tests 2 2 m 2 

Subtotals Legal 35 27 33 16 27 15 24 

5 n 5 5 5 5 

Legal right to be listed on panels as PCP 5 o 5 o 5 o 5 o 

Medicaid % x 10 10 10 p 10 10 10 8 p 8 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 15 15 

Subtotals Reimbursement 35 20 35 35 33 13 29 

Reimbursement 

Medicare 5 5 5 

5 5 

9 

continued 

140
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

OK OR PA RI SC SD 

How Received: 

Automatic 4 4 r 

Application or Approval Required 2 2 2 2 2 2 2 r 

Uses Own DEA number 3 s 3 3 3 3 s 3 

How defined t 

Defined by Legislation/Phys.agmt.doesn't determine 5 5 

Collaborative agreement defines 4 4 

Supervisory agreement defines 3 

Defined Formulary (inclusive or exclusive) 1 1 1 1 t 1 t 1 t 

Type of Authority u 

Full authority within Scope (II-V and Legend) 12 12 12 u 12 u 12 12 u 

Extensive authority (III-V and Legend) 9 9 u 

Limited authority (IV-V and Legend) 6 

Restricted (V and Legend) 3 3 u 

Legends only 1 

Durable medical equipment/devices 1 1 1 1 

Sign for samples 1 w 1 1 w 1 w 1 

Distribute samples 1 x 1 1 1 x 1 

NP signs prescription 2 y 2 2 2 2 

Continuing Ed requirements 1 z 1 1 1 1 

Subtotals Prescriptive Authority 30 20 24 22 23 15 25 

Prescriptive Authority 

3 3 

1 

1 1 

1 1 

2 2 2 

1 1 

TOTAL 100 67 92 73 83 43 78 

FOOTNOTES 

OKLAHOMA 

b) Certificate of recognition 

c) Practice independently except for prescriptive authority 

d) Prescriptive authority, rules use supervisory language 

e) A formulary Advisory council of Oklahoma State Medical Association, Oklahoma 

Pharmacy Association and Oklahoma Board of Nursing determine exclusionary 

formulary 

g) Master's required for prescriptive authority after 7/1/2002 

h) Written " documentation" of relationship with physician for prescriptive authority only 

I) No more than 2 with prescriptive authority or 4 total 

j) Not detailed 

k) State law prohibits APNs from admitting patients 

o) In rural areas only 

u) Optional prescriptive authority with physician supervision required only for prescribing 

OREGON 

b) Certificate of special competency 

c) Independently accountable 

h) Not required 

j) Not necessary 

k) Law prohibits discrimination in hospital privileges, SOP lists admission to hospitals 

and management of patients 

u) Write and dispense, dispensing limited to geographically remote areas 

continued 

141
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

PENNSYLVANIA 

b) Certified 

d) Supervising physician/collaborating physician 

e) BON with BOM 

h) Bureau of Professional and Occupational Affairs 

I) No more than 4 CRNPs with prescriptive authority at any one time 

o) Department of Health regulations allow HMOs to file waivers to list NPs as PCPs 

t) Formulary of American Hospital Formulary Service, collaborative agreement documents 

drugs allowed 

u) Schedule ll for 72 hrs, schedule lll - V for 30 days 

RHODE ISLAND 

b) License to practice as ARNP 

c) Collaboration required for prescriptive authority only 

e) Department of Health and Division of Professional Regulation, Board of Nursing 

Registration and Nursing Education and Board of Nursing 

j) Not defined 

o) Medicaid program allows NPs as PCPs 

p) Unable to determine rate, rate unavailable - 8 chosen as reasonable 

t) Prescribe from formulary as agreed with physician in written collaboration agreement 

w) May procure and dispense samples 

SOUTH CAROLINA 

a) Use specialty designation of certification but no limits on use 

b) BON officially "recognizes NPs", keeps a list of qualified NPs 

e) BON with BOME 

h) Protocol onsite available for audit by BON 

I) Not greater than 3 on site unless exempted, if NPs further than 45 miles from physician 

it must be reviewed 

j) Not defined 

s) Schedule V allowed, requires DEA 

t) Formulary from listing approved by BON, BOME, BOP 

u) Determined by physician in protocol 

w,x) 2000 Law 

SOUTH DAKOTA 

c) 1996 Nurses allowed to form professional service corporations 

e) BON with BOME and BOOE 

f) Effective from 11/99 

h) May be permitted more than one, with board approval up to 4 

j) Not defined 

r) Application to Department of Health 

u) Schedule ll for 48 hrs only 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

continued 

142
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

OKLAHOMA 

Oklahoma Public Legal Research System, http://oklegal.onenet.net/oklegal 

OREGON 

National Council of State Boards of Nursing, www.ncsbn.org/search/documents/actsand regs/or/

Oregon State Archives, http://arcweb.sos.state.or.us/rules

Oregon State Board of Nursing, http://www.osbn.state.or.us

PENNSYLVANIA 

The Pennsylvania Code Online, http://www.pacode.com/secure/data 

Pennsylvania Department of State – Professional Licensure, http://www.dos.state.pa.us/bpoa/nurbd 

RHODE ISLAND 

Rhode Island Department of Human Services, http://www.dhs.state.ri.us/dhs

The State of Rhode Island General Assembly, http://www.rilin.state.ri.us/Statutes/TITLES

The State of Rhode Island General Assembly, http://www.rilin.state.ri.us/gen-assembly/genmenu.html

SOUTH CAROLINA 

South Carolina Board of Nursing, http://www.llr.state.sc.us/POL/Nursing 

South Carolina State House Network, http://www.lpitr.state.sc.us/code 

SOUTH DAKOTA 

South Dakota Legislature, http://legis.state.sd.us/rules 

South Dakota Legislature, http://legis.state.sd.us/statutes 

143
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for TN, TX, UT, VT, VA, and WA 

Scoring Category Points 

Optimal 

Score fn 

State 

TN TX UT VT VA WA 

Legal Authority 

Title protection 3 3 a a 3 3 a 3 a 3 

How Licensed 

Lic as Nurse Practitioner 

Lic as Nurse & Cert, Reg or Approved as NP 

RN license only 

b 

3 3 3 b 3 3 

2 2 b 2 b 2 b 

1 

Autonomous practice possible 7 7 c 7 c 7 

Relationship with Physicians: 

No mention of physician in legislation 

Collaborative language 

Supervisory Language 

Electronic communication permitted/Indirect sup. 

d 

5 5 

4 4 d 4 d 4 d 4 d 

2 2 d 2 d 

1 1 

Regulated by: 

State Board of Nursing Alone/or Board of APN 

Regulation by State BON with another entity 

Regulation by Board of Medicine or other 

e 

3 3 3 e 3 e 

2 2 e 2 e 2 e 2 e 

1 1 

National certification required 1 1 f 1 1 1 1 1 1 f 

Master's degree required for licensure 1 1 g 1 g 1 g 1 1 g 

Practice Agreements: 

No written practice agreement required 

Written practice agreement avail on site 

Written practice agreement filed with reg agency 

h 

3 3 

2 2 2 h 

1 1 h 1 1 h 1 

Ratios > 2 in outpatient settings, or not legislated 1 1 I 1 I 1 I 1 I 

Review of Records by Physician: 

No legislated time requirement for review 

Periodic/Regular Reviews 

Strict/Daily 

j 

3 3 3 j 3 j 3 j 3 j 3 j 

2 2 j 

1 

Hospital Privileges protected in legislation 1 1 k 1 k 1 k 

Can refer directly for health/medical services 2 2 l 2 2 2 

Can order or perform diagnostic or lab tests 2 2 m 2 

Subtotals Legal 35 14 20 27 20 13 31 

5 n 5 5 5 5 

Legal right to be listed on panels as PCP 5 o 5 o 5 o 5 

Medicaid % x 10 10 10 p 10 8.5 10 10 10 10 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 q 15 15 

Subtotals Reimbursement 35 35 33.5 30 15 15 35 

Medicare 

Reimbursement 

5 5 5 

5 

continued 

144
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

TN TX UT VT VA WA 

How Received: 

Automatic 4 4 r 4 

Application or Approval Required 2 2 2 2 2 

Uses Own DEA number 3 s 3 3 3 3 

How defined t 

Defined by Legislation/Phys.agmt.doesn't determine 5 5 

Collaborative agreement defines 4 4 t 4 t 4 t 

Supervisory agreement defines 3 3 3 t 3 

Defined Formulary (inclusive or exclusive) 1 

Type of Authority u 

Full authority within Scope (II-V and Legend) 12 12 12 12 u 12 u 

Extensive authority (III-V and Legend) 9 

Limited authority (IV-V and Legend) 6 6 u 

Restricted (V and Legend) 3 3 u 

Legends only 1 1 

Durable medical equipment/devices 1 1 1 1 

Sign for samples 1 w 1 1 w 

Distribute samples 1 x 1 1 1 

NP signs prescription 2 y 2 2 2 2 

Continuing Ed requirements 1 z 1 Z 1 

Subtotals Prescriptive Authority 30 15 12 27 26 19 25 

Prescriptive Authority 

4 

3 3 

1 

1 1 1 

1 1 1 

2 2 2 

1 

TOTAL 100 64 65.5 84 61 47 91 

FOOTNOTES 

TENNESSEE 

a) RN title protected 

b) Certification of fitness to prescribe 

d) For prescriptive authority 

e) With BOME for prescriptive authority 

g) For prescriptive authority 

I) Not legislated 

j) Not defined 

o) Registered Professional Nurses are classified as PCPs in Tenn Care Contracts 

by state law 

u) Although NPs may prescribe Schedule ll-V, BOME regulation make the physician 

professionally responsible and view all scripts to be MDs. Also limitations exist 

about sites where prescriptive authority may be exercised 

TEXAS 

b) Authorized to practice, approval 

d) Supervisory and collaborative (acts independently) language depending on setting 

and prescriptive authority 

e) BOME influences prescriptive authority 

g) Master's degree required, effective from 2003--2007 ( waiver possible) 

h) On-site 

I) No more than 3 

j) Not defined 

k) Clinical privileging conditions in law 

o,q) HB 2846-1997 

t) Agreement with physician defines, delegatory language, prescriptive authority is 

site specific - MUA, physician's primary practice site, facility based site, HPSA - and is 

limited to legend drugs 

continued 

145
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

UTAH 

a) Only 1 licensure, APRN license supersedes RN license 

b) With or without prescriptive privilege 

d) Consultative language 

e) Department of Commerce, Division of Occupation and Professional Licensing and BON 

h) For prescriptive authority only 

j) No more than 2 NPs with prescriptive authority without the permission of BON 

j) Not defined 

t) Consultation plan required for Schedule ll and lll prescriptive authority 

z) Only if licensed prior to 1992 

VERMONT 

b) Registration and endorsement 

d) Protocol 

e) BON with APRN Committee 

j) Not defined 

t) Privilege described in practice guidelines 

u) Dispensing authority 

VIRGINIA 

a) RN title protected 

c) Separate practice setting not allowed when NP has prescriptive authority 

d) Collaborative, supervisory, delegatory (mostly supervisory) 

e) BON with BOM under Medical Practice Act 

g) Regulations delineate approved programs which grant master's degree 

h) Protocol, practice agreement approved before issuance of prescriptive authority 

I) In 2000, limit reduced from 4 to 2 nurses with prescriptive authority 

j) Monthly review of random sample of records 

u) May dispense if supervising physician permits, New statute Schedule lll-V phased 

in from 2000-2003 rules with rules effective from 2002 

w) Effective in 2000 legend drugs only 

WASHINGTON 

d) No physician involvement except for prescriptive authority 

e) Called Nursing Care Quality Assurance Commission 

f) "Graduate education" 

j) Not defined 

k) Admit patients, part of SOP 

o) Eligible as participating providers under Washington States Health Care Reform 

Program 

t) To exercise prescriptive authority, Joint Practice Agreement with physician 

required 

u) Passed 7/1/2000, rules effective from 8/1/2001, can dispense 72 hr supply of 

controlled substances 

continued 

146
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997,

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

TENNESSEE 

Tennessee Nurses Association, http://www.tnaonline.org/ap

Lexis Nexis, http://198.187.128.12/tennessee/

TennesseeAnytime: The Official Site Of the State Of Tennessee, http://www.state.tn.us/sos/rules

TEXAS 

Coalition for Nurses in Advanced Practice, http://www.cnaptexas.org/legislation/sessions

National Council of State Boards of Nursing, http://www.ncsbn.org/files/npa/wholenpas/txrnnpa.asp

Board of Nurse Examiners, http://www.bne.state.tx.us

UTAH 

Utah Administrative Rules Online, http://www.rules.state.ut.us/publicat/code

Utah Department of Commerce, http://www.commerce.state.ut.us

Utah State Legislature, http://www.le.state.ut.us

VERMONT 

Vermont Statutes Online, http://www.leg.state.vt.us/statutes

Secretary of State, Office of Professional Regulation, http://www.sec.state.vt.us/opr/rules/nursing 

VIRGINIA 

Virginia Board of Nursing, http://dhp.state.va.us/nursing 

Legislative Information System, http://leg1.state.va.us 

WASHINGTON 

Washington State Department of Health, Nursing Care Quality Assurance Commission, 

http://www.doh.wa.gov/nursing/scopeofp.htm 

Washington State Department of Health, Nursing Care Quality Assurance Commission, 

http://www.doh.wa.gov/unursing/rules.htm 

Washington State Legislature, http://search.leg.wa.gov/wslwac 

Revised Code of Washington, http://search.leg.wa.gov/wslrcw 

147
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for WV, WI, and WY 

Scoring Category Points 

Optimal 

Score fn 

State 

WV WI WY 

Title protection 3 a 3 a 3 a 

How Licensed b 

Lic as Nurse Practitioner 3 3 3 b 

Lic as Nurse & Cert, Reg or Approved as NP 2 2 b 2 b 

RN license only 1 

Autonomous practice possible 7 c 7 

Relationship with Physicians: d 

No mention of physician in legislation 5 5 

Collaborative language 4 4 d 4 d 4 

Supervisory Language 2 

Electronic communication permitted/Indirect sup. 1 

Regulated by: e 

State Board of Nursing Alone/or Board of APN 3 3 3 3 3 

Regulation by State BON with another entity 2 

Regulation by Board of Medicine or other 1 

National certification required 1 f 1 1 

Master's degree required for licensure 1 g 1 1 

Practice Agreements: h 

No written practice agreement required 3 3 

Written practice agreement avail on site 2 2 h 

Written practice agreement filed with reg agency 1 1 h 1 

Ratios > 2 in outpatient settings, or not legislated 1 I 1 I 1 I 

Review of Records by Physician: j 

No legislated time requirement for review 3 3 3 j 3 j 3 j 

Periodic/Regular Reviews 2 

Strict/Daily 1 

Hospital Privileges protected in legislation 1 k 

Can refer directly for health/medical services 2 l 2 

Can order or perform diagnostic or lab tests 2 m 2 

Subtotals Legal 35 16 31 29 

Legal Authority 

3 a 

7 7 

1 1 

1 1 

1 1 

1 

2 2 

2 

Reimbursement 

Medicare 5 5 n 5 5 5 

Legal right to be listed on panels as PCP 5 5 o o 

Medicaid % x 10 10 10 p 10 10 p 10 

Language permits reimb by 3rd party or HMO 15 15 q 15 15 q 

Subtotals Reimbursement 35 30 15 30 

continued 

148
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for WV, WI, and WY, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

WV WI WY 

Prescriptive Authority 

How Received: 

Automatic 

Application or Approval Required 

4 4 r 

2 2 2 2 

Uses Own DEA number 3 3 s 3 3 3 

How defined 

Defined by Legislation/Phys.agmt.doesn't determine 

Collaborative agreement defines 

Supervisory agreement defines 

Defined Formulary (inclusive or exclusive) 

t 

5 5 5 t 

4 

3 

1 1 1 t 

Type of Authority 

Full authority within Scope (II-V and Legend) 

Extensive authority (III-V and Legend) 

Limited authority (IV-V and Legend) 

Restricted (V and Legend) 

Legends only 

u 

12 12 12 u 

9 9 u 9 u 

6 

3 

1 

Durable medical equipment/devices 1 1 1 

Sign for samples 1 1 w 1 

Distribute samples 1 1 x 1 1 1 

NP signs prescription 2 2 y 2 2 2 

Continuing Ed requirements 1 1 z 1 1 1 

Subtotals Prescriptive Authority 30 20 23 23 

TOTAL 100 66 69 82 

FOOTNOTES 

WEST VIRGINIA 

a) RN title protected 

b) Recognition "for announcement of Advance Practice" 

d) For prescriptive privilege 

h) Verification of a collaborative agreement for prescriptive authority is required 

I) Not legislated 

j) Not defined 

o) Excluded in HMO legislation 

u) Schedule lll -72 hr supply only, IV-V for 6 months 

WISCONSIN 

a) Under rules for prescriptive authority 

b) Certificate to prescribe 

d) Collaboration required for prescriptive authority 

h) Relationship must be documented 

j) Not defined 

p) Medicaid bonuses for NPs working in certain areas 

t) Collaborative relationship required 

u) Dispensing limited to samples or to facility 30 miles from nearest pharmacy 

WYOMING 

a) Title determined by national certification, limits on use in violation 

b) Recognition and licensure 

I) Not legislated 

j) Not defined 

q) Any Willing Provider Law 

t) No physician involvement 

u) Dispense in accordance with state and federal laws, limited to samples or to facilities 

30 miles from nearest pharmacy 

continued 

149
Table E-1, continued 

Professional Practice Index Scoring Criteria for Nurse Practitioners in 2000 

New Index for WV, WI, and WY, continued 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy 

Project, The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997,

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

WEST VIRGINIA 

West Virginia RN Nurse Practice Act, http://www.ncsbn.org/search/documents/actsandregs/wvrn 

West Virginia Board of Examiners for Registered Professional Nurses, http://www.state.wv.us/nurses 

Code of State Regulations, http://www.state.wv.us/csr 

WISCONSIN 

Wisconsin State Legislature, http://www.legis.state.wi.us/rsb/code 

Wisconsin Nurses Association, http://www.wisconsinnurses.com 

WYOMING 

Wyoming State Board of Nursing, http://nursing.state.wy.us/rules 

Wyoming State Board of Nursing, http://nursing.state.wy.us/NPA 

150
Appendix F. New CNM Scope Index Calculations 

This appendix contains a table that documents the detailed calculations used to compute the new 

professional practice index for CNMs for each of the 50 States plus the District of Columbia. 

Legal Status (Maximum = 35) 

Title protection indicates acceptance and acknowledgement of the skills required to 

practice as a professional. Legal protection provides a safeguard for both the public and 

the practicing professional. 

CNMs are licensed, certified, or approved in all fifty States and the District of Columbia. 

Licensure as a nurse midwife provides recognition of the status of the profession. CNMs 

are frequently regulated as a category of Advanced Practice Nurse (APN). They are 

sometimes addressed as a separate category within the statutes and regulations which 

speak to professional practice, licensure requirements, and prescriptive authority. In some 

States, Midwives or CNMs are considered independently from other nurses and are 

regulated as a separate profession from APNs. 

Regulation by the Board of Nursing is the most common structure when CNMs are 

considered to be APNs. Separate regulation by a Board of Midwifery is considered 

ideal since a separate board can best represent the interests and the orientation of 

midwives. When midwives are regulated by a separate entity, non-nurse midwives may 

be included in the rules. 

Gynecological care in statute or regulation suggests that midwives are viewed as 

practicing in an expanded role. Limiting midwives to care in pregnancy and at birth does 

not fully use their professional competencies. 

The nature of midwifery practice demands a relationship with a physician. Complicated 

pregnancies and deliveries require the availability of specialty physicians with the skills 

to provide needed patient care. Practice as a self-employed (autonomous) midwife is an 

151
option in several States, but the need for a collaborating physician is universal. Practice 

agreements and review of records that are left to the discretion of the midwife and the 

physician acknowledge the competency and skill of each profession and the ability of 

both to safely meet patient need. 

Temporary permits allow nurse midwives awaiting the results of the certification 

examination to practice. 

Inactive or retired status allows non-practicing CNMs to use their title. 

The profession of Midwifery philosophically supports non-nurse midwives who are 

properly trained and regulated. The roots of midwifery practice are in the care of women 

during pregnancy and childbirth in communities where other medical resources are 

limited. Requiring a masters degree, although elevating to a profession, limits the ability 

of non-nurse midwives (also referred to as direct entry or lay midwives) to provide care. 

Rather, professional midwifery associations support adequate skill and competency in 

midwifery and have opened their certification examinations to these midwives. 

Hospital privileges permit a nurse midwife to admit a patient without a supervising 

physician and provide autonomy to the professional. Signing birth certificates and the 

ability to directly refer indicate recognition of the professional ability of the midwife. 

Reimbursement (Maximum = 35) 

In 1997, the Balanced Budget Act, expanded the locations at which CNM could be 

reimbursed for services. Since this was a progression in reimbursement from 1992, a 

score was awarded to every State for direct Medicare payment. 

State reimbursement policy for payment of services rendered to Medicaid-eligible 

patients varies considerably by State and by profession. 

The legal right to be reimbursed for services provided is critical to the autonomy of 

CNMs. Although services may be provided totally by the CNM, the inability to bill third 

parties for payment as an identified provider can be a barrier to the provision of care. 

Direct access legislation allows women to choose well care services from a nurse 

midwife. Legislation enabling that independent choice acknowledges the skill of the 

CNM and suggests the roles that CNMs can play in healthcare delivery. 

Prescriptive Authority (Maximum = 30) 

When prescriptive authority is granted as part of the licensure process for nurse 

midwives, it is recognition of confidence in the education and skill of the CNM. The 

necessity of a separate application for prescriptive privilege suggests special requirements 

for the authority not fundamental to the didactic and clinical preparation of the midwife. 

Although DEA numbers are a requirement for prescribing controlled substances, a 

separate score was allotted to emphasize the importance of the privilege of writing scripts 

for scheduled drugs. 

Definition of the prescriptive privilege in law rather than by individual physicians 

suggests full recognition of the capability of the professional. Dependence for 

prescriptive authority on physician delegation limits the nurse midwife by creating 

barriers to efficient practice. Review with another health professional of patient needs 

152
and ordering of appropriate medications is a necessary part of practice. However, the 

circumstances under which that consultation occurs may best be determined by the 

midwife and may not need to be detailed in law or in a cooperative agreement. 

The ability to receive and distribute sample medications, to independently sign a 

prescription and to prescribe medical devices are suggestive of recognition of the 

expertise of nurse midwives. 

Continuing education requirements maintain the skill of the professional and update 

competencies. 

The actual point allocations for the 50 States are presented below. 

153
Table F-1

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000

New Index for AL, AK, AZ, AR, CA, and CO 

Scoring Category Points 

Optimal 

Score fn 

State 

AL AK AZ AR CA CO 

Legal Status 

Title protected 3 3 a 3 a a 3 a 3 a 3 

Type of recognition: 

Licensed 

Certified, Registered, or Approved 

b b 

3 3 3 

2 2 2 b 2 b 2 b 2 b 

Regulated How: 

Separate Statute/Separate Rules 

Regulated as APN 

c 

2 2 2 

1 1 1 1 c 1 1 

Regulated By: 

Board of Midwifery 

BON w/ Midwifery Committee or Midwife on Board 

BON w/APN rep (when reg as APN) or sep APN Bd 

BON with no specific midwifery representation 

Board of Medicine involved/other 

d 

3 3 

2 2 d 

1 1 1 

1 1 1 

0 0 d 

Scope Defined: 

Scope defined in broad terms 

Scope more specifically defined 

Scope restricted (list of excluded/included tasks) 

No scope defined at all 

e 

3 3 3 3 3 3 

2 2 2 

1 

0 

Gynecological care in SOP defined 1 1 f 1 1 1 1 1 

Masters degree required 0 g 0 0 g 0 g 

National Certification 1 1 h 1 1 1 1 1 1 

Autonomous practice possible 5 5 I 5 I 5 5 5 I 

Relationships with Physicians: 

Independent language 

Colllaborative, referral language 

Supervisory language 

j 

3 3 3 j 

2 2 2 j 2 2 2 j 

1 

Temporary Permit, or not necessary 1 1 k 1 1 k 1 1 k 1 

Inactive or Retired Status Available 1 1 l 1 1 1 

Practice Agreements: 

No written agreement 

Agreement btw phys and midwife on on site/available 

Agreement btw phys and midwife with regulatory body 

m 

3 3 3 

2 2 m 2 

1 1 1 m 1 m 

Practice permissible for lay or direct entry midwives 1 1 n 1 n 1 n 1 n 1 n 1 n 1 n 

Review of Records by Physician: 

Not defined in statutes or laws 

Periodic/Defined Intervals 

Strict/Daily 

o 

2 2 2 2 2 2 2 

1 1 o 

0 

Hospital Privileges in legislation 1 1 p 1 p 1 p 

CNMs can sign birth certificates 1 1 q 1 1 1 1 q 1 1 

Can refer directly for other health services 1 1 r 1 r 1 r 1 1 r 1 r 

Subtotals Legal 35 19 25 0 25 28 23 26 

Reimbursement 

Medicare 

Medicaid % x 10 

Language that permits reimb by 3rd party/HMO 

Any "direct access" legislation for women 

5 5 s 5 5 5 s 5 5 5 

0-10 10 t 8 10 6 8 10 10 

15 15 u 15 u 15 15 15 

5 5 v 5 v 

Subtotals Reimbursement 35 13 35 26 13 30 30 

continued 

154 
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for AL, AK, AZ, AR, CA, and CO, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

AL AK AZ AR CA CO 

Prescriptive Authority AL AK AZ AR CA CO 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 

2 2 2 2 2 w 2 2 

Own DEA number 3 3 x 3 3 3 3 

CNM name on Rx pad 1 1 y 1 1 1 1 1 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 z 16 z 

12 12 

8 

4 

1 1 1 z 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 4 4 ^ 

3 3 3 ^ 

2 2 

1 1 

0 

Durable medical equipment or devices 1 1 # 1 1 1 1 

Continuing Ed requirements 1 1 $ 1 1 1 1 1 1 

Subtotals Prescriptive Authority 30 6 28 0 28 23 7 26 

TOTAL OIN P TS 100 38 88 79 64 60 82 

FOOT NOTES 

ALABAMA: 

b) Certification of Qualification 

d) One midwife on Joint Practice Committee 

n) Lay midwives with permit may practice but DOH has no present method for issuing permits; the statute 

is inactive (ACNM) 

o) Plan for review of records required in regulations 

r) Referral in definition of practice 

ALASKA: 

a) ANP title only,includes CNM

I,j,m) Procedures for consultation referral must be filed with BON but no direct relationship required

n) Certified Direct Entry (CDEMs) Midwives regulated by Board Of Certified Direct Entry Midwives (ACNM)

r) Referral to other health care professionals

u) Any Willing Provider Law

v) No managed care in Alaska, direct access implied by independent nature of practice

z) Dispensing authority as of 1994 

ARIZONA: 

a) RNP title protected includes CNMS

b) Certified to practice

c) Category of RNP

g) After 2001

j) All acts performed must be in collaboration with a physician

k) RN temporary license

n) Midwifery regulated by DOH Nurse Midwives by BON

p) Scope of practice in statute includes admitting patients to hospitals

s) Arizona has an innovative managed care plan called Arizona Health Cost Containment 

System that covers medicaid eligibles, pregnant women etc. RNPs can contract with the plan

z) Prescribe and dispense -limits on refills

^) No physician collaboration required on Application for Authority

continued 

155
Exhibit F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for AL, AK, AZ, AR, CA, and CO, continued 

ARKANSAS: 

a) CNM 

m) For intrapartum care and prescriptive authority only 

n) Lay midwives regulated by state DOH (ACNM) 

q) Licensed midwifery statute provides this privilege 

r) Referrals in definition of practice 

w) Granted a certificate of prescriptive authority 

CALIFORNIA: 

a) Holding oneself out as CNM without certification is grounds for discipline 

b) Certificate to practice 

d) BON with Midwifery Committee 

k) Not necessary because of various avenues available for certificates to practice 

m) Standardized procedures which are protocols for medical acts including prescribing 

provide guidelines for practice 

n) Licensed midwives are regulated by Division of Licensing of Medical Board since 1993 (ACNM) 

p) RNs may be granted expanded role privilege in hospitals 

z) Medically delegated 

COLORADO: 

b) Registration 

g) For prescriptive authority and beginning 7/1/2008 required 

I) Direct entry midwives are licensed and regulated under Colorado Medical Practice Act 

J) 2000 legislation changed language to collaboration 

n) Supervisory language for medical functions, collaborative language for prescriptive authority 

r) In definition of collaborative agreement 

z) Dispensing limited to prepackaged samples, prescriptive authority limited to acute self limiting condition, 

chronic condition, terminal comfort care 

^) Name of at least one collaborating physician required 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

ALABAMA 

Alabama Board of Nursing, http://www.abn.state.al.us 

ALASKA 

Alaska Legislature Online, http://www.legis.state.ak.us

Alaska Division of Occupational Licensing: Board of Nursing, http://www.dced.state.ak.us/occ

ARIZONA 

Arizona Health Care Cost Containment System, http://www.ahccs.state.az.us 

Arizona State Board of Nursing, http://www.azboard of nursing.org 

ARKANSAS 

Arkansas State Board of Nursing , http://www.accessarkansas.org/nurse 

continued 

156
Exhibit F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for AL, AK, AZ, AR, CA, and CO, continued 

CALIFORNIA 

State of California-State and Consumer Services Agency, Board of Registered Nursing, http://www.rn.ca.gov 

National Council of State Boards of Nursing, http://www.ncsbn.org 

American College of Nurse Midwives, http://www.acnm.org 

COLORADO 

Colorado Department of Regulatory Agencies, http://www.dora.state.co.us/Nursing 

157
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for CT, DE, DC, FL, GA, and HI 

Scoring Category Points 

Optimal 

Score fn 

State 

CT DE DC FL GA HI 

Legal Status 

Title protected 3 3 a 3 a 3 a 3 a 

Type of recognition: 

Licensed 

Certified, Registered, or Approved 

b 

3 3 3 3 3 

2 2 b 2 b 2 b 

Regulated How: 

Separate Statute/Separate Rules 

Regulated as APN 

c 

2 2 2 c 

1 1 1 1 1 1 

Regulated By: 

Board of Midwifery 

BON w/ Midwifery Committee or Midwife on Board 

BON w/APN rep (when reg as APN) or sep APN Bd 

BON with no specific midwifery representation 

Board of Medicine involved/other 

d 

3 3 

2 

1 

1 1 1 1 

0 0 d 0 d 0 d 

Scope Defined: 

Scope defined in broad terms 

Scope more specifically defined 

Scope restricted (list of excluded/included tasks) 

No scope defined at all 

e 

3 3 3 3 3 3 3 

2 

1 1 

0 

Gynecological care in SOP definition 1 1 f 1 1 1 1 1 1 

Masters degree required 0 g 0 g 0 0 g 0 g 0 g 

National Certification 1 1 h 1 1 1 1 h 1 1 h 

Autonomous practice possible 5 5 I 5 I 5 5 5 I 5 I 

Relationships with Physicians: 

Independent Language 

Collab, Consult, Referral 

Supervisory Language 

j 

3 3 3 

2 2 j 2 2 j 

1 1 j 1 j 

Temporary Permit, or not necessary 1 1 k 1 1 1 1 1 k 

Inactive or Retired Status Available 1 1 l 1 1 1 

Practice Agreements: 

No written agreement 

Agreement btw phys and midwife on site/available 

Agreement btw phys and midwife with regulatory body 

m 

3 3 3 m 3 

2 2 2 m 

1 1 m 1 

Practice permissible for lay or direct entry midwives 1 1 n 1 n 1 n 1 n 1 n 1 n 

Review of Records by Physician: 

Not defined in statutes or laws 

Periodic/Defined Intervals 

Strict/Daily 

o 

2 2 2 2 2 2 

1 1 1 o 

0 

Hospital Privileges in legislation 1 1 p 1 1 1 p 

CNMs can sign birth certificates 1 1 q 1 1 1 1 1 1 

Can refer directly for other health services 1 1 r 1 r 1 1 1 

Subtotals Legal 35 24 26 32 21 20 23 

Reimbursement 

Medicare 

Medicaid % x 10 

Language that permits reimb by 3rd party/HMO 

Any "direct access" legislation for women 

5 5 s 5 5 5 5 5 5 

0-10 10 t 9 10 10 t 8 10 7.5 

15 15 u 15 15 15 u u 15 

5 5 v 5 

Subtotals Reimbursement 35 34 30 15 28 15 27.5 

continued 

158
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for CT, DE, DC, FL, GA, and HI, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

CT DE DC FL GA HI 

Prescriptive Authority 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 4 4 4 

2 2 2 

Own DEA number 3 3 x 3 3 3 

CNM name on Rx pad 1 1 y 1 1 1 1 1 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 z 16 z 

12 

8 

4 

1 1 z 1 z 1 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 4 

3 3 3 ^ 

2 2 2 ^ 

1 1 ^ 

0 

Durable medical equipment or devices 1 1 # 1 1 1 

Continuing Ed requirements 1 1 $ 1 1 1 $ 1 1 $ 

Subtotals Prescriptive Authority 30 28 27 25 9 8 7 

TOTAL POINTS 100 86 83 72 58 43 57.5 

FOOT NOTES 

CONNECTICUT: 

c) Midwifery Practice Act 

d) Department of Public Health and Addiction Services, a committee of 3 CNMs 

serves as advisory panel 

I) Clinical practice relationship with OB/GYN required 

j) Services "directed" by a qualified OB/GYN however, statute indicates this is not to 

be construed as supervision 

m) Protocols for prescriptive authority filed with DOH 

n) Unlicensed midwives who practice independently of physicians are allowed to 

practice (ACNM) 

z) May prescribe, dispense, administer 

DELAWARE: 

a) APN title protection only 

m) Name of collaborating physician on application for licensure 

n) Traditional midwives practice under a special waiver of the regulation (ACNM) 

r) Initiating referrals in definition of scope 

z) Prescribing medications and treatments independently - can dispense 

^) A copy of the collaborative agreement must be submitted to the Joint Practice 

Committee 

DISTRICT OF COLUMBIA: 

n) Persons previously licensed under now deleted provisions may continue to practice, 

other "midwives unregulated but legal" (ACNM) 

t) Managed care system 

z) No refills on controlled substances 

continued 

159
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for CT, DE, DC, FL, GA, and HI, continued 

FLORIDA: 

a) ARNP title only 

b) Certified 

d) Joint Practice Committee BON with BOM with two APN members 

g) Included in list of options in rules for certification 

h) For initial certification only 

I) Limited practice in licensed midwifery 

j) Supervision with protocols, collaborative language 

n) Council of Licensed Midwifery regulates practice of other midwives since 1992 (ACNM) 

u) Any Willing Provider law 

z) Dispensing allowed but special application for privilege is required 

$) RN requirement 

GEORGIA: 

b) Authorization to practice 

g) Effective 1/1/99 

j) SOP collaborative, prescriptive authority is supervisory and delegatory 

p) Hospitals must provide due process rights to licensed medical professionals 

u) Georgia has an Any Willing Provider law but APRNs do not seem to qualify under the 

definitions 

z) Controlled substances and legend drugs may be prescribed and dispensed if included 

in protocol but location of practice, where this is allowed, is restricted to clinic and 

government settings 

^) Written protocols define privilege, on delegated medical authority of physicians 

HAWAII: 

a) APRN title only 

b) Recognized 

d) BON but BOME involved with prescriptive authority, Department of Commerce and 

Consumer Affairs approves prescriptive authority 

g) For prescriptive authority 

h) Certification or masters 

j) No particular relationship specified except for prescriptive authority 

k) Not necessary if a nurse has a masters degree 

m) For prescriptive authority the name of physician must be submitted 

n) Midwifery practice appears to be legal (ACNM) 

o) Joint and periodic evaluation 

^) Prescribing, administering, dispensing and distribution of drugs 

$) For prescriptive authority 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

continued 

160
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for CT, DE, DC, FL, GA, and HI, continued 

CONNECTICUT 

Connecticut Department of Public Health, http://www.state.ct.us/dph 

DELAWARE 

State of Delaware, Delaware Administrative Code, http://www.state.de.us 

DISTRICT OF COLUMBIA 

Lexis Nexis, http://198.187.128.12/dc 

FLORIDA 

Online Sunshine, State of Florida, http://www.leg.state.fl.us 

GEORGIA 

State Government of Georgia, http://www.ganet.org 

HAWAII 

Hawaii State Legislature, http://www.capitol.hawaii.gov 

Hawaii State Government, Department of Commerce and Consumer Affairs, http://www.state.hi.us 

161
Table F-1, continued

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000

New Index for ID, IL, IN, IA, KS, and KY 

Scoring Category Points 

Optimal 

Score fn 

State 

ID IL IN IA KS KY 

Title protected 3 a 3 3 3 a 3 a 

Type of recognition: b 

Licensed 3 3 3 b 3 b 

Certified, Registered, or Approved 2 2 b 2 b 2 b 

Regulated How: c 

Separate Statute/Separate Rules 2 2 

Regulated as APN 1 1 1 1 c 1 1 c 

Regulated By: d 

Board of Midwifery 3 3 

BON w/ Midwifery Committee or Midwife on Board 2 

BON w/APN rep (when reg as APN) or sep APN Bd 1 1 d 1 d 1 d 

BON with no specific midwifery representation 1 1 1 1 

Board of Medicine involved 0 

Scope Defined: e 

Scope defined in broad terms 3 3 3 3 3 3 3 

Scope more specifically defined 2 2 

Scope restricted (list of excluded/included tasks) 1 

No scope defined at all 0 

Gynecological care in SOP 1 f 1 1 1 1 1 

Masters degree required 0 g 0 g 0 g 0 g 

National Certification 1 h 1 1 1 h 1 

Autonomous practice possible 5 I 5 I 5 I 5 I 5 I 

Relationships with Physicians: j 

Independent Language 3 3 

Collab, Consult, Referral 2 2 j 2 j 2 j 2 j 

Supervisory Language 1 1 j 

Temporary Permit, or not necessary 1 k 1 k 1 

Inactive or Retired Status Available 1 l 1 

Practice Agreements: m 

No written agreement 3 3 3 

Agreement btw phys and midwife on site/available 2 2 2 m 2 

Agreement btw phys and midwife with regulatory body 1 1 m 1 m 

Practice permissible for lay or direct entry midwives 1 n 1 n 1 n 1 n 1 n 

Review of Records by Physician: o 

Not defined in statutes or laws 2 2 2 2 o 

Periodic/Defined Intervals 1 1 o 1 o 1 o 1 o 

Strict/Daily 0 

Hospital Privileges in legislation 1 p 1 p 

CNMs can sign birth certificates 1 q 1 1 1 q 1 

Can refer directly for other health services 1 r 1 1 r 1 1 

Subtotals Legal 35 27 20 20 26 22 27 

Legal Status 

3 3 

3 

1 

1 1 

1 1 

5 

3 

1 k 1 

1 

1 n 

1 

1 1 1 

1 1 1 

Reimbursement 

Medicare 

Medicaid % x 10 

Language that permits reimb by 3rd party/HMO 

Any "direct access" legislation for women 

5 5 s 5 5 5 5 5 5 

0-10 10 t 10 7 7.5 8 7.5 7.5 

15 15 u 15 u 15 u 15 15 15 u 

5 5 v 

Subtotals Reimbursement 35 30 12 27.5 28 27.5 27.5 

continued 

162
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for ID, IL, IN, IA, KS, and KY, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

ID IL IN IA KS KY 

Prescriptive Authority 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 4 4 4 w 

2 2 w 2 2 

Own DEA number 3 3 x 3 3 3 3 3 

CNM name on Rx pad 1 4 y 2 2 2 4 4 4 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 16 z 16 

12 

8 

4 4 z 

1 1 z 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 4 

3 3 3 3 

2 2 ^ 

1 

0 

Durable medical equipment or devices 1 1 # 1 1 1 1 

Continuing Ed requirements 1 1 $ 1 1 1 1 $ 1 

Subtotals Prescriptive Authority 30 24 11 26 30 27 14 

TOTAL POINTS 100 81 43 73.5 84 76.5 68.5 

FOOT NOTES 

IDAHO: 

b) Licensed as a CNM, authorized as a prescriber 

d) BON with Advisory Committee on APNs 

j) " Shall consult and collaborate with other members of health care team" 

"autonomy... of the practice category " but "practice with supervision" 

n) A direct entry midwife could practice legally in the state under certain restrictions (ACNM) 

o) BOM regulations for supervising physician require periodic review of a representative 

sample 

u) Any Willing Provider law includes CNMs 

w) " May be part of initial licensure by separate application" 

z) " Prescribe, deliver, distribute and dispense" -- limits on controlled substances 

ILLINOIS: 

d) APN Board 

g) 2001 

o) Periodic 

z) Schedule III -V but delegated only 

INDIANA: 

b) "Limited license" 

c) Addressed separately in rules for SOP but jointly with NPs for prescriptive authority 

i) Performs as an independent and interdependent member of the health care team 

j) In collaboration with a "licensed practitioner", specific exclusion for collaboration 

with other APNs 

k) No temporary permit under any circumstance 

m) For prescriptive authority only 

n) Not regulated but appears to be legal (ACNM) 

o) Periodic and joint evaluation chart reviews within 7 days with prescriptive authority 

r) Refer clients to other health care providers as appropriate 

u) Discrimination prohibited in law 

continued 

163
Table F-1, continued

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000

New Index for ID, IL, IN, IA, KS, and KY, continued 

IOWA: 

b) Registered 

g) Optional 

I) Referred to as "solo practitioners", practice occurs within an interdisciplinary health 

care team which provides for consultation, collaboration, referral 

j) Collaborative agreement reflects both independent and cooperative decision making 

m) Required with respect to " delegated medical function" 

n) A Bill for the establishment of a Midwifery Advisory Council in the Department of 

Public Health which would issue certificate to qualified midwives was introduced 

but not passed (ACNM) 

p) Hospital Fairness Act 1999 

q) By designation of institution or out of hospital 

z) Prescribe, deliver, distribute or dispense 

KANSAS: 

a) APRN title only 

b) Certificate of qualification 

g) After 2002 

h) Optional 

I,j) Physician's involvement with prescriptive practice only, ARNPs function independently, 

"collegial relationship with physicians and other health professionals", "interdependent 

member of physicians directed team with mutually adopted protocols" 

n) Lay midwife must have an arrangement with a licensed physician to handle 

complications (ACNM) 

o) Periodic and joint evaluation of services rendered 

^) Protocol for prescribing, administering or supplying ( no dispensing except samples) 

$) Requirement for RN licensure 

KENTUCKY: 

a) "Use of ARNP or any other words, letters..to indicate" 

b) Registration and designation 

c) Nurse midwives who held a permit to practice from the State Cabinet of Human 

Resources prior to 1986 have option to practice as nurse midwife ( not ARNP) 

d) Advanced Registered Nurse Practice Council including nurse midwives 

I) May practice independently but "established protocol required" 

j) Protocol defined as similar to national standard of practice, consultation and referral 

language 

m) For prescriptive authority 

n) Lay midwifery regulated and legal (ACNM) 

o) Not defined 

u) Any Willing Provider law 

w) No application process 

z) " Issue prescriptions for and dispense" ( samples only) 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

continued 

164
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for ID, IL, IN, IA, KS, and KY, continued 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

IDAHO 

Idaho State Board of Nursing, http://www2.state.id.us/adm 

ILLINOIS 

Illinois General Assembly, http://www.legis.state.il.us

Illinois Bar Journal, http://www.illinoisbar.org

National Council of State Boards of Nursing, http://www.ncsbn.or/files/npa/wholenpas/ilnpa.asp

INDIANA 

Indiana Health Professions Bureau, http://www.IN.gov/hpb/boards 

Indiana State Board of Nursing, http://www.state.in.us/hpb/boards 

IOWA 

Iowa Board of Nursing, http://www.state.ia.us/nursing 

KANSAS 

Kansas Legislative Services, http://www.accesskansas.org/legislative 

KENTUCKY 

Kentucky Legislature, http://www.lrc.state.ky.us/kar 

Kentucky Board of Nursing, http://www.kbn.state.ky.us 

165
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for LA, ME, MD, MA, MI, and MN 

Scoring Category Points 

Optimal 

Score fn 

State 

LA ME MD MA MI MN 

Legal Status 

Title protected 3 3 a a 3 a 3 3 a 3 3 

Type of recognition: 

Licensed 

Certified, Registered, or Approved 

b 

3 3 3 

2 2 b 2 b 2 b 2 b 2 b 

Regulated How: 

Separate Statute/Separate Rules 

Regulated as APN 

c 

2 2 2 

1 1 1 c 1 c 1 1 

Regulated By: 

Board of Midwifery 

BON w/ Midwifery Committee or Midwife on Board 

BON w/APN rep (when reg as APN) or sep APN Bd 

BON with no specific midwifery representation 

Board of Medicine involved 

d 

3 3 

2 2 2 

1 

1 

0 0 d 0 d 0 d 0 d 

Scope Defined: 

Scope defined in broad terms 

Scope more specifically defined 

Scope restricted (list of excluded/included tasks) 

No scope defined at all 

e 

3 3 3 3 3 3 3 e 

2 

1 

0 0 e 

Gynecological care in SOP definition 1 1 f 1 1 1 1 1 

Masters degree required 0 g 0 g 0 g 

National Certification 1 1 h 1 1 1 1 1 1 

Autonomous practice possible 5 5 I 5 5 I 5 

Relationships with Physicians: 

Independent Language/Collaboration not indicated 

Collab, Consult, Referral 

Supervisory Language 

j 

3 3 3 3 

2 2 2 2 j 2 

1 

Temporary Permit, or not necessary 1 1 k 1 1 1 1 1 

Inactive or Retired Status Available 1 1 l 1 l 

Practice Agreements: 

No written agreement 

Agreement btw phys and midwife on site/available 

Agreement btw phys and midwife with regulatory body 

m 

3 3 3 3 

2 2 

1 1 m 1 

Practice permissible for lay or direct entry midwives 1 1 n 1 n n 1 n 1 n 1 n 

Review of Records by Physician: 

Not defined in statutes or laws 

Periodic/Defined Intervals 

Strict/Daily 

o o 

2 2 2 o 2 o 2 0 

1 1 o 1 1 o 

0 

Hospital Privileges in legislation 1 1 p 

CNMs can sign birth certificates 1 1 q 1 1 1 1 1 1 

Can refer directly for other health services 1 1 r 1 1 1 1 1 1 

Subtotals ega L l 35 17 28 19 20 25 26 

Reimbursement s 

Medicare 

Medicaid % x 10 

Language that permits reimb by 3rd party/HMO 

Any "direct access" legislation for women 

5 5 t 5 5 5 5 5 5 

0-10 10 u 10 10 10 10 10 10 

15 15 v 15 u 15 15 15 15 u 15 u 

5 5 5 5 v 

Subtotals Reimbursement 35 30 35 35 30 30 30 

continued 

166
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for LA, ME, MD, MA, MI, and MN, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

LA ME MD MA MI MN 

Prescriptive Authority 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 4 4 

2 2 2 2 w 2 w 

Own DEA number 3 3 x 3 3 3 3 3 

CNM name on Rx pad 1 1 y 1 1 1 1 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 z 16 16 z 

12 

8 

4 4 z 

1 1 z 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 4 ^ 4 

3 3 

2 2 2 

1 1 

0 

Durable medical equipment or devices 1 1 # 1 1 1 

Continuing Ed requirements 1 1 $ 1 1 1 1 $ 1 1 

Subtotals Prescriptive Authority 30 9 28 26 24 14 28 

TOTAL POINTS 100 56 91 80 74 69 84 

FOOT NOTES 

LOUISIANA: 

a) APRN protection only under" violation" section in statute 

d) Joint Administrative Committee on Prescriptive Authority; BON with BOM governs 

prescribing by APRNs 

g) 1996 

l) For prescriptive authority 

n) Licensed midwives regulated by BOME with Advisory Committee on Midwifery within 

Department of Health and Hospitals (ACNM) 

o) Frequency determined by APRN and collaborating physician 

u) Any Willing Provider Law 

z) The Board may make exceptions and broaden authority on an individual review of 

APRN qualifications 

MAINE: 

a) "Or the title designated by national certifying body" , also CNM 

b) Approval 

c) Statutes classify as APRN, separate rules 

d) Joint Practice Council on APRN composed of BON, BOME and BOO makes 

recommendations on prescriptive authority and other matters 

g) 2006 

n) Unclear (ACNM) 

o) Not defined 

z) Prescription and dispensing (prescribe, administer, dispense or distribute) 

^) Formulary, referred to in rules, is a very broad guideline 

MARYLAND: 

b) Certified 

d) Joint Committee of BON and BOPQA ( Board Of Physicians Quality Assurance) 

approves applications 

l) Illegal - also has Midwife Peer Review Advisory Committee 

v) Bill in 2000-- provides for direct access to nurse midwives 

z) Dispensing, limited to practice in non profit, government and public facilities 

continued 

167
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for LA, ME, MD, MA, MI, and MN, continued 

MASSACHUSETTS: 

a) No person may use any letters, words suggesting expanded role 

b) Authorization, endorsement 

c) Addressed separately in rules 

d) An Advisory Committee to BON for each class of nurse practitioners in "expanded 

role", Board of Registration and Discipline in Medicine approves BON regulations 

and Department of Public Health approves prescriptive authority 

j) Collaborative language in SOP, supervisory language in prescriptive authority 

and in SOP 

n) Not prohibited (ACNM) 

o) At least every three months 

w) Registration with Massachusetts Department of Public Health 

$) RN Requirement 

MICHIGAN: 

b) Certification 

e) Scope of Practice not defined 

I) No relationship with health professionals is described except for prescriptive 

authority which is delegated 

n) Midwifery practice not regulated but not prohibited (ACNM) 

o) Not defined 

u) Attorney General Opinion 

z) Schedule II - V may be prescribed but only as a delegated medical act 

MINNESOTA: 

b) Certification 

e) "Functioning as direct care providers" 

n) Licensed traditional midwives regulated by Board of Medical Practice (ACNM) 

o) Not defined 

u) Mandated but only if NP(CNM) is working under supervision of physician 

w) 1999 law requires fee and proof that criteria for prescribing are met 

z) Prescribe and dispense( authority more liberal for CNMs than NPs) 

$) RN requirement 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

LOUISIANA 

Louisiana State Board of Nursing, http://www.lsbn.state.la.us 

MAINE 

Maine Legislature, http://janus.state.me.us/legis 

MARYLAND 

Maryland General Assembly, http://mlis.state.md.us 

Maryland Board of Nursing, http://dhmh.state.md.us 

continued 

168
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for LA, ME, MD, MA, MI, and MN, continued 

MASSACHUSETTS 

Commonwealth of Massachusetts, http://www.state.ma.us/legis 

MICHIGAN 

National Council of State Boards of Nursing, http://www.michiganlegislature.org/law 

Michigan Legislature, http://www.michiganlegislature.org/law 

MINNESOTA 

State of Minnesota Board of Nursing , http://www.nursingboard.state.mn.us 

Minnesota Office of the Revisor of Statutes, http://www.revisor.leg.state.mn.us 

169
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for MS, MO, MT, NE, NV, and NH 

Scoring Category Points 

Optimal 

Score fn 

State 

MS MO MT NE NV NH 

Legal Status 

Title protected 3 3 a 3 3 3 3 3 a a 

Type of recognition: 

Licensed 

Certified, Registered, or Approved 

b 

3 3 3 

2 2 b 2 b 2 b 2 b 2 b 

Regulated How: 

Separate Statute/Separate Rules 

Regulated as APN 

c 

2 2 2 

1 1 1 1 1 1 

Regulated By: 

Board of Midwifery 

BON w/ Midwifery Committee or Midwife on Board 

BON w/APN rep (when reg as APN) or sep APN Bd 

BON with no specific midwifery representation 

Board of Medicine involved 

d 

3 3 

2 

1 

1 1 d 

0 0 d 0 d 0 d 0 d 0 d 

Scope Defined: 

Scope defined in broad terms 

Scope more specifically defined 

Scope restricted (list of excluded/included tasks) 

No scope defined at all 

e 

3 3 3 3 3 

2 2 e 2 e 

1 

0 0 e 

Gynecological care in SOP 1 1 f 1 1 1 

Masters degree required 0 g 0 0 g 0 g 0 g 

National Certification 1 1 h 1 1 1 1 1 1 

Autonomous practice possible 5 5 I 5 5 

Relationships with Physicians: 

Independent Language/Collaboration not indicated 

Collab, Consult, Referral 

Supervisory Language 

j 

3 3 3 j 3 j 

2 2 j 2 j 2 j 2 

1 

Temporary Permit, or not necessary 1 1 k 1 1 1 1 1 k 1 

Inactive or Retired Status Available 1 1 l 1 1 

Practice Agreements: 

No written agreement 

Agreement btw phys and midwife on site/available 

Agreement btw phys and midwife with regulatory body 

m 

3 3 3 m 3 

2 2 

1 1 1 m 1 

Practice permissible for lay or direct entry midwives 1 1 n 1 n 1 n 1 n 1 n 

Review of Records by Physician: 

Not defined in statutes or laws 

Periodic/Defined Intervals 

Strict/Daily 

o 

2 2 2 o 2 o 2 o 

1 1 o 1 o 

0 0 o 

Hospital Privileges in legislation 1 1 p 

CNMs can sign birth certificates 1 1 q 1 1 1 1 q 1 1 

Can refer directly for other health services 1 1 r 1 1 1 1 1 1 

Subtotals Legal 35 16 19 27 20 17 26 

Reimbursement s 

Medicare 

Medicaid % x 10 

Language that permits reimb by 3rd party/HMO 

Any "direct access" legislation for women 

5 5 t 5 5 5 5 5 5 

0-10 10 u 9 10 8 10 8.5 t 10 

15 15 v 15 u 15 u 15 u 15 15 

5 5 

Subtotals Reimbursement 35 29 30 28 15 28.5 30 

continued 

170
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for MS, MO, MT, NE, NV, and NH, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

MS MO MT NE NV NH 

Prescriptive Authority 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 4 4 w 4 

2 2 2 w 2 w 

Own DEA number 3 3 x 3 x 3 

CNM name on Rx pad 1 1 y 1 1 1 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 z 

12 

8 

4 4 

1 1 z 1 z 1 z 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 4 

3 3 ^ 

2 2 ^ 2 ^ 2 

1 1 

0 

Durable medical equipment or devices 1 1 # 1 1 

Continuing Ed requirements 1 1 $ 1 1 1 1 1 1 

Subtotals Prescriptive Authority 30 9 10 27 9 7 26 

TOTAL OIN P TS 100 54 59 82 44 52.5 82 

FOOT NOTES 

MISSISSIPPI: 

b) Certification 

d) Rules jointly promulgate by BON and State Board of Medical Licensure 

with Advisory Committee 

e) 1998 

j) Must practice in collaborative relationship, protocols required 

to outline diagnostic, therapeutic and prescriptive activities 

n) Legal but unregulated (ACNM) 

o) Not defined 

u) Mandated but only if NP(CNM) is working under supervision of physician 

z) Controlled substances may be ordered by CNMs in a health care facility if set forth 

in protocol which details what can be "ordered, administered, dispensed and or 

prescribed" 

^) Protocols define 

MISSOURI: 

b) Document of Recognition 

d) Board of Nursing in Department of Economic Development 

g) 1998 

j) "Physician should be available for immediate consultation", 30 mile 

distance (non-HPSA), 50 mile distance in a HPSA 

n) Lay midwives licensed by Healing Arts Board if practicing before 1959- no new 

license since that year (ACNM) 

o) Every two weeks 

u) RSMO 376.407 1998 

w, ^) Collaborative agreement defines "delegated" authority and must be in place before 

prescribing occurs 

z) "Administer, dispense or prescribe," legend drugs, controlled substances only as "delegated" 

for individual patients 

continued 

171
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for MS, MO, MT, NE, NV, and NH, continued 

MONTANA: 

b) Certificate of Nurse Midwifery, endorsement of RN license 

d) Department of Commerce licenses RNs, BON, BOM, BOP act jointly on rules for 

Prescriptive Authority in advisory capacity 

g) 1995 

j) Independent language 

m) Quality assurance process for Prescriptive Authority 

n) Direct entry midwives exempted from medical practice act, no physician supervision 

required, licensed and regulated by "alternate health care board" (ACNM) 

o) Sample reviewed quarterly by peers or physicians 

u) Freedom of choice statute 

z) Prescribe, dispense, administer with some limitations on quantities prescribed 

NEBRASKA: 

b) Certificate to practice 

d) Joint regulation BON and Board of Examiners in Medicine and Surgery under Department 

of Health and Human Advisory Committee Council of Certified Nurse Midwives 

j) Statute specifically states that nothing in it may be interpreted to permit independent 

practice, collaboration within SOP, supervision for medical functions 

m) Must be reviewed by both BON and BOM 

q) Act says that CNMs may practice in a facility 

w) CNM must notify board of collaborating physician and practice address before 

prescribing 

^) Prescriptive Authority limited to what is permitted in the protocol, Schedule 

III - V permitted under physician supervision-- no DEA 

NEVADA: 

a) "Use title APN or any similar title" 

b) Certificate of Recognition 

d) Protocol and written agreement must be approved 

e) A list of tasks including "other" if certified to perform 

g) 2005 

k) For practice only, no prescriptive authority 

o) Monthly in person review, periodic chart review 

t) Rate unclear, NP rate 85% 

w) In addition to certificate from BON, CNM must apply to pharmacy board for 

" certificate of registration" to prescribe 

x) DEA for administering and dispensing not prescribing 

z) APN may dispense controlled substances if passes exam and has approval 

from BOP 

NEW HAMPSHIRE: 

a) ARNP title only 

d) BON with ARNP member and ARNP Committee, Joint Health Council for 

Prescriptive authority BON, BOM, BOP appointees 

e) Lists of included acts 

j) "Shall be competent to practice independently" 

n) State Midwifery Council issues certification to other midwives (ACNM) 

o) Not defined 

z) Possess, compound, prescribe, administer, dispense or distribute 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

continued 

172
Table F-1, continued

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000

New Index for MS, MO, MT, NE, NV, and NH, continued 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

MISSISSIPPI 

Lexis Nexis, http://198.187.128.12/mississippi 

Mississippi State Board of Nursing, http://www.msbn.state.ms.us/laws 

MISSOURI 

Missouri General Assembly, http://www.moga.state.mo.us/statutes

Missouri Department of Economic Development, Board of Nursing, http://www.ecodev.state.mo.us/pr/nurising

MONTANA 

Montana Department of Commerce, Board of Nursing, http://www.com.state.mt.us/License 

Montana State Documents Online, http://statedocs.msl.state.mt.us 

NEBRASKA 

National Council of State Boards of Nursing, http://www.ncsbn.org/serach/documents 

NEVADA 

Nevada Legislature, http://www.leg.state.nv. us/NRS

Nevada Legislature,http:// www.leg.state.nv.us/nac

National Council of State Boards of Nursing, http://www.ncsbn.org/search/documents/actsand regs/nv

NEW HAMPSHIRE 

New Hampshire Board of Nursing, http://www.state.nh.us/nursing

National Council of State Boards of Nursing, http://www.ncsbn.org/search/documents/actsand regs/nh

173
Table F-1, continued

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000

New Index for NJ, NM, NY, NC, ND, and OH 

Scoring Category Points 

Optimal 

Score fn 

State 

NJ NM NY NC ND OH 

Title protected 3 a 3 a 3 a 3 

Type of recognition: b 

Licensed 3 3 3 b 3 3 

Certified, Registered, or Approved 2 2 b 2 b 

Regulated How: c 

Separate Statute/Separate Rules 2 2 2 2 2 2 

Regulated as APN 1 1 1 

Regulated By: d 

Board of Midwifery 3 3 3 

BON w/ Midwifery Committee or Midwife on Board 2 2 d 

BON w/APN rep (when reg as APN) or sep APN Bd 1 

BON with no specific midwifery representation 1 1 1 

Board of Medicine involved 0 0 d 0 d 

Scope Defined: e 

Scope defined in broad terms 3 3 3 3 

Scope more specifically defined 2 2 

Scope restricted (list of excluded/included tasks) 1 1 

No scope defined at all 0 0 e 0 e 

Gynecological care in SOP definition 1 f 1 1 1 

Masters degree required 0 g 0 g 0 

National Certification 1 h 1 h 1 

Autonomous practice possible 5 I 5 

Relationships with Physicians: j 

Independent Language/Collaboration not indicated 3 3 j 

Collab, Consult, Referral 2 2 j 2 2 

Supervisory Language 1 1 j 

Temporary Permit, or not necessary 1 k 1 1 1 

Inactive or Retired Status Available 1 l 

Practice Agreements: m 

No written agreement 3 3 3 m 

Agreement btw phys and midwife on site/available 2 2 m 2 m 

Agreement btw phys and midwife with regulatory body 1 1 m 1 m 

Practice permissible for lay or direct entry midwives 1 n 1 n 1 n 1 n 1 n 

Review of Records by Physician: o 

Not defined in statutes or laws 2 2 2 o 2 

Periodic/Defined Intervals 1 1 o 1 o 1 o 1 o 

Strict/Daily 0 

Hospital Privileges in legislation 1 p 1 p 

CNMs can sign birth certificates 1 q 1 1 1 1 

Can refer directly for other health services 1 1 1 1 1 1 

Subtotals Legal 35 16 28 30 15 17 20 

Legal Status 

3 a 3 

3 

1 1 1 

1 1 1 1 

5 5 

3 

2 

1 1 1 

1 

2 

1 n 

1 p 

1 1 1 

1 

Reimbursement 

Medicare 

Medicaid % x 10 

Language that permits reimb by 3rd party/HMO 

Any "direct access" legislation for women 

5 5 s 5 5 5 5 5 5 

0-10 10 t 7 10 10 10 7.5 10 

15 15 u 15 15 15 15 15 15 

5 5 v 5 v 5 v 5 v v 

Subtotals Reimbursement 35 32 35 35 30 27.5 30 

continued 

174 
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for NJ, NM, NY, NC, ND, and OH, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

NJ NM NY NC ND OH 

Prescriptive Authority 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 4 w 

2 2 2 w 2 w 2 2 

Own DEA number 3 3 x 3 3 3 3 3 

CNM name on Rx pad 1 1 y 1 1 1 1 1 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 16 16 z 

12 12 z 

8 

4 

1 1 z 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 4 

3 3 

2 2 

1 1 ^ 1 1 

0 

Durable medical equipment or devices 1 1 # 1 1 1 1 1 1 

Continuing Ed requirements 1 1 $ 1 $ 1 $ 1 1 1 

Subtotals Prescriptive Authority 30 7 25 27 28 26 21 

TOTAL POINTS 100 55 88 92 73 70.5 71 

FOOT NOTES 

NEW JERSEY: 

a) None

b) Must pass an examination given by the state

d) BOME regulates CNM liaison committee advises

e) Very descriptive rules

j) "Shall not work ...in an ... independent practice but shall function within...

a system that provides collaborative management"

m) Name of collaborating physician supplied to board with application

n) Statute applies to all midwives but non-nurses cannot have prescriptive authority (ACNM)

o) Periodic

v) CNMs qualify as PCPs under state law

z) Controlled substances in licensed hospitals only

^) Protocol with "collaborating physician required, formulary determined by BOME

$) For prescriptive authority

NEW MEXICO: 

d) Department of Health/Public Health Division with CNM Advisory Board 

j,) Independent management of women's health care within a system that provides, etc 

m) No physician agreement required, SOP includes "written clinical practice guidelines" 

n) Licensed midwives under separate rules, may administer drugs but no 

prescribing allowed (ACNM) 

o) Peer review required of all CNMs

v) Pharmacy law defines CNMs as having the ability to "serve as a primary care provider"

w) Permit to prescribe

z) Prescribing, administering and distributing of drugs ( pre packaged by pharmacist

or manufacturer)

$) CE and participation in peer review required for licensure

continued 

175
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for NJ, NM, NY, NC, ND, and OH, continued 

NEW YORK: 

h) Passing an examination in midwifery satisfactory to Department of Education 

n) Direct entry midwives licensed under same practice act (ACNM) 

o) Not defined 

v) Public Health Law requires direct access 

w) Certificate to prescribe 

NORTH CAROLINA: 

a) Holding oneself out to practice midwifery unless approved is a violation of law 

b) Approval 

d) Joint Committee of BON and MB with CNM advisors 

j) Collaborative language but practice "under supervision of physician" 

m) Protocols and written guidelines 

n) Those licensed prior to 1983 are grandmothered (ACNM) 

o) Periodic and joint review by physician and nurse midwife 

p) All persons admitted to hospitals must be under care of a physician 

v) Required only if APRN is not employee of physician or hospital 

w) With CNM approval application 

NORTH DAKOTA: 

a) "Use the applicable category designation", "no person may use an APN title 

without authority 

e) "The APRN retains the responsibility and accountability for SOP" 

g) 2001 

m) Scope of practice statement submitted to board at initial application and renewal 

which includes physician collaboration arrangement for prescriptive authority 

n) Midwifery practice "not legally defined but not prohibited" (ACNM) 

o) No less than once every two months 

z) May dispense samples 

OHIO: 

b) Authorization 

m) Standard care arrangement 

o) Regular review of care outcomes 

p) Law prohibits discrimination against NMs if hospital provides maternity services 

z) Recent legislation 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997,

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

continued 

176
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for NJ, NM, NY, NC, ND, and OH, continued 

NEW JERSEY 

New Jersey State Legislature, http://www.njleg.state.nj.us

New Jersey.the online state, http:// www.state.nj.us

New Jersey State Nurses Association, http://www.nurse.org/nj/njsna

NEW MEXICO 

Lexis Nexis, http://198.187.128.12/newmexico

i Bienvenidos a Nuevo Mexico! – Welcome to New Mexico!, http://www.state.nm.us/clients/nursing

NEW YORK 

New York State Coalition of Nurse Practitioners,http:// www.nysconp.org/gvtaffairs 

New York State Assembly-Consolidated Laws – Education, http://assembly.state.ny.us 

New York State Education Department, Office of the Professions, http://www.op.nysed.gov/rap.htm 

NORTH CAROLINA 

North Carolina Board of Nursing, http://www.ncbon.com

National Council of State Boards of Nursing, http://ncsbn.org/files/npa/wholenpas/ncnpa.asp

North Carolina General Assembly, http:www.ncga.state.nc.us

NORTH DAKOTA 

North Dakota Board of Nursing, http://www.ndbon.org 

OHIO 

National Council of State Boards of Nursing, http://www.ncsbn.org/files/npa/wholenpas/ohnpa.asp 

State of Ohio Government Info and Services, http:// www.state.oh.us/nur 

Anderson’s Online Documentation, http://onlinedocs.andersonpublishi 

Session Law from the 124th General Assembly of the State of Ohio, http://ohioacts.avv.com 

177
Table F-1, continued

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000

New Index for OK, OR, PA, RI, SC, and SD 

Scoring Category Points 

Optimal 

Score fn 

State 

OK OR PA RI SC SD 

Legal Status 

Title protected 3 3 a 3 a 3 a 3 a 3 a 3 

Type of recognition: 

Licensed 

Certified, Registered, or Approved 

b 

3 3 3 3 3 

2 2 b 2 b 2 b 

Regulated How: 

Separate Statute/Separate Rules 

Regulated as APN 

c 

2 2 2 2 

1 1 c 1 1 1 c 

Regulated By: 

Board of Midwifery 

BON w/ Midwifery Committee or Midwife on Board 

BON w/APN rep (when reg as APN) or sep APN Bd 

BON with no specific midwifery representation 

Board of Medicine involved 

d 

3 3 

2 2 d 

1 

1 1 

0 0 d 0 d 0 d 0 d 

Scope Defined: 

Scope defined in broad terms 

Scope more specifically defined 

Scope restricted (list of excluded/included tasks) 

No scope defined at all 

e 

3 3 3 3 3 3 3 

2 2 e 

1 

0 

Gynecological care in SOP definition 1 1 f 1 1 1 1 1 

Masters degree required 0 g 0 g 0 

National Certification 1 1 h 1 h 1 h 1 1 h 

Autonomous practice possible 5 5 I 5 5 I 5 5 I 

Relationships with Physicians: 

Independent Language/Collaboration not indicated 

Collab, Consult, Referral 

Supervisory Language 

j 

3 3 3 3 j 

2 2 j 2 2 j 

1 1 

Temporary Permit, or not necessary 1 1 k 1 1 k 1 1 

Inactive or Retired Status Available 1 1 l 1 

Practice Agreements: 

No written agreement 

Agreement btw phys and midwife on site/available 

Agreement btw phys and midwife with regulatory body 

m 

3 3 3 m 3 

2 2 m 2 m 2 m 

1 

Practice permissible for lay or direct entry midwives 1 1 n 1 n 1 n 1 n 1 n 1 

Review of Records by Physician: 

Not defined in statutes or laws 

Periodic/Defined Intervals 

Strict/Daily 

o 

2 2 2 o 2 2 o 2 o 2 o 2 

1 

0 

Hospital Privileges in legislation 1 1 p 1 p 

CNMs can sign birth certificates 1 1 q 1 1 1 1 1 1 

Can refer directly for other health services 1 1 1 1 1 

Subtotals Legal 35 26 29 22 30 13 24 

Medicare 5 s 5 5 

Medicaid % x 10 0-10 10 t 10 10 10 8 t 8 

Language that permits reimb by 3rd party/HMO 15 15 u 15 15 u 15 u 15 

Any "direct access" legislation for women 5 v 5 v 

Subtotals Reimbursement 35 15 35 30 33 13 29 

Reimbursement 

5 5 5 5 5 

9 

5 5 

continued 

178 
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

OK OR PA RI SC SD 

Prescriptive Authority 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 

2 2 2 2 2 2 w 

Own DEA number 3 3 x 3 3 3 3 x 3 

CNM name on Rx pad 1 1 y 1 1 1 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 z 

12 12 z 12 z 

8 

4 4 z 

1 z 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 

3 3 ^ 3 

2 

1 1 ^ 1 1 

0 

Durable medical equipment or devices 1 1 # 1 1 

Continuing Ed requirements 1 1 $ 1 1 1 1 

Subtotals Prescriptive Authority 30 19 21 0 25 13 25 

TOTAL POINTS 100 60 85 52 88 39 78 

FOOT NOTES 

OKLAHOMA: 

a) Use of any "title, abbreviation, sign or device to indicate that ..... One is an ANP 

unless duly licensed" 

b) Certificate of Recognition 

c) Addressed separately in the rules 

d) BON and Formulary Advisory Council (State Medical Association involved) and State Pharmacy 

Association 

g) Effective from 2002 for prescriptive authority 

j) "Within a ...... system which provides for medical consultation, medical management 

or referral" but supervisory language for prescriptive authority 

m) A requirement to file a written statement as part of the initial and renewal application for prescriptive 

authority detailing physician supervision 

o) Not defined 

z) May prescribe and administer 

^) Supervisory language attached to prescriptive authority-written agreement required 

"subject to medical direction by a supervising physician" 

OREGON: 

a) Title NP protected, called Nurse Midwife, Nurse Practitioner in state 

b) Certificate of Special Competency 

I) Independently responsible and accountable 

k) No national certification required, so not necessary 

n) 1993 statue governing direct entry midwifery (ACNM) 

p) Law prohibits discrimination 

z) Write and dispense-dispensing limited to geographically remote areas 

continued 

179
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

PENNSYLVANIA: 

a) Statute entitles midwife to use title but does not restrict or prohibit use 

by unlicensed or inactive midwives 

d) Board of medicine has exclusive jurisdiction 

h) An option for licensing 

m) Both a midwife protocol which details the procedures and routines of care and a 

collaborative agreement are required 

n) Statute ambiguous, would appear to permit a lay midwife to practice (ACNM) 

o) Not defined 

u) Insurance Payment to Registered Nurse Law 1986 

z) "May relay to other health providers medical regimens prescribed by the physician 

including drug orders", no delegation of prescriptive auth. allowed 

RHODE ISLAND: 

d) Department of Health with Advisory Council on Nurse Midwifery 

h) Requirement found in " Discipline of Licensees" (effective 2000) 

j) Independent management of cases with evidence of prearranged provision 

for collaboration 

m) Guidelines describing prescriptive authority between physician and CNM 

n) Statute and regulations allow non nurses to be licensed (ACNM) 

o) Not defined 

t) Unclear, 80% used as average 

v) Insurance law protects eligibility to participate as network provider, RITE CARE 

allows CNMs to be PCPs 

z) CNMs only, other midwives may not prescribe 

^) Guidelines describe provision for prescriptive authority 

SOUTH CAROLINA: 

a) A specialty area...shall be declared and the specialty title to be used but no 

limitation on use is described 

b) Official recognition 

d) BON within Department of Labor with protocols for prescriptive authority jointly 

authored by BON, BOME, BOP and BON, BOME agreeing on additional acts to 

be performed 

e) SOP defined in general terms as encompassing additional acts, delegated acts, 

extended role, expanded role all of which are described in detail 

m) Protocols that establish physician delegation 

n) Licensed midwives regulated by State Board of Health and Environmental Control (ACNM) 

o) Not defined 

x) For Schedule V only 

z) Formulary restricted to schedule V and legends- designated by physician in protocol 

SOUTH DAKOTA: 

c) Regulated under same statute but separate classification 

d) Joint regulation of BON, BMOE ( Board of Medicine and Osteopathic Examiners) 

h) Effective from 1/1/99 

I) 1996 Nurses allowed to form professional services corporation 

j) MD must be onsite one half day a week 

w) Application to Department of Health 

z) Limited to 48 hours on schedule ll (schedule II to IV in regulation but in South Dakota 

Schedule IV includes Federal Schedule V 

continued 

180
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for OK, OR, PA, RI, SC, and SD, continued 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

OKLAHOMA 

Oklahoma Public Legal Research System, http://oklegal.onenet.net/oklegal 

OREGON 

National Council of State Boards of Nursing, www.ncsbn.org/search/documents/actsand regs/or/

Oregon State Archives, http://arcweb.sos.state.or.us/rules

Oregon State Board of Nursing, http://www.osbn.state.or.us

PENNSYLVANIA 

The Pennsylvania Code Online, http://www.pacode.com/secure/data 

Pennsylvania Department of State – Professional Licensure, http://www.dos.state.pa.us/bpoa/nurbd 

RHODE ISLAND 

Rhode Island Department of Human Services, http://www.dhs.state.ri.us/dhs

The State of Rhode Island General Assembly, http://www.rilin.state.ri.us/Statutes/TITLES

The State of Rhode Island General Assembly, http://www.rilin.state.ri.us/gen-assembly/genmenu.html

SOUTH CAROLINA 

South Carolina Board of Nursing, http://www.llr.state.sc.us/POL/Nursing 

South Carolina State House Network, http://www.lpitr.state.sc.us/code 

SOUTH DAKOTA 

South Dakota Legislature, http://legis.state.sd.us/rules 

South Dakota Legislature, http://legis.state.sd.us/statutes 

181
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for TN, TX, UT, VT, VA, and WA 

Scoring Category Points 

Optimal 

Score fn 

State 

TN TX UT VT VA WA 

Legal Status 

Title protected 3 3 a a 3 a 3 a 3 3 

Type of recognition: 

Licensed 

Certified, Registered, or Approved 

b 

3 3 3 b 3 3 

2 2 b 2 b 2 b 

Regulated How: 

Separate Statute/Separate Rules 

Regulated as APN 

c 

2 2 2 

1 1 c 1 c 1 c 1 1 

Regulated By: 

Board of Midwifery 

BON w/ Midwifery Committee or Midwife on Board 

BON w/APN rep (when reg as APN) or sep APN Bd 

BON with no specific midwifery representation 

Board of Medicine involved 

d 

3 3 3 d 

2 2 d 2 d 

1 

1 

0 0 d 0 d 0 d 

Scope Defined: 

Scope defined in broad terms 

Scope more specifically defined 

Scope restricted (list of excluded/included tasks) 

No scope defined at all 

e 

3 3 3 3 3 

2 2 2 

1 

0 0 e 

Gynecological care in SOP definition 1 1 f 1 1 1 1 1 

Masters degree required 0 g 0 g 0 g 0 g 0 g 

National Certification 1 1 h 1 h 1 1 h 1 1 1 

Autonomous practice possible 5 5 I 5 I I 5 I I 5 

Relationships with Physicians: 

Independent Language/Collaboration not indicated 

Collab, Consult, Referral 

Supervisory Language 

j 

3 3 3 j 

2 2 j 2 j 

1 1 j 1 j 1 j 

Temporary Permit, or not necessary 1 1 k 1 k 1 1 1 1 1 

Inactive or Retired Status Available 1 1 l 1 1 k 1 

Practice Agreements: 

No written agreement 

Agreement btw phys and midwife on site/available 

Agreement btw phys and midwife with regulatory body 

m 

3 3 

2 2 m 2 m 2 m 

1 1 1 1 m 

Practice permissible for lay or direct entry midwives 1 1 n 1 n 1 n n 1 n 1 n 

Review of Records by Physician: 

Not defined in statutes or laws 

Periodic/Defined Intervals 

Strict/Daily 

o 

2 2 2 o 2 o 2 o 2 o 

1 1 o 1 o 

0 

Hospital Privileges in legislation 1 1 p 1 p 1 p 1 p 1 p 

CNMs can sign birth certificates 1 1 q 1 1 1 1 1 1 

Can refer directly for other health services 1 1 r 1 1 1 

Subtotals ega L l 35 19 20 29 21 16 30 

Reimbursement 

Medicare 

Medicaid % x 10 

Language that permits reimb by 3rd party/HMO 

Any "direct access" legislation for women 

5 5 s 5 5 5 5 5 5 

0-10 10 t 9 9 8 t 10 10 10 

15 15 u 15 15 15 u 15 u 15 

5 5 v 5 v 5 v 5 

Subtotals Reimbursement 35 29 34 33 15 30 35 

continued 

182
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

Scoring Category Points 

Optimal 

Score fn 

State 

TN TX UT VT VA WA 

Prescriptive Authority 

How received: 

Automatic/No additional application required 

Application required 

w 

4 4 4 w 4 

2 2 2 2 2 

Own DEA number 3 3 x 3 3 3 3 3 

CNM name on Rx pad 1 4 y 2 2 4 4 2 2 

Extent of Authority: 

Full auth within scope of pract (Schedule II-V & legend) 

Extensive auth w/in scope (Schedule III-V and legend) 

Limited auth within scope (Schedule IV-V and legend) 

Restricted auth within scope (Schedule V and legend) 

Legends only 

z 

16 16 16 z 16 z 16 z 

12 

8 

4 4 z 4 z 

1 1 z 

Authority through: 

In legislation/collaborative agrmnt not required 

Collab agrmnt defines privilege OR no phys involvemen 

Supervisory agreement defines privilege 

Defined Formulary (inclusive or exclusive) 

No Authority at all 

^ 

4 4 

3 3 ^ 3 ^ 3 ^ 

2 2 ^ 2 ^ 2 ^ 

1 

0 

Durable medical equipment or devices 1 1 # 1 1 1 

Continuing Ed requirements 1 1 $ 1 1 1 

Subtotals Prescriptive Authority 30 11 8 27 28 13 27 

TOTAL POINTS 100 59 62 89 64 59 92 

FOOT NOTES 

TENNESSEE: 

a) RN title protection only 

b) Certification for prescriptive authority only--certificate of fitness, otherwise regulated as RNs 

C) For prescriptive authority 

d) BON, with rules jointly adopted with BOME and prescriptive authority regulated by 

Primary Care Advisory Board within Tennessee's Licensing Board of the Healing Arts 

e) Only prescriptive authority defined 

g) Masters required for prescriptive authority 

h,J,K) For prescriptive authority 

I) CNM could technically practice independently without prescriptive authority 

m) Acts that would be regulated outside state definition of midwifery require protocol 

n) Midwifery practice is legal but unregulated (ACNM) 

p) Regulations permit but do not require CNMs to be granted privileges 

o) Not defined 

z) Prescribes or issues (dispense and administer) schedule II to V and legends 

but medical acts make MD responsible, requires physician supervision and treats 

scripts as MDs 

^) Name of supervising physician and formulary of drugs must be submitted to 

BON and Division of Health Related Boards 

TEXAS: 

a) Use title specified on authorization--APN not to be used as title 

b) Approval in statute, authorization to practice in regulations 

c) NMs addressed separately in rules for provision of controlled substances 

d) BON with BOME involved when prescriptive authority is approved 

g) 2003 

I) Acts independently and/or in collaboration with other health professionals 

j) The regulations speak of independence or collaboration for nursing aspects of care 

but require that APNs must utilize mechanisms(I.e. protocols or written 

authorization) which provide authority for medical aspects of care 

m) Protocols or written authorization need not to be detailed 

n) Midwifery Act 1993 provides regulation for other midwives by Texas Board of 

Midwifery (ACNM) 

continued 

183
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

o) Not defined 

p) Due process privileges when hospitals extends privileges to APNs(1999) 

v) State Medicaid identifies CNMs as eligible primary care providers 

z) NM may provide one or more doses of controlled substances during intrapartum 

or postpartum care if delegated by a physician, prescriptive authority limited to 

eligible sites which include MUAs and HPSAs, primary care locations and health 

care facilities 

^) Although language suggests independence of APN, protocols and written 

authorization are required for prescriptive authority along with availability of 

physicians for immediate consultation 

UTAH: 

a) Representing oneself as a CNM when not licensed subject to fine 

( including using any title) 

b) Licensed as Certified Nurse Midwife, BON has no jurisdiction 

d) Certified Nurse Midwife Board advises Department of Commerce 

h) Additional state exam on Utah laws and rules 

I) Consulting physician required 

j) Consulting physician 

m) Written plan required for prescriptive privilege of Schedule ll and lll and for 

management of intrapartum care 

n) Utah has a law protecting right of parents to deliver baby when, where, how 

and by whom they choose regardless of licensure 

o) Participation in a quality review program is a condition of renewal of license 

t) CNMs have own fee schedule, 80% chosen as representative of prior 

physician reimbursement 

u) Any Willing Provider Law 

v) Medicaid rules define NMs as primary care providers 

w) Automatic when all conditions are met on license application--- if the 

conditions are not met a license as CNM without prescriptive authority is 

issued 

z) Administer(includes administration of anesthesia) and prescribe, Schedule 

ll to lll authority requires "consulting" physician with written guidelines 

VERMONT: 

b) Endorsement

d) BON with APRN Advisory Committee

j) Independent dealing with nursing needs and under practice guidelines for medical functions

o) Not defined

^) May write and sign prescriptions as described in practice guidelines

VIRGINIA: 

d) Joint Board of BOM and BON with Advisory Committee of APNs 

g) Graduate of a program which grants a masters in nursing -in definition 

18VAC 90-30-10 

I) Midwives may establish separate offices but a physician must visit monthly 

j) Supervision and direction by a physician in accord with written protocols 

for all medical acts 

n) Prior to 1977 lay midwives were issued permits by the Board of Health, these 

midwives are "grandmothered" but no new permits are being issued (ACNM) 

o) Monthly review 

p) Statute prohibits discrimination of CNMs on a class basis 

u) CNM only 

z) Prescriptive authority changed in 2000 (V AND VI), effective 2002 schedule IV will be 

allowed and in 2003, schedule III. Rules are still being promulgated 

^) Prescribe from an approved formulary in accordance with practice agreement. Effective 

2000, may dispense if authorized to do so in agreement 

continued 

184
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for TN, TX, UT, VT, VA, and WA, continued 

WASHINGTON: 

d) BON called Nursing Care Quality Assurance Commission, one direct entry midwife, two NPs 

on board ( may be CNM) 

g) 1995 

j) Practice is grounded in nursing and incorporates the use of independent judgement 

as well as collaborative interaction with other health care professionals 

m) New requirement in 2000( rules are being written) which mandates an agreement 

between NP and physician for prescriptive authority for Schedule ll to IV 

n) Direct entry midwives regulated by Midwifery Advisory Committee of Department of 

Health (ACNM) 

p) Admit patients to health care facilities in regulations WAC 246-840-300, not in 

statutes 

z) Prescribe and dispense( schedule ll to IV may only be dispensed for a 72 hour 

supply) 

^) New law now requires collaborative agreement for prescriptive authority 

schedule ll to IV 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

TENNESSEE 

Tennessee Nurses Association, http://www.tnaonline.org/ap

Lexis Nexis, http://198.187.128.12/tennessee/

TennesseeAnytime: The Official Site Of the State Of Tennessee, http://www.state.tn.us/sos/rules

TEXAS 

Coalition for Nurses in Advanced Practice, http://www.cnaptexas.org/legislation/sessions

National Council of State Boards of Nursing, http://www.ncsbn.org/files/npa/wholenpas/txrnnpa.asp

Board of Nurse Examiners, http://www.bne.state.tx.us

UTAH 

Utah Administrative Rules Online, http://www.rules.state.ut.us/publicat/code 

Utah Department of Commerce, http://www.commerce.state.ut.us 

Utah State Legislature, http://www.le.state.ut.us 

VERMONT 

Vermont Statutes Online, http://www.leg.state.vt.us/statutes

Secretary of State, Office of Professional Regulation, http://www.sec.state.vt.us/opr/rules/nursing

VIRGINIA 

Virginia Board of Nursing, http://dhp.state.va.us/nursing 

Legislative Information System, http://leg1.state.va.us 

WASHINGTON 

Washington State Department of Health, Nursing Care Quality Assurance Commission, http://www.doh.wa.gov/nursing/scopeofp

Washington State Department of Health, Nursing Care Quality Assurance Commission,

http://www.doh.wa.gov/unursing/rules.htm

Washington State Legislature, http://search.leg.wa.gov/wslwac

Revised Code of Washington, http://search.leg.wa.gov/wslrcw

185
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for WV, WI, and WY 

Scoring Category Points 

Optimal 

Score fn 

State 

WV WI WY 

Legal Status 

Title protected 3 3 a 3 a 3 3 a 

Type of recognition: 

Licensed 

Certified, Registered, or Approved 

b 

3 3 3 b 3 3 b 

2 

Regulated How: 

Separate Statute/Separate Rules 

Regulated as APN 

c 

2 2 2 2 c 

1 1 

Regulated By: 

Board of Midwifery 

BON w/ Midwifery Committee or Midwife on Board 

BON w/APN rep (when reg as APN) or sep APN Bd 

BON with no specific midwifery representation 

Board of Medicine involved 

d 

3 3 

2 

1 

1 1 1 1 

0 

Scope Defined: 

Scope defined in broad terms 

Scope more specifically defined 

Scope restricted (list of excluded/included tasks) 

No scope defined at all 

e 

3 3 

2 

1 

0 0 0 e 0 

Gynecological care in SOP definition 1 1 f 1 1 1 

Masters degree required 0 g 0 g 0 

National Certification 1 1 h 1 1 1 

Autonomous practice possible 5 5 I 5 I 

Relationships with Physicians: 

Independent Language/Collaboration not indicated 

Collab, Consult, Referral 

Supervisory Language 

j 

3 3 

2 2 2 

1 1 

Temporary Permit, or not necessary 1 1 k 1 1 k 

Inactive or Retired Status Available 1 1 l 

Practice Agreements: 

No written agreement 

Agreement btw phys and midwife on site/available 

Agreement btw phys and midwife with regulatory body 

m 

3 3 

2 2 m 2 

1 1 m 

Practice permissible for lay or direct entry midwives 1 1 n n 1 n 

Review of Records by Physician: 

Not defined in statutes or laws 

Periodic/Defined Intervals 

Strict/Daily 

o 

2 2 2 o 2 2 

1 

0 

Hospital Privileges in legislation 1 1 p 

CNMs can sign birth certificates 1 1 q 1 1 1 

Can refer directly for other health services 1 1 r 1 1 

Subtotals Legal 35 18 19 24 

Medicare 5 s 5 5 

Medicaid % x 10 0-10 10 t 10 8 t 10 

Language that permits reimb by 3rd party/HMO 15 15 u 15 15 u 

Any "direct access" legislation for women 5 v 5 v 

Subtotals Reimbursement 35 35 13 30 

Reimbursement 

5 5 

5 

continued 

186 
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for WV, WI, and WY, continued 

Optimal 

Scoring Category Points Score fn 

How received: w 

Automatic/No additional application required 4 4 

Application required 2 2 2 w 2 

Own DEA number 3 x 3 3 

CNM name on Rx pad 1 y 1 1 

Extent of Authority: z 

Full auth within scope of pract (Schedule II-V & legend) 16 16 16 z 

Extensive auth w/in scope (Schedule III-V and legend) 12 12 z 12 z 

Limited auth within scope (Schedule IV-V and legend) 8 

Restricted auth within scope (Schedule V and legend) 4 

Legends only 1 

Authority through: ^ 

In legislation/collaborative agrmnt not required 4 4 

Collab agrmnt defines privilege OR no phys involvemen 3 

Supervisory agreement defines privilege 2 

Defined Formulary (inclusive or exclusive) 1 1 1 

No Authority at all 0 

Durable medical equipment or devices 1 # 1 

Continuing Ed requirements 1 $ 1 1 

Subtotals Prescriptive Authority 30 20 25 23 

TOTAL POINTS 100 73 57 77 

WV WI WY 

Prescriptive Authority 

State 

3 3 

1 1 

4 

1 

1 1 

FOOT NOTES 

WEST VIRGINIA: 

a) No person shall hold themselves out as practicing nurse midwifery without a 

license 

b) Also annual certificate of registration 

m) Name and address of physician in collaboration must be submitted to 

Board of Examiners of Registered Professional Nurses 

n) Lay midwives licensed prior to 1973 were grandmothered under legislation 

but no subsequent licenses are issued to lay midwives (ACNM) 

o) Not defined 

v) Women's access to health care bill 1998 

z) Schedule lll limited to 72 hour supply 

WISCONSIN: 

c) Considered APNs for prescriptive authority only, governed as CNMs by different section of 

Nurse Practice Act 

e) CNM practice limited to approved facilities 

g) For prescriptive authority (effective 7/1/1998) 

t) Higher if qualifies as an NP or has a masters 

w) Prescriptive authority as APN. Certificate to Issue Prescription Orders issued to 

"prescribe, order or dispense", dispensing limited to samples or to facilities at 

least 30 miles from nearest pharmacy 

z) Significant limitations on Schedule ll 

continued 

187
Table F-1, continued 

Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 

New Index for WV, WI, and WY, continued 

WYOMING: 

a) "A specialty area of nurse practice shall be declared and the specialty 

title to be utilized shall be the title which is granted by ...", violation to use any 

words, titles, etc unless person is duly licensed 

b) Recognition and licensure 

I) BON is prohibited from limiting nurses from entering into practice with other 

health care professionals 

k) National Certification or masters required for licensure. No temporary 

certification but if masters prepared not necessary to be certified so could 

apply for license 

m) Written plan which outlines SOP and guidelines for collaboration 

n) No regulation prohibits lay midwifery practice, if limits to medical practice act are adhered 

to (midwifery exempted in medical practices as long as certain conditions are met) (ACNM) 

u) Any Willing Provider law covering all HMOs and PPOs 

z) Prescribe, provide, dispense 

REFERENCES 

Main Resources 

American College of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and 

Regulations 2000, Washington, DC, 2000. 

Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen Publications, Gaithersburg, Maryland, 1999. 

Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting, April 2001, Washington, DC. 

Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers, Intergovernmental Health Policy Project, 

The George Washington University, February 1994. 

Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for Advanced Practice Registered Nurses, 

Primary Care Resource Center, Intergovernmental Health Policy Project, The George Washington University, 

December 1995. 

Henderson T, Norris S, National Conference of State Legislators, Inc.

National Council of State Boards of Nursing, http://www.ncsbn.org.

National Council of State Boards of Nursing, The Regulation of Advanced Practice Registered Nurses 1997, 

Chicago, IL, 1998. 

Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative Issues Affecting Advanced Nursing 

Practice, The Nurse Practitioner 26(1):7-57. 

US Department of Justice, Drug Enforcement Administration, Diversion Control Program, 

http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html. 

Washburn University School of Law, http://www.washlaw.edu 

WEST VIRGINIA 

West Virginia RN Nurse Practice Act, http://www.ncsbn.org/search/documents/actsandregs/wvrn 

West Virginia Board of Examiners for Registered Professional Nurses, http://www.state.wv.us/nurses 

WISCONSIN 

Wisconsin State Legislature, http://www.legis.state.wi.us/rsb/code 

Wisconsin Nurses Association, http://www.wisconsinnurses.com 

WYOMING 

Wisconsin State Legislature, http://www.legis.state.wi.us/rsb/code 

Wisconsin Nurses Association, http://www.wisconsinnurses.com 

188
Appendix G. Field Work Details 

This appendix contains a discussion of some of the details of the field work conducted in seven 

States as part of this study. It includes the following subsections: 

• Introduction 

• The Field Work 

• Detailed Discussion of the Fieldwork 

• Summary of the Statutes and Regulations 

• Separate reports describing the fieldwork in each of the seven States in more detail are 

available by request. 

Introduction 

To understand the growth of NPs, PAs, and CNMs and their impact on the health of the 

American public, the Health Resources and Services Administration commissioned the Center 

for Health Workforce Studies at the State University of New York at Albany to perform research 

and report on the changes in the three professions across the decade. As pert of this study, the 

Albany Center contracted with the Regional Center for Health Workforce Studies in Illinois, the 

North Carolina Center for Nursing, the WWAMI Center for Health Workforce Studies, and the 

Center for Health Economics and Policy at the University of Texas Health Science Center at San 

Antonio to conduct field work to help understand how the three professions had changed 

between 1992 and 2000. The fieldwork was conducted in seven States (California, Illinois, New 

York, North Carolina, Ohio, Oregon and Texas) chosen for their geographic diversity and for the 

variety of legal and regulatory climates for the three professions. Of significant interest was the 

impact of the three professions on delivery of care to underserved populations. The fieldwork 

was also intended to inform and confirm the findings of the work on the research. 

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The Fieldwork 

Fieldwork was conducted by the centers in a variety of formats. Focus groups were convened in 

State capitals, large urban settings, and in rural locations across the fieldwork states to discuss 

legal and professional practice issues for the three professions. In some cases, individual 

telephone interviews occurred and in others, written communication was involved. 

Those interviewed in the fieldwork included State legislators and government regulators, State 

and local policymakers, educators of the three professions, representatives of primary care 

coordinating councils and area health education centers, representatives of the physician, nurse 

practitioner, certified nurse midwife and physician assistant provider communities, directors of 

community health clinics, mobile clinics, hospital systems, long term care facilities, and rural 

health projects. Participants were identified through a variety of means including identification 

by the Project Advisory Committee, by professional associations, by educational programs, 

through Internet resources and literature searches, and through other identified peers. Although 

the general experience of the research centers was that the physician profession was 

underrepresented in the fieldwork process, that professional group was invited to participate in 

all States and in all venues. Participants in the focus groups and interview process represented a 

wide range of constituents and provided broad based perspectives on the professions and their 

contributions to health care delivery. 

The fieldwork was structured by a list of questions generated by the cooperating research centers 

and by the Project Advisory Committee that was convened to monitor and direct the study 

process. A list of the questions can be found at the end of this appendix. 

In most cases, the fieldwork was conducted at defined locations through invitation by the project 

research staff. Discussions were structured to last over a morning or afternoon session and 

generally involved mixed groups of participants. However, the composition of the groups varied. 

For instance, in New York City, individual professional focus groups were hosted that included 

only nurse practitioners in one session, physician assistants in another, and certified nurse 

midwives in a third. In other locations, participants included representatives from a range of 

professional, regulatory, and organizational groups. One center found that individual physician 

interviews were the most convenient way to obtain the insights from that constituent group. 

Individual State fieldwork reports relied on a variety of published data for background 

information on the supply of the professions in the States, the educational programs available to 

the professions, the numbers of recent graduates from those educational programs, and the 

demographics of the States involved. The findings of the fieldwork are based heavily on the 

observations of those who provided insights to the discussions about the professional experiences 

of NPs, PAs, and CNMs in the various States. 

The Objectives of The Fieldwork 

Fieldwork was guided by the following broad objectives: 

• To assess the kinds of legislative and regulatory change that has occurred in 

individual States and to understand the effects of legislative change on actual 

practice environment; 

190
• To evaluate the process of change and to discover how regulatory change occurs 

within States; 

• To examine and assess the data available about the three professions both locally and 

nationally; 

• To understand how the environment in which the professions practice impacts the 

supply of the professions in a State; 

• To understand the relationships of these professionals to their peers and to other 

professions within the complex health care delivery systems in which services are 

provided; 

• To understand the influence of the three professions on delivery of health care; 

• To investigate how practice by the three professions affects care to underserved 

populations; 

• To understand what enables and conversely, what impedes provision of care by the 

professions within the individual State legal scopes of practice. 

Topics Covered in the Fieldwork 

A number of topics were covered in the interviews, discussions, and communications conducted 

as part of the field work. The primary topics were: 

The Elements of the Scoring System 

 Changes in Professional Practice 

 Economic Positioning and Reimbursement 

 Prescriptive Authority 

Relationships 

 Relationships with Physicians 

 Relationships Between the Professions 

The Professions 

 Effects on access to Care 

 Education of the Professions 

 Supply of the Profession 

Important themes and concepts covered in the seven states are summarized below. This summary 

is not meant to be exhaustive, but rather to introduce what the field work staff and the project 

staff seem to be the most important themes that inform the goals of the study. 

Changes in Professional Practice 

Informants underscored the importance that patient safety issues can have in motivating changes 

in professional practice for the three professions. Political and economic constituents who have a 

variety of interests to protect also heavily influence change. Both external and internal 

stakeholders can effectively move the legislative process with persistence and support. 

191
Achieving a workable balance among all constituents affected by change is often difficult with 

the process requiring compromise by many stakeholders. The resulting legislation may not be as 

comprehensive as interested parties might have initially advocated. Therefore, change often 

occurs incrementally. 

What is actually allowed in legislation may differ markedly from what actually happens when 

the new features are implemented in medical practice. Although legislation may enable practice, 

the conditions under which these professions actually work may be more confined than what is 

permitted in law. 

When statutes are permissive in nature, actual practice possibilities may not be fully used. 

Informants in Oregon cited certified nurse midwives who are, by law, permitted to practice 

autonomously in the State. However, in actual practice, autonomous practice rarely happens. 

Standards of patient care dictate that CNMs work collaboratively with a physician to provide 

back-up care in emergency situations so CNMs practice collaboratively. This is a State where 

actual practice is not generally as expansive as legislation allows. The needs of the patient and 

the provider moderate practice configurations within the legal parameters. 

On the other hand, established legal parameters may create restrictive boundaries. Fieldwork 

participants indicated that legislated professional practice impacts practice quite directly and 

definitively. The extent to which professional practice is defined in law is an example. 

In some practice acts, professional practice is broadly defined or expansively defined, as in 

Oregon. In others, it is so highly detailed in law that the performance of daily tasks is restricted. 

Statutes or rules which list, by task, the services that can be performed by a professional in 

practice provide no latitude for that practitioner or for his/her supervising or collaborating 

physician to make determinations about additional competencies that might be used within a 

practice to enhance provision of care for patients. In the State of Ohio, physician assistants are 

restricted by a very defined professional practice in statute and regulations. Physicians in the 

State were previously able to delegate tasks to untrained medical assistants that they were not 

permitted to delegate to physician assistants because of the restrictive language in law describing 

PA professional work. The State addressed this rather confusing situation with a recent opinion 

by the Attorney General that addresses medical delegation to licensed and unlicensed personnel. 

However, the situation provides an illuminating example of how detailed legislation can 

complicate actual practice. 

In some States, the PA, NP, or CNM and the cooperating, employing, or supervising physician 

define professional practice. These States require written or verbal agreements that detail the 

conditions and standards of practice for these professionals. In Ohio, in addition to the statutory 

and regulatory description of professional practice, physician assistants must work under 

protocols that are called “standard utilization plans” or under expanded “supplemental utilization 

plans” that further define and proscribe their practice. In California, NPs, PAs, and CNMs work 

under directives called “standardized procedures”. 

Actual provision of care to patients informs efforts to expand professional practice legislation in 

many States. Prescriptive authority for nurse practitioners in Ohio provides an example of how 

practice and legislation interface. NPs had no prescriptive authority in the State until quite 

recently. This prevented the State of Ohio from accessing Federal money available for targeted 

initiatives to increase access to care for underserved populations. In order to take advantage of 

these existing funding streams, the Ohio legislature enacted remedial enabling legislation in 1993 

192
to create a “pilot” program for NPs. Administered by three schools of nursing in the State and 

supervised through standard care arrangements, this program permitted qualified nurse 

practitioners to have prescriptive privileges in certain underserved settings in the State. This 

enabled practice in extended locations with broader populations. When NPs sought expanded 

prescriptive privilege in all practice venues several years later, the path to legislative approval 

was informed by the positive experiences from the pilot project. The demonstration project 

experience enabled change in legislation so that in 2002, NPs who meet certain requirements are 

granted prescriptive privileges for controlled substances in Schedule III to V within the 

parameters of a formulary and when supervised by a physician in all settings in the State. The 

pilot program also eased the expansion of Medicaid reimbursement for NPs in the State so that 

Medicaid now reimburses non-pilot program NPs for services to Medicaid eligible patients. Now 

that these privileges have been extended to all qualified NPs in the State, the pilot program will 

sunset. 

Practice acts are in need of refinement on a continuing basis as practice changes. New York 

informants indicate that enabling legislation for the three professions in the State was enacted 

about 30 years ago with the main purpose of enhancing primary care services for underserved 

populations. Informants suggest that now that the professions have moved to provision of 

specialty care in addition to primary health services, statutes and regulations should be revised to 

reflect the different conditions of more specialized practice. Since the existing laws and 

regulations mainly address the provision of primary care, they are not always applicable to 

practice in specialty areas. 

Professional practice legislation in a State can provide a competitive edge for one profession 

over another. In New York State, PAs must have all prescription orders co-signed by their 

supervising physician within 24 hours of issuance. This is not true for nurse practitioners 

working in the same State. Rural providers in New York suggest that it is easier to hire a nurse 

practitioner for remote practice because the conditions for practice are less demanding of the 

cooperating physician. In Ohio, the countersignature requirement for medical orders written by a 

physician assistant may be a deterrent to hiring. A physician considering the benefits of hiring 

one kind of professional or another might consider a nurse practitioner over a physician assistant 

since a NP is not subject to that same strict review requirement as a PA in Ohio. In California, 

other interesting circumstances affect hiring practices. The unionization of nurses (and therefore, 

nurse practitioners) in hospitals has led some hospitals to show a preference for hiring physician 

assistants who are not subject to strict union rules. 

Changes in professional practice have occurred at varying rates across the States and with 

varying emphasis. The practice environment for the professions has only recently evolved as 

substantially in Illinois as it has in other States over the last decade. Illinois is a State where a 

strong medical lobby represented by the national presence of the American Medical Association 

and the American Hospital Association has been more reluctant to provide expansion of practice 

in law for these professions. In 1998, Illinois was the last State to enact advanced practice 

nursing legislation that directly addressed practice by nurse practitioners and certified nurse 

midwives. Prior to that time, the professions had been regulated under the nurse practice act as 

registered nurses. Prescriptive authority for CNMs and NPs in the State is still “delegated” 

authority. Physician assistants in Illinois received delegated authority to prescribe some 

controlled substances in the year 2000. 

193
There are also variations in professional practice within States across the professions. Nurse 

midwives in New York were previously more confined by the language within their professional 

practice legislation than were nurse practitioners. Sekscenski rated New York as among the most 

hospitable environments for physician assistants and nurse practitioners in 1992 and these 

favorable conditions for PAs and NPs continue to prevail today. Nurse practitioners can own 

independent practices in the State and collaborate with physicians in many healthcare settings. 

Physician assistants work with physicians under indirect supervision guided by verbal or written 

agreements. In 1992, however, the practice environment for Certified Nurse Midwives was much 

more limited. CNMs have made significant progress within the State both legislatively and 

operationally. Presently, Certified Nurse Midwives in New York experience one of the top 

ranked practice environments in the 2000 index created as part of this study. In fact, New York 

State presently has more licensed midwives than any other State in the country except California. 

The privileges allowed the three professions within States also vary. In Ohio, Nurse Practitioners 

have been granted prescriptive authority for controlled substances in Schedule III to V if the NP 

meets certain educational and training requirements. Physician Assistants who practice more 

consistently with physicians in a medical paradigm rather than a nursing model have yet to attain 

these same privileges. Physician assistants have no prescriptive authority and may only convey a 

doctor’s medication orders in the State. The legislative dynamics in Ohio are particularly 

interesting since there is a strong medical lobby bolstered by the presence of seven medical 

education programs and the presence of a world-renowned medical center, the Cleveland Clinic. 

These political forces have seemingly been historically resistant to the expansion of privileges 

for the three professions. 

Another concern of informants in the seven States was that significant expansion of privileges 

for many professions over the last decade might actually result in some backlash from regulatory 

and medical communities. At times, physicians and their professional organizations react as if 

threatened by the incursions on their professional practice. Some wariness was expressed about 

continuing to seek further expansion of legal scope for these professions by some of the 

informants. At times, the physician community seems to be entrenched in resistance to further 

change because of the pressure on physicians to continually grant more privileges to other 

professions. 

Fieldwork participants suggested that researchers examine the differences in how professional 

practice legislation affects provision of and access to care in outpatient versus inpatient settings. 

Variation in requirements by setting results in different styles of practice for the professions 

depending on the location where services are provided. Informants indicated that they felt that 

the three professions were often viewed as being most appropriate in primary care outpatient 

settings where practice is differently configured than in acute care settings. In fact, all three 

professions practice in all kinds of settings, types of practice, and types of facilities. 

Hospital privileges (inpatient environments) provide an example of how complex the interplay 

between enabling legislation and practice environments can be. Although the law may permit 

hospitals to provide NPs, PAs, and CNMs with admitting privileges and may prohibit hospitals 

from discrimination in the awarding of admitting or staff privileges, in actual practice there is 

tremendous variation in the granting of privileges to the three professions. Even though legal 

supports are present in law, hospitals may choose, in voluntary environments, not to provide 

privileges to the professions. In situations where privileges are mandated, they may impose a coadmission regulation that requires a physician to co-admit with the NP, PA, or CNM. Such 

194
requirements effectively restrict direct patient admissions by the professions. Some hospitals 

offer admission privileges but require that every patient have a physician of record on file. 

Again, this requires direct physician involvement and restricts practice for the professionals. 

In Oregon, hospitals may not discriminate against NPs, PAs, and CNMs, but they may impose a 

co-admission requirement. Informants in the State suggest that obtaining staff privileges in rural 

hospitals is a major challenge. The standards to qualify for admitting privileges may require an 

internship. Nurse practitioners and nurse midwives do not meet those requirements since their 

educational process differs from that of physicians and PAs who are trained in a medical model, 

and often in inpatient settings. 

PAs also seem to have fewer problems gaining hospital privileges because of their traditional 

rapport with physicians. The relationship between physician and physician assistant is 

supervisory in nature and PAs are often viewed as members of a two-person team. This 

perception seems to help them to more easily gain hospital admitting privileges. As one 

informant suggested, PAs gain “more independence from their dependence on physicians”. 

Physician acceptance of PAs may actually result in more autonomy in practice since PAs are 

seen as less threatening. NP professional practice, although legally more autonomous than that 

for PAs, may cause more resistance or wariness from physicians when certain privileges, such as 

hospital admissions, are involved. 

PAs in New York suggest that external regulatory groups have some influence over how 

admitting privileges in hospitals are awarded. JCAHO, for instance, influences how hospitals 

credential staff. PAs and NPs are increasingly working in hospital environments where the 

numbers of resident physicians have been reduced by funding changes over the last decade. NPs 

and PAs are also working increasingly in specialty practices that admit to inpatient beds. 

Informants expressed concern that hospitals might potentially restrict professional practice for 

NPs and PAs in inpatient settings in order to comply with regulatory guidelines. Regulations 

from certifying and accrediting bodies could result in the creation of an environment that is too 

restrictive for effective practice for PAs and NPs. Examples of such restriction include authority 

to write medical or prescription orders for inpatients. 

The importance of these professions to the provision of inpatient care should not be ignored. PAs 

are substituting in some hospitals for residents who are no longer working on service for as many 

hours as was historically the custom. Additionally, Departments of Medicine are giving up 

residency positions in some medical education programs and physician assistants are filling the 

gaps in care caused by the lower number of resident positions. Restricted practice in hospitals 

can affect the efficiency of care in inpatient environments. As an example, a PA in Ohio cited the 

difficulties in ordering medication for inpatients as a burdensome process since, in that State, 

PAs may only convey physician’s direct orders. The example of a patient needing Tylenol and 

having to call the doctor in the early hours of the morning for authorization was offered as an 

instance where practice may be unduly restrictive. 

Economic Positioning and Reimbursement Issues 

Fieldwork participants in North Carolina suggested that the view of NPs, PAs, and CNMs as 

“providers of less expensive care” positions the professions poorly and puts them in competition 

with family practice doctors and other primary care physicians. There was consensus across the 

fieldwork States that this economic emphasis places the three professions at a disadvantage. The 

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professions prefer, instead, to foster a public image that emphasizes quality care provided 

efficiently and effectively. 

To completely ignore the economic advantage in hiring these professions would, however, be 

specious in an economy seeking reduction in cost as a primary objective. Cost of care is a 

universal concern for all stakeholders. The cost effectiveness of the professions is indisputable. 

Nurse practitioners, physician assistants, and certified nurse midwives are paid lower salaries 

than physicians. At certain levels of care when reimbursement is equal, the “profits” of a 

provider organization are increased when services are provided by lower paid and therefore, less 

costly providers. NPs, PAs, and CNMs suggest that placing only this kind of value on their work 

ignores the quality of the services they provide. One Texas informant described this as viewing 

these professions as “cash cows” to be used only to increase the volume of patient visits resulting 

in increased reimbursement and net profit. A more comprehensive view of the professions as 

providing “cost effective in a cost conscious health care environment” more accurately reflects 

the benefits of the care provided. 

The refusal of many managed care organizations to empanel these professionals (contract with 

NPs, PAs, and CNMs as participating providers) was another recurring issue across States in the 

various fieldwork experiences. The issue of managed care organizations providing ambivalent 

responses to these professions was discussed. Of particular note at this juncture in our report is 

the consistency between the philosophies advanced in nursing education and the managed care 

mantra of prevention and early diagnosis. Nursing professions have long fostered, as a primary 

goal, education of patients about prevention of illness and careful management of diagnosed 

illnesses. This nursing paradigm is precisely that espoused by the managed care model, which is 

constructed on the fundamental premise that prevention, early diagnosis of illness, and 

appropriate intervention with effective medical management is less expensive for the system. 

Although the motivations vary, positive patient outcomes achieved through provision of 

preventive services and effective management of chronic illness are the ultimate goal for both 

nursing professionals and MCOs (managed care organizations). However, even though the 

nursing professions and HMOs are in philosophical agreement about desired outcomes, there is a 

disconnect in the paths defined to achieve those goals. Managed care and preferred provider 

organizations have been reluctant to embrace NPs, PAs, and CNMs as full participants in the 

process of achieving these commonly valued outcomes by providing them with participation 

agreements as contracted approved professionals on provider panels. 

The educational aspects of medical encounters are part of the problem. Although patient 

education is an important part of prevention and management, payers have been reluctant to pay 

for those services. The economic accent in provision of care is on treating an acute or emergent 

condition as quickly and effectively as possible. There is little financial incentive in current 

reimbursement methodologies to address chronic issues or to provide patient management 

services. This emphasis is contrary to the practice paradigm for advanced nursing professions. 

Patient education requires extra time during an encounter and reduces the number of patients 

seen in a day. New York State informants indicate that this is an example of reimbursement 

driving the delivery of health care when delivery should be driven by best practices and patient 

need. The importance of finding a way to reimburse for educational services was a recurrent 

theme in all seven States. The expertise of nurses in providing education services is recognized 

by physicians as one of the many incentives to hire NPs and CNMs. 

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The lack of available reimbursement for patient education affects the clinical precepting of 

professionals in training in addition to the nature and duration of patient encounters. Training a 

student requires time from the clinical preceptor and many physicians and other professional 

providers feel they can no longer afford to take time from patient visits to educate clinicians in 

training. Clinicians who precept students often see reduced patient volumes with a concomitant 

reduction in reimbursable services. This situation contributes to the lack of available clinical 

rotations for students of the professions. 

Direct reimbursement to NPs and CNMs was another recurrent issue among fieldwork 

participants. Of the three professions, physician assistants were the least concerned about current 

reimbursement methodologies. Physician assistants are more aligned with supervising physicians 

and the profession is generally comfortable with current reimbursement mechanisms. 

Informants suggested that the prevailing reluctance by managed care organizations to pay NPs, 

PAs, and CNMs directly may be an indirect reverberation from the physician community. Many 

health maintenance organizations are associated with independent practice associations and 

managing boards dominated by physicians. These physicians recommend and establish the 

standards for participation by and payment of providers and they have been reluctant to place 

professions that are perceived as “lesser” on the same provider panels, which positions them with 

similar privileges as the physician community. 

There were some contradictions in the private and public behavior of physicians noted by 

fieldwork participants. Many physicians in private practice will hire NPs, CNMs, and PAs to 

augment their professional practice and their profits. An employing physician will lament that 

these employees are paid at lower rates by public payers, such as Medicare and Medicaid, who 

require that NPs, PAs and CNMs bill directly for the services they provide to patients. (Medicare 

only reimburses NPs and PAs at 85 percent of the physician fee schedule and CNMs at 65 

percent of that same schedule. Midwives are actively working to increase the Medicare 

reimbursement rate to make it more proportionately equal. Medicaid reimbursements vary by 

State from a low of about 70 percent of the physician fee schedule for these professions to as 

much as 100 percent in some locales.) Physicians express discontent with these proportionate 

reimbursements. 

However, physician attitudes are more ambivalent when payment is solicited from private third 

party insurers who allow NP, PA and CNM services to be billed using the physician identifier. 

This practice results in the actual provider of the service becoming effectively invisible to the 

payer. The need for change in this regard is seen as pressing by NPs and CNMs. Physicians, in 

this context, seem content with the status quo since they receive full reimbursement through their 

HMO participation regardless of who provided the service. 

Placing PAs, CNMs, and NPs on approved provider panels, raises some significant questions. 

Should these providers be paid at the same rates as physicians for services rendered at the same 

level of care? Lower payment rates would directly impact the income of their practices. And 

would such recognition foster moves to “independent” practice? These issues are surfacing in 

several States and are occupying a dominant place among practice issues for the professions 

across States. In New York, reimbursement was a common issue throughout all fieldwork 

discussions. This is a more complex issue than might appear, because lack of reimbursement is 

often a major barrier to access to and provision of care. 

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The inability to identify the actual provider of services on claims has implications for analysis of 

the practice characteristics and patterns of providing care. Such billing practices affect the ability 

of researchers to assess the effect of NPs, PAs, and CNMs on access to care for underserved 

populations. Data on the kinds of services provided and on the patient populations served are 

largely unavailable because NPs, PAs, and CNMs are not identified in billing documents as 

providers. Federal legislation under HIPAA will require a provider identifier for each 

professional involved in diagnosis or treatment. However, until third party payers actually 

require use of those provider identifiers and/or change participation and payment policies across 

the States, the lack of visibility for these professions will continue as will the inability to assess 

to whom care is provided, at what level of service, in what locations. 

This situation is further complicated when public and private payers contract in cooperative 

agreements to provide Medicaid Managed Care Plans, Child Health Insurance Plans, and 

Medicare risk contracts. In indemnity models, in which government payers traditionally operate, 

access to NPs, PAs, and CNMs is generally unimpeded. However, when government contracts 

with MCOs to administer these public programs, access is affected. MCOs limit patient access to 

a defined list of participating providers. If NPs, PAs, and CNMs are not on the lists, access to 

them is prohibited. 

In Oregon where the Oregon Health Plan engaged a number of insurers in their Medicaid 

Managed Care Plan, NPs were particularly well positioned by their autonomous professional 

practice to provide care in that system. They were able to contract with the managed care 

organizations as participating providers. Several of these insurers are now abandoning their 

contracts with Oregon Health, and NP practices in the State are jeopardized by the change in 

payers. If they do not have contracts with the remaining MCOs in the program, patients will be 

unable to access them. 

Throughout the fieldwork States, private payers appear to limit participation by NPs, PAs, and 

CNMs in their preferred provider plans or HMOs. This is an interesting issue since this study 

demonstrates direct statistical correlation between the growth of these professions within States 

and HMO penetration rates. One of the findings of this study is that the growth of the professions 

is directly correlated with the increasing penetration of HMOs during the decade. 

Even when insurance reimbursement is mandated in law through “any willing provider” 

legislation or through State insurance law providing that qualified providers must be paid for 

services provided if a physician would have been paid for the same service, the actual 

implementation of the law may differ from the legislative intent. There are many factors that 

affect compliance. For instance, ERISA, which is a Federal law, exempts companies who selfinsure from having to meet State insurance mandates. Federal law supersedes State legislation 

and ERISA-protected plans are not required to comply with State insurance mandates. 

Implementation of law is circumvented in a variety of other ways. HMOs may avoid the full 

force of insurance law by not contracting with NPs, PAs, and CNMs as plan providers. Insurance 

law does not require that HMOs contract with NPs, PAs, and CNMs, only that they pay them 

equitably when they are participating. This is another example of legislation providing 

supportive pathways for professions, but actual practice environments have an influence on the 

implementation of the law. There is significant variation in interpretation and application of law 

across States in regards to reimbursement. 

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North Carolina was cited as a good example of a State where private insurance policy and public 

health policy vary. Whereas there is strong public support and financial incentives in the public 

sector for these professions to practice in public health settings, private insurance carriers have 

been less willing to embrace the professions as participating providers. Although there was 

acknowledgement within the State that managed care penetration had fostered growth of the 

professions, there is still significant resistance by private payers to full recognition and 

empanelment. 

Prescriptive Authority 

Prescriptive authority is an important aspect of practice when meeting patient needs. Prescriptive 

authority includes writing prescriptions as well as the ability to provide samples or dispense 

medication in certain practice settings. Prescriptive authority has been a major focus for all of the 

professions over the decade since it enhances the efficiency of patient encounters. The ability to 

provide sample medications or to dispense medications also contributes to increased access. 

Dispensing authority for samples or other pharmaceuticals is particularly critical when services 

are provided to populations who cannot afford to buy needed drugs or when travel to a pharmacy 

is difficult because a drug store is not conveniently located. 

Expanded prescriptive authority was seen as a major issue for NPs in Texas. A restrictive 

formulary and the inability to prescribe controlled substances were identified as barriers to 

effective practice. NPs in the State have no prescriptive authority for scheduled drugs and work 

from a limited formulary when prescribing legend drugs. This is seen as an impediment to 

effective care. 

Physician Assistants in Ohio also view the lack of prescriptive authority as a major impediment 

in practice particularly in inpatient environments. The requirements for physician participation 

were seen as unduly restrictive. Physician assistants have only delegated prescriptive authority in 

the State. 

The reluctance of HMOs to empanel NPs, PAs, and CNMs occasionally impedes the use of their 

prescriptive authority in States where they have been granted those privileges. When an HMO 

provides coverage for prescriptions, there may be a requirement that the script be written or 

signed by a participating physician. Scripts authored by professionals, such as NPs, PAs, and 

CNMs, who are not listed on the panels of MCOs may not be reimbursed to the pharmacy or the 

patient. These circumstances often force a countersignature by the collaborating physician. This 

is the kind of detail in practice environments that impedes and complicates provision of care. 

In New York State, informants suggested that prescriptive authority is important to many 

professions and that NPs were fortunate to have the privilege. NP educators cited the example of 

licensed psychologists studying in NP programs in the State in order to gain prescriptive 

privileges for their practices. In Ohio, when prescriptive authority was discussed, informants 

suggested that prescriptive authority was difficult to obtain and that physician advocacy groups 

are inclined to favor permitting only professions which require graduate education to have 

prescriptive authority. 

Relationships with Physicians 

There was general agreement in the fieldwork States that professional acceptance for nurse 

practitioners, certified nurse midwives and physician assistants is important to efficient and 

effective practice. The ideal relationships in health care environments were seen as symbiotic, 

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interdependent, and team based. However, it is considered important that physicians are not 

always positioned as leaders of the team. Representatives of the three professions recognize that 

physicians have advanced training and education that qualifies them for more complex medical 

decision-making. However, the professions, jointly and individually, seek recognition for the 

special expertise they have developed through defined education, special training, and (often) 

extensive experience. Independence versus dependence was seen as an archaic way of framing 

relationships within the system. Interdependence seemed a preferable descriptive term. 

The impact of the professions on the character of health care practices varies. Physicians suggest 

that they sometimes end up with different, more complicated practices when they collaborate 

with NPs, PAs, and CNMs who are providing acute and preventive care to patients. Since these 

services tend to be largely primary and straightforward, physicians in practices that include NPs, 

PAs, or CNMs often see greater numbers of patients with complex medical conditions and comorbidities that may be more chronic in nature and more difficult to manage. This has 

ramifications for the practice and for the professionals who are providing care. 

Of concern to informants in several States was the legal relationship between physicians and 

NPs, PAs, and CNMs. In both Ohio and New York, informants were concerned about the 

assumption that doctors are liable for the acts of the professionals in their employ. 

Representatives of the three professions in those States indicate that they are licensed 

professionals with independent responsibility for their work performed within the scope of their 

training and education. The assumption of “vicarious liability” by physicians for the practice of 

NPs, PAs, and CNMs jeopardizes positive relationships between the professions and physicians 

and alters their participation in patient care. 

Professional informants suggest that, although there are similarities in their interactions with 

physicians, each of the professions has a unique relationship that is affected by their particular 

training and skills. Whereas NPs and PAs tend to fill complementary roles in physician practices, 

CNMs, although also complementary to physicians, often have a somewhat more competitive 

relationship with physicians. In certain locations they compete both directly and indirectly with 

family care physicians for patients. 

Primary care physicians who provide obstetrical services and CNMs compete indirectly for the 

same target population of childbearing women who are at minimum risk for complications in 

both rural and urban settings. CNMs also compete with family physicians for back-up obstetrical 

specialist physicians to provide help with difficult deliveries and at-risk obstetrical patients. 

Another source of competition is the requirement by health maintenance organizations that each 

patient have a primary care gatekeeper who will screen and refer for higher-level services only as 

needed. This issue was discussed in the Texas and North Carolina fieldwork as an aspect of the 

present health care delivery system that affects the provider of care. HMO gatekeepers include 

family practice doctors who may be reluctant to refer obstetrical patients to Ob/Gyn practices for 

normal obstetrical care or for well woman gynecological care, since they can provide those 

services. These patients are traditionally the patients seen by CNMs. Since CNMs are most often 

employed in Ob/Gyn practices, this further limits CNM access to patients. This is not as 

important in some States, such as New York, where direct access to obstetrician/gynecologists 

without referral by their primary care physician is legislated by the State. Women can determine 

independently from whom they will seek maternity or gynecological care. 

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The same issues arise with Medicaid insured patients in States where Medicaid contracts to 

HMOs. Access to nurse midwives may be limited under those circumstances. This would not 

seem to be an issue because Medicaid insured patients often have difficulty finding providers 

because of the generally lower reimbursement rates. However, in some States, the opposite is 

true. Interestingly, informants in both Ohio and New York suggest that State Medicaid programs 

have built waivers for at-risk childbearing women that reimburse providers at very close to the 

commercial rates, which makes Medicaid-insured pregnant women attractive to private practice 

doctors. This experience suggests that an increase in Medicaid rates for other services might also 

enhance access for Medicaid-eligible patients needing other kinds of services. 

Relationships between the Professions 

NPs and PAs are more likely to compete between themselves for available practice positions. 

Although the three professions have many common attributes that are made more obvious by 

their positioning in the health care delivery system, they are undoubtedly different professions. 

Each of the professions is affected variously by the environments in which work is performed, by 

the education and training of the professional, and by the relationships with other providers. The 

greatest overlap in function seems to occur between PAs and NPs whose roles in private practice 

and hospital settings are somewhat similar. However, the models on which they base their 

practices are quite distinct. 

An informant in Oregon described these differences as “diverging practice paradigms – 

independence from physicians and adherence to the nursing model for NPs versus dependence 

and adoption of the medical model for PAs.” However, the variations in practice orientation may 

only be apparent to those with extensive knowledge of the differences between NP and PA 

training and education. Informants suggest that most patients receiving care from an NP or PA 

would find it difficult initially to differentiate the kind of services being provided. 

CNMs are less competitive with NPs and PAs. Although CNMs are legally enabled by advanced 

practice nurse (APN) legislation in many States, their practices are usually more limited than that 

of NPs. Certified nurse midwives generally treat women of childbearing age. This positions them 

to be less competitive with physician assistants and nurse practitioners for practice positions than 

NPs and PAs are with each other. Although women’s health nurse practitioners provide similar 

services, the numbers in this NP specialty are not yet substantial. NPs and PAs often work with a 

more diverse population than CNMs, i.e., both males and females, pediatric populations, etc. 

This helps to reduce the competition. 

It must be noted that this competition is often subtle. The individual professions understand there 

is danger inherent in undermining another of the similar professions. There is recognition that 

competition needs to be kept in check. However, informants commented that competition for 

clinical training sites currently exists between NPs and PAs. Additionally, concern was 

expressed in several States that, should an oversupply of these providers be present, there is 

likelihood of competition developing in the workplace for jobs. Some of that competition may 

already exist in a variety of markets across the States as noted variously by fieldwork informants. 

Participants in the fieldwork discussions in the various States indicate that it is important that 

these professions be given recognition and appropriate positioning within the delivery system. 

Providers who encounter resistance to their roles from peers, other providers, payers or the 

public are more likely to leave the professions because of lack of acceptance. It is important for 

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these professionals to work in cooperative, collaborative environments where their skills and 

talents are understood and used effectively. 

Access to Care 

Definitive assessment of the impact of these professions on access to care continues to be 

elusive. In all States, professionals suggest that access to care is enhanced by the use of these 

providers in a myriad of settings. Researchers were reminded by representatives of the 

professions in the various States that the professions share common roots grounded in the 

provision of primary health care to patients with limited access. The professions were all 

conceived and legally enabled because of national policy concerns about meeting the health care 

needs of underserved populations. In fact, informants suggested that for many years NPs, PAs, 

and CNMs worked in underserved settings in greater numbers proportionately than physicians. 

For instance, in North Carolina, NPs and PAs originally practiced only in health clinics and 

public health settings. They have subsequently moved into more mainstream practice 

environments as the professions have become more recognized. 

Initially, Federal reimbursement policy encouraged practice in underserved settings by limiting 

public reimbursement for services to special public health, institutional and clinic settings. The 

1997 Balanced Budget Act (BBA) equalized reimbursement across all settings providing less of 

an incentive to remain in locations designated as underserved. The BBA extended a 10 percent 

bonus for physicians practicing in identified underserved locations but did not extend that same 

benefit to NPs, PAs, and CNMs practicing in the same settings. Informants suggested that this is 

counterproductive to Federal policy, which is to encourage NPs, PAs, and CNMs to work with 

populations who have limited access to health services. 

The present increase in specialization for PAs and NPs was cited as concerning. As these 

professions move to specialty and sub-specialty care, the opportunities for practice with needy 

populations are reduced. Since specialist physicians are not found in great numbers among the 

medically underserved or in health professional shortage areas, NPs, PAs, and CNM s with 

whom specialist physicians collaborate are also less likely to be found in those settings. 

Determining if care is being provided to the underserved by NPs, PAs, and CNMs is a complex 

undertaking, which has less than satisfying results. Informants suggest that underserved 

populations can be found in almost any medical setting and limiting assessment of provision of 

care to particular locations was of concern. As an example, in New York, PAs discussed 

institutionally-based care in a non-HPSA certified facility. This is not identified as care to the 

underserved even though there is a significant provision of care to underserved individuals in 

such settings. There are many “needy” patients who would be classified as underserved who 

receive treatment in community hospitals, major medical centers, and even private physician 

offices. Care to patients who are uninsured or publicly insured is provided by medical 

professionals who work in settings not traditionally identified as meeting the needs of 

underserved populations. However, the care provided is often considerable and should be 

identified as contributing to access. Evaluating to whom, by whom, where, and how this care is 

provided is difficult and may involve the need to track patients on public assistance rather than 

provider data to ascertain care patterns. In any case, when considering the issue of how to 

increase access, these settings should not be ignored. 

Once again, informants reiterate that reimbursement affects access to care. Uninsured 

populations and publicly insured populations do not always have the same access as privately 

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insured patients. One informant described the Balanced Budget Act of 1997 as “a house of 

cards”. Rural health was greatly affected by its implementation since clinics with greater than 50 

beds were no longer supported. Larger clinics closed causing some professionals working in 

underserved areas to leave for other positions. 

In Texas, informants indicate that reimbursement is an especially difficult issue in rural areas. 

Lack of funding for services to needy populations is a disincentive to practice in locations where 

those populations are located. Reimbursement policies impact both utilization by patients and 

recruitment of professionals since payment for services is a fundamental issue for all medical 

professionals. 

Informants suggest that many newer graduates are not interested in working with underserved 

populations. They are more interested in practicing where the money is. Students were viewed as 

being savvier and more aggressive than they had been in the past. This change in orientation 

affects the pool of providers who might have traditionally sought work with the underserved. 

According to informants, public initiatives that encourage professionals to work in health 

professions shortage areas encounter difficulty because decisions about where to practice are 

often driven by personal preferences. Individuals make decisions about where they will practice 

based on personal background, personal goals, family obligations, and practice opportunities. 

Economics is an important factor, for instance, for new graduates who have loans to repay. 

Educational indebtedness may obligate the new professional to find a position that is lucrative 

versus one that may be more professionally satisfying but doesn’t pay as well. These are 

exogenous factors over which policymakers have little control. 

However, there was a feeling among fieldwork participants that there are several policy 

initiatives that encourage professionals with potential interest to practice in underserved 

environments. Examples of valued inducements would be expanded loan repayment programs, 

expansion of the number of clinical rotations for student professionals available in underserved 

settings, and targeted efforts to recruit new professionals into underserved areas. These are 

considered important strategies for increasing the numbers of NPs, CNMs, and PAs available to 

provide primary care to underserved populations. 

An example of a successful collaborative effort to increase the numbers of PAs, CNMs, and NPs 

in underserved settings, is an educational initiative called Partnerships in Training, funded by the 

Robert Wood Johnson Foundation. The program has as its objectives, “the development and 

implementation of a regional educational system for nurse practitioners, physician assistants, and 

certified nurse midwives involving a culturally competent interdisciplinary curriculum, distance 

learning modalities, and shared resources among the education partners.”39 The program 

presently operates in eight States, Arkansas, California, Colorado, Michigan, Minnesota, New 

Mexico, North Carolina, and Wisconsin.40 In California, the partnership consortium is operated 

in collaboration with several area health education centers as well as several college and 

university programs. Potential NPs, PAs, and CNMs are recruited from underserved 

communities and then educated in or near those same communities. The program encourages 

students to remain in their home communities after training. A recent survey by the California 

Center for Health Workforce Studies, indicates that 39 percent of NPs, 39 percent of PAs, and 47 

39 Partnerships for Training, San Joaquin Valley Health Consortium, http://www.sjvhc.org/programs/pft/index.htm. 40 Partnerships for Training Projects, http://www.uchsc.edu/ahec/mapp/about/pft.htm. 

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percent of CNMs surveyed in the State presently practice in underserved settings.41 Informants 

credit the program with encouraging new providers who have increased access to care. 

Informants were concerned about the move by various States and the Federal government to 

increase educational requirements for the professions and the concomitant impact on the 

professional workforce. New York informants suggest that a requirement for graduate education 

for the professions changes the complexion of the professional programs and places these 

professional credentials out of the reach of some potential candidates. Concern was expressed 

that the cost of elevated educational requirements would adversely affect the diversity of 

graduates from programs and further impede the creation of a culturally competent workforce. 

Liberal loan repayment programs or scholarship support for diverse students would provide at 

least a partial remedy. 

The environment in which the professional is educated and trained affects employment 

opportunities and prospects. Changes in educational models may also affect choice of work after 

graduation. Physician assistants in New York indicate that present educational models affect 

practice patterns. PA education in New York was initially provided mostly in community 

programs with clinical rotations provided in community settings. This subtly encouraged 

graduating PAs to work in community settings by acquainting them with those workplaces. 

Many PA programs in the State have now turned to the medical training model in which clinical 

training occurs in hospitals and large medical centers. Graduates from these programs are not as 

likely to have connections to a community health provider and may be less inclined to return to 

community healthcare settings when seeking employment. 

At Duke University in North Carolina, which housed the first physician assistant training 

program in the country, the PA program uses Title VII funding to support clinical rotations in 

medically underserved areas. Several informants suggested that providing clinical rotations in a 

variety of environments was critical to the process of placing the professions in settings where 

they are exposed to needy populations. Students sometimes discover that they particularly enjoy 

working in those environments and will choose to work in them after graduation because of their 

exposure to the opportunity during training. 

Legislation affects access to care in very direct ways. For instance, State requirements for the 

professions to have supervisory relationships with physicians affects practice in rural locations. 

In Ohio, a physician assistant or an NP with prescriptive authority must work within 60 minutes 

travel time of his/her supervising physician. This requirement significantly limits practice 

opportunities for PAs and NPs in the far reaches of Appalachia where supervising physicians are 

largely unavailable. PAs and NPs might contribute to care for those populations if the distance 

limitations did not exist. 

Special circumstances tend to influence CNMs and the locations where they choose to practice. 

CNMs are especially constrained in rural areas because of their need for backup physicians in 

case of obstetrical emergency. In many areas of very rural North Carolina there are no physicians 

to provide on-call services, so CNMs are prevented from working in such places. Although the 

relationship with physicians constrains the NPs and PAs, most patients of NPs and PAs are able 

to travel to a physician to whom they have been referred for more complex care, even if distance 

41 Office of Statewide Health Planning and Development and the Center for California Health Workforce Studies at 

the University of California, San Francisco, “Nurse Practitioners, Physician Assistants, & Certified Nurse Midwives 

in California”, San Francisco, California, Spring 2000. 

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is great. However, obstetrical patients are limited by their emergent medical situations from 

traveling long distances to any provider. Collaborating physicians must be available to come to 

the obstetrical patient for delivery rather than having the patient come to them. CNMs, therefore, 

encounter very particular professional difficulties. 

In Oregon, informants suggested that CNMs are rarely available in rural practice even though 

Medicaid guarantees coverage for services provided for the poor in underserved areas in the 

State. CNMs in Oregon suggested that opportunities to work in rural areas are scarce largely due 

to opposition from rural physicians who face an oversupply of obstetricians in the State. Some 

CNMs in Oregon have even chosen not to provide obstetrical services and instead provide only 

well-woman gynecological services in their practices. 

Informants viewed provision of health care in rural environments as a special issue since the 

physical aspects of the rural environment affect practice. The example of prescriptive authority 

was provided to illustrate how location can influence practice. Expanded prescriptive authority 

for nurse practitioners is of no use in a location where there is no pharmacy available to fill the 

prescription, unless the NP also has the ability to dispense samples or to dispense medications. 

These conditions require rural providers to be creative and collaborative. A rural provider must 

establish extensive networks and negotiate a variety of cooperative agreements with other 

providers including pharmacies in order to operate effectively and provide all needed services. 

Dispensing authority for nurse practitioners in such locations is one such solution. Clinics could 

then stock many needed medications to meet the needs of the service population. 

The unique circumstances of rural communities require and inspire unique responses to limiting 

situations. In upstate New York, for instance, emergency rooms in very small, qualifying 

hospitals (under 15,000 visits per year) are staffed solely by physician assistants. This is effective 

in providing rural populations with access to care in emergency situations. 

Another example of creative collaboration in rural New York State is a health care cooperative 

which involves the participation of a variety of stakeholders. A family care physician conceived 

and implemented a creative model for delivery of care to small rural communities in the 

Adirondack Mountains. Town governments in a variety of locations participate in cooperative 

arrangements with a medical network, the Hudson Headwaters Health Network, by providing 

buildings and other support services for the medical practices. The managing healthcare 

organization staffs the facilities with providers on an ongoing basis. The resulting health 

consortium provides a range of physician, PA, NP, and CNM professional services in each 

practice location. This strategy has resulted in an effective delivery system that manages a broad 

network of providers working cooperatively in an extensive geographic area. Several locations 

are staffed strictly by one or another of the three professions with physicians traveling to a clinic 

only on particular day(s) of the week to see complicated cases and to review caseloads with the 

staff providers. A network of specialist physicians and local hospitals has been developed to 

provide referral mechanisms for more complicated care for patients living in these remote areas. 

The consortium covers a significant geographic area and serves a large number of patients. 

The characteristics of rural practice dictate different responses to provider resources. In Oregon, 

informants suggested that rural practices have more difficulty predicting the need for providers 

and for assuring that they can afford them since patient caseload and insurance is unpredictable 

and the pool of potential patients is smaller. 

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In Ohio, physicians in a rural area suggested that employing other providers creates special 

challenges. Ohio has particularly strict rules about the supervision of PAs. A physician must 

review the PA’s medical orders for patients on an ongoing basis. One rural physician informant 

suggested that, although hiring a PA had been wonderful for his patients because it had increased 

opportunities for them to see a medical provider on a more frequent basis, his caseload had 

effectively doubled because of record review requirements. He is not only required to document 

the records of his patients on a daily basis, but he is also required to review his PA’s notations in 

patient records. Additionally, the severity of his patient caseload has increased since his PA sees 

many of the patients with routine illness or needing preventive services. The physician’s 

schedule now includes a high number of patients with more complicated or chronic problems. 

Although it is helpful that he is more available to these patients, the time required from him for 

their medical management has also increased. As a result, the physician was finding his practice 

more burdensome even though he had more help. When considering whether to hire another 

provider for his practice in the future, the informant felt he would give serious consideration to 

hiring a physician who would be more independent in practice and not require ongoing 

supervision. 

Rural populations are also seen as having different characteristics. In Texas, informants indicate 

there are a number of illegal aliens in the State who are afraid to seek care for fear of deportation. 

Farm and migrant workers are also unable to take time off from work to see a health care 

provider. In fact, many border workers travel to Mexico for care since medical services are 

available in that country at more convenient hours for the working poor. Getting to medical 

appointments is also an issue for people without private transportation. In Texas, mobile health 

care clinics or clinicians who can travel to the colonias in the evening to provide care and 

medications enable access. 

Cultural competency among providers is also an issue. There are not enough providers and there 

are even fewer who are culturally diverse or culturally competent. Texas informants cited the 

shortage of physician providers in underserved areas as a reason for the absence of nurse 

practitioners, nurse midwives, and physician assistants who must be supervised in practice. If 

doctors are not available for supervised practice then NPs, PAs, and CNMs are not able to 

practice. 

Some States have implemented special statutory and regulatory provisions that create exceptions 

for professionals who wish to practice in underserved areas. For purposes of this study, we have 

identified these states as “dual scope of practice environments”. The legal requirements for 

supervision or collaboration by a physician, the parameters for prescriptive authority and 

reimbursement are expanded in defined locations to encourage practice with medically 

underserved populations or in health professional shortage areas. Texas and Oregon are 

examples of States where these kinds of provisions exist. 

In Oregon, physician assistants are permitted to apply for remote supervision by a physician, 

which is intended to extend provision of care to medically disadvantaged areas. PAs must apply 

for this privilege and must have the ability to directly communicate with a supervising physician 

in case of need. Additionally, the ratio of physician-to-physician assistants is expanded in the 

State to allow every physician in an underserved area or facility to supervise up to 4 PAs, rather 

than the 2 PAs allowed in traditional practice settings. 

206
In Texas, physician assistants can practice with underserved populations under special 

circumstances that permit the PA and supervising physician more latitude. The physician must 

visit the clinic site every 10 days, perform a review of at least 10 percent of the medical records 

on a timely basis, and be available by telecommunication on a continuing basis. 

Government programs dedicated to increasing access are important. In rural upstate New York, a 

prenatal program, which initially provided care only in the early stages of pregnancy has been 

quite successful and has now expanded to include a full range of obstetrical services. CNMs and 

NPs provide much of the care to pregnant and parenting women in the program, which reaches 

some of the more remote mountain communities of the State. 

Increasing provider incentives to work in rural areas is also important. Oregon provides a $5,000 

yearly income tax credit to rural providers including NPs, PAs, and CNMs. Financial incentives 

might create an inducement to more remote practice. 

Education Programs 

The following table reflects the number of educational programs in each of the fieldwork States 

for each of the three professions and includes the total number of graduates from those programs 

in each of the professions in the year 2000. 

An analysis of the educational programs in these seven States indicates that 95.6 percent of the 

Nurse Practitioner programs award a masters degree, 2.2 percent award a certificate, and 64.8 

percent offer a post-master’s certificate. Over 82 percent of the programs offer study to become a 

family nurse practitioner, with a total of 28 areas of specialization and sub-specialization being 

offered within the 91 programs examined. These include such areas of study as neonatal, 

cardiovascular, neurocognitive, palliative care, and child and adolescent health nurse 

practitioner. 

The majority of PA programs in the fieldwork States award bachelor’s degrees (54.1 percent) 

while 35.1 percent award master’s, 8.1 percent award associate degrees, and 10.8 percent offer a 

certificate. Most PA programs focus on primary care study, but 5.4 percent of the programs offer 

specialty study in surgery with a total of 8 possible areas of specialization including orthopedic, 

cardiothoracic, and neurosurgery physician assistant programs. 

The number of education programs for the three professions has grown over the decade. Many 

States have not, until recently, had education programs for these professions. When programs did 

exist, they were often insufficient in number or size to supply the needs of the State. PAs have 

only been educated and trained in Oregon since 1995. Presently, there are two programs 

providing PA education in that State, and only two programs training NPs. CNMs are trained in a 

single program. According to the State Area Health Education Center, 52 percent of the NPs in 

the State were trained elsewhere, largely in California, Washington, or on the east coast. [Oregon 

fieldwork reference AHECS, 2000]. 

In North Carolina where the physician assistant profession began, NPs were legally recognized 

as early as 1970. However, education programs for nurse practitioners lagged in that State. Six 

programs for NPs have opened there in the past 10 years. North Carolina has implemented some 

public policy that fosters the use of these professionals in underserved areas, including funding 

incentives with public dollars for health centers that employ them. 

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Table G-1 

Numbers of Educational Programs and Graduates in 

2000 for Nurse Practitioners, Physician Assistants, and 

Certified Nurse Midwives in the Seven Fieldwork States

State # NP Ed 

Progs 

# NP 

Grads+ 

# PA Ed 

Progs 

# PA 

Grads^ 

# CNM Ed 

Progs 

# CNM 

Grads* 

California 21 385 6 331 7 51 

Illinois 10 162 4 218 1 14 

New York 26 773 14 579 5 82 

North Carolina 6 80 2 131 1 6 

Ohio 9 228 4 90 3 6 

Oregon 2 38 2 37 1 16 

Texas 17 260 5 334 4 21 

+ National Organization of Nurse Practitioner Faculties and the American Association of Colleges of 

Nursing, 1999-2000 Enrollment and Graduations. 

^ American Academy of Physician Assistants 

* The American College of Nurse Midwives 

Federal programs, which provide funding to train more of these professionals, have contributed 

to the proliferation of educational programs. One of the conditions for access to and continuation 

of Federal funding for training programs is documentation of growth in the numbers of students. 

Several informants across States indicate that an infusion of funds for educational programs 

occurred at the same time that registered nurses were looking for expanded practice 

opportunities. These circumstances worked synergistically to create a growing supply of advance 

practice nurses over the last decade. 

Presently, there is concern about further expansion in the number of educational programs for the 

professions. Containment is seen as desirable for several reasons. Controlling the number of 

available slots for new students permits education institutions to be more selective in admitting 

students. This in turn supports the development and implementation of important educational 

standards which helps to maintain the high quality of practitioners in the professions. These are 

important considerations in any strategy to avoid an oversupply of competently trained 

professionals. This strategy may also restrict access to the professions, which could result in 

higher salaries and therefore higher costs of care. 

New York informants discussed the importance of primary health care education to the 

professions since much of the care provided, regardless of setting or specialty is primary in 

nature. Discussion among informants revealed that even when NPs and PAs are working in 

specialty environments, they are still providing a high volume of primary care services to 

patients. These professionals need to be broadly trained to acquire the sets of skills needed to 

provide both primary care and specialty care services. 

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Access to educational programs is a critical issue for potential students according to those who 

participated in discussions in New York State. Most CNM programs in New York are located in 

or near New York City making them inaccessible to working nurses in other areas of the State. 

The need for programs that are geographically dispersed was discussed. A nurse midwifery 

program located near New York City at the State University of New York, Stony Brook has a 

distance-learning component, which allows students to visit the school for orientation and then to 

do their academic work on line while doing their clinical placements in their respective 

communities under the supervision of regional clinical faculty. Even though the program is 

located on Long Island, 85 percent of the students are in upstate New York. 

Programs for distance learning may be particularly important for increasing the opportunities 

available to a profession and for encouraging graduates to remain in underserved communities. 

The Frontier School of Midwifery in Hyden, Kentucky was cited across the fieldwork States as 

an exemplary model for professional education. The focus of the program is the education of 

professionals for practice in locations where there is medical need. This is one of the two oldest 

midwifery schools in the country having been founded in 1925 by Mary Breckenridge, the 

granddaughter of a U.S. vice-president. Nurse midwives trained in England initially staffed the 

Frontier Nursing Service that eventually evolved into an educational program. 

The educational program component of the Frontier Service, the Community Based NurseMidwifery Education Program, is a graduate-level distance-learning program, now associated 

with Case Western Reserve University in Ohio, which allows students to remain in their own 

communities for clinical training while completing on-line course work. Several trips to 

Kentucky for training with clinical faculty are required during the 2 year program. Regional 

faculty representatives monitor student placements and oversee the clinical practicums in the 

home communities. 

Interdisciplinary training in medical institutions was seen by informants in New York as a 

desirable way to introduce the professions to each other and to physicians-in-training and to 

increase understanding of the competencies of the respective professions. Interdisciplinary 

training is also an important way of educating professionals about effective collaborative 

relationships and recognizing and respecting the unique skills that each of the professions brings 

to the delivery of health care. New York and California informants discussed productive 

interfaces that occurred within interdisciplinary training programs in their States. Nurse 

midwives who taught resident physicians felt that the experience helped new doctors to 

understand and respect the profession. A physician assistant working in emergency rooms who 

trained residents indicated that there were many positive outcomes from her experience including 

recognition of the substantive skills of the PA by the physicians. 

The importance of training in clinical rotations with other professionals was a recurring theme. 

In Ohio and in Illinois, informants suggested that they encountered more resistance in their 

professional practices as NPs, CNMs, and PAs from international medical graduates. Many of 

these physicians come from countries where NPs and PAs do not exist. Foreign grads are 

unfamiliar with these providers because they have not encountered them in their training and 

they often lack a clear understanding of the skills and competencies of NPs, PAs, and CNMs. 

Finding clinical placements for students is seen as a particularly difficult issue. As previously 

stated, there is presently no funding mechanism to cover the cost of internships for the three 

professions. This is especially true for certified nurse midwives. There are not as many 

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institutional supports for midwifery programs as there are for nurse practitioner and physician 

assistants. These circumstances make it especially difficult to find clinical placements for 

midwives-in-training. Physician assistant training programs are often located in or affiliated with 

medical centers where clinical opportunities are readily available. One nurse midwife educator in 

New York suggested that she had never denied acceptance to her program to a qualified student 

for lack of space within the program but she had refused acceptance to students because of lack 

of availability of clinical placements in which to train. 

Informants in New York feel that clinical placements in public health clinics are an excellent 

way of identifying or screening competent and compatible PAs and NPs as prospective hires. 

However, lack of a source for reimbursement for time spent educating new professionals is a 

significant impediment for clinics interested in offering clinical rotations. There was strong 

agreement among informants that time spent precepting should be reimbursable since it requires 

a substantial investment of resources for the person supervising the clinical rotation. Previously, 

rate differentials helped professionals absorb some of the costs of clinical precepting. Whereas it 

was possible, in the past, to cross-subsidize some of these activities under previous health care 

reimbursement streams, new payment methodologies presently make this impossible. 

Equalization of payment rates across payers has occurred so that there are no longer higher rates 

available to help offset unreimbursed education costs in medical settings. 

Although Federal policy is important to address the needs of the medically underserved, State 

policy also has very direct effects on access to care. State responses to the needs of underserved 

populations vary. North Carolina is a State that identified and responded to some of its public 

health issues. The Governor of the State convened a conference to address the high maternalinfant mortality and morbidity rates early in the decade. One of the strategies identified to 

address the problem was to fund nurse midwives to work in critically underserved areas of the 

State. This initiative resulted in a 1990 mandate for the establishment of a nurse midwifery 

education program at East Carolina University (ECU) to train professional nurses for this role. 

The Office of Rural Health manages the program that resulted in improvements to obstetrical 

care for the targeted populations. Prior to that time, there was no midwifery education program 

in the State. Nurse midwives are now trained in both the ECU program and through the Frontier 

School of Nurse Midwifery in Kentucky. 

The aging of faculty is a particular problem for educational programs, as is the ongoing need for 

new PhD faculty to staff graduate programs. This is particularly relevant because so many of the 

programs were created or grew quickly in response to the availability of increased funding. 

Faculty may not have been as well prepared as desirable in the years when significant program 

growth occurred because faculty were needed immediately to staff developing programs. 

Another factor that affects the qualifications and the number of faculty is the competing 

employment environment. It is very difficult to attract NPs from practice in direct care settings to 

staff educational programs when salaries are not competitive in academic institutions. Another 

problem for NP faculty is that they are often required to meet the same educational standards as 

academic faculty in other departments of the college or university where the nursing programs 

are located. In fact, a nursing professor may need very different competencies than a professor in 

a purely academic program. A nurse faculty member with significant clinical experience and 

technical training enhances a nursing education program in much the same way that a professor 

with an advanced degree might enhance an academic program. Informants supported the concept 

that clinical experience should be given greater weight in faculty appointment processes. 

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Elevating the level of required educational attainment for the three professions, although seen as 

easing the path to such expanded privileges as prescriptive authority, is also seen as an 

impediment to the education of a culturally competent workforce. A requirement for a graduate 

degree might limit potential professionals coming from poorer backgrounds who are without the 

funds for extensive education. However, education at the graduate level is seen as critical for 

increasing professional practice. In a discussion in Ohio, nurse practitioners suggested that the 

reason that prescriptive authority was legislated for NPs in the State (and not for other 

professions) was that master’s education is required for certification for NP practice and 

legislators and advocates are more comfortable with expanding privilege when professional 

education is extensive. 

Texas informants suggested that the requirement for a master’s education for NPs was an 

impediment in border towns because it reduces opportunities to recruit a minority workforce. On 

the other hand, advanced degrees are perceived to provide more credibility and respect for the 

profession. A solution might be educational loan programs to help bridge the resource gap for 

some minority populations. Existing loan programs are perceived to be extremely limited in 

amount of funding and in repayment options. 

Educational loan repayment incentives are important for the professions and help to increase 

access to care. Students with scholarships who are required to work in underserved areas as a 

condition of repayment sometimes remain in those locations after their commitment is fulfilled. 

PA informants in New York indicate that clinicians may find greater opportunity to work with a 

wider variety of patients and more latitude in public health settings and health clinics that serve 

indigent and underserved populations. This makes employment in those settings more appealing 

to professionals who are challenged by such environments. PA practice in mainstream or 

traditional settings may be limited to performing more routine tasks like histories and physicals 

while in clinic locations, practice is often more varied and challenging. It is important that states 

not be overly restrictive about the settings in which graduating students work to repay loans. If 

clinical opportunities are too limited in designated settings, students won’t access the 

scholarships, further limiting exposure to underserved populations. 

Some education programs, like Cornell University’s PA program in New York City, recruit PA 

students directly from underserved areas. The Cornell program fosters the education of physician 

assistants who are interested in returning to their home areas to work. The Partnerships in 

Training Program of the Robert Wood Johnson Foundation also encourages the education of 

individuals from underserved areas. The program operates in several states including California 

and North Carolina and targets student recruits from medically underserved areas and diverse 

populations. Students are encouraged to remain in or return to their home communities to work 

after graduation. 

Another strategy is to place students in settings with underserved populations by offering clinical 

rotations in community hospitals and health clinics. These opportunities are important because 

they provide exposure to the special characteristics of those settings. These practice 

environments are appealing to some graduating professionals because of the expanded practice 

opportunities available. Informants suggest however, that initially new graduates may want to 

practice in larger environments to gain some professional experience and to reinforce the skills 

introduced but not mastered in their educational programs. This does not preclude a professional 

from eventually choosing to work in an underserved area or with medically underserved 

211
populations. However, informants acknowledge that there is some danger that, once established 

in a practice setting, a professional might be more reluctant to move. 

Supply of the Professions 

Fieldwork in this project was fueled by the idea that hospitable legal environments foster growth 

in the supply of these health professions within a State. A greater supply of providers would 

then, hypothetically, result in an increase in access to care for underserved populations. The issue 

of the supply of these health professions generated interesting responses from fieldwork 

participants. 

The following counts (the most recent available when the compilation was done) suggest that the 

numbers of these professionals working in the fieldwork States vary considerably. The mix of 

the professions is also quite various across the seven States. Counts of Nurse Midwives and 

Nurse Practitioners in Illinois were unavailable for 1999 since they have only recently been 

licensed separately in that State. In prior years, they were regulated as registered nurses. 

Informants in the fieldwork States indicate that there is presently a relatively sufficient supply of 

PA, NP, and CNM professionals. Informants suggest that lack of supply is most probably not the 

issue of concern when discussing access. Rather, it is important to consider how these 

professionals distribute themselves in health care settings across the States. Statistics gathered 

for this study suggest that, unlike physicians who demonstrate greater density in urban areas, the 

three professions appear to be more evenly distributed across States. However, informants also 

suggest that the practice patterns of NPs, PAs, and CNMs tend to parallel those of physicians. 

Legal requirements for physician supervision and collaboration tend to support the hypothesis 

that these professions will be found in the same places as we find physicians. Since legal 

supervision or collaboration requires the cooperation of physicians, it is to be expected that 

practice patterns are analogous. 

Table G-2 

Numbers of Nurse Practitioners, Physician Assistants 

And Certified Nurse Midwives in the Seven Fieldwork States 

State 

Nurse 

Practitioners 

1999* 

Physician 

Assistants 2001^ 

Certified Nurse 

Midwives 1999* 

California 9,259 3,929 1,006 

Illinois N/A 923 N/A 

New York 9,607 4,894 895 

North Carolina 1,613 2,125 130 

Ohio 2,074 1,162 264 

Oregon 1,470 371 197 

Texas 3,831 2,511 331 

* Data obtained by the University of Wisconsin from the National Council of State Boards of 

Nursing, from individual State Boards of Nursing, or the Regulating Agency within a State. 

^ American Academy of Physician Assistants, Census Report 2001. 

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Complicating the interlinking of the professions in practice settings is the move to specialty 

certifications within the professions. The development of the three professions mirrors the 

evolution of the physician workforce. NPs, PAs, and CNMs, although rooted in primary care, are 

now expanding into specialty practices as the supply of providers has increased and as the 

demand for their services has become more pervasive across the spectrum of care. Specialty 

physicians are more likely to be attached to major medical centers located in urban environments 

where there is a greater population resource. NPs, PAs, and CNMs who collaborate with those 

specialists are, thus, also in those environments. 

The distribution of professionals is difficult to influence or predict. There is a strong element of 

personal choice that contributes to the selection of work settings. There are several elements that 

affect personal choice: 

• A professional who enjoys an urban environment will probably choose to live and to 

work in an urban environment, just as one who wishes to be in a rural setting will seek 

employment there. 

• The availability of jobs also affects the distribution of these professions. The location of 

healthcare delivery facilities and organizations determines job opportunity and there is 

often a concentration of health systems in urban areas. Obviously, professionals work 

where the jobs are most available. 

• Professionals may distribute differently depending on the legal limitations on practice in 

a State. Most States require supervision or collaboration with a physician which plainly 

dictates physical proximity. A few States even place legislated limits on distance or travel 

time that separates the physician from the professionals with whom collaboration occurs. 

• The choice of location in which to practice may be attributed to patient demand. There 

are greater supplies of potential patients and more opportunities for successful practice in 

larger metropolitan areas. 

• The shortage of nurses has also had an effect on the supply of potential nurse 

practitioners and nurse midwives. Many RNs presently work overtime to meet the 

staffing needs of their employers. This prevents them from making the commitment to 

further their education because they simply do not have the extra time to devote to study. 

As well, the higher salaries and the overtime pay currently available to an RN diminish 

the financial incentives of advanced practice. 

Whatever the reasons a concentration of professionals may occur in a certain environment, 

quality healthcare is still unavailable to some populations in rural and urban areas. 

The issue of supply of the three professions is also complicated. Some informants in Illinois 

suggest that there is job market saturation in that State for these professions, but other informants 

suggest that the situation is not that simplistic. There are significant regional variations in job 

markets that are difficult to understand and the reasons are many and multi-faceted. 

PAs in New York indicate that the profession has addressed the threat of oversupply by moving 

into new areas of specialization, thereby, creating new demand. PAs in the State have found jobs 

in pain management, in oncology, and in other specialties where PAs would not traditionally be 

found, thus moving the profession into new areas of expertise. Contributing to specialization is 

the fact that there are a number of PAs who have come from other health professions with 

213
backgrounds that provide them with special talents. For instance, medical examiners hire 

physician assistants with medical technology backgrounds since they have a good understanding 

of laboratory forensics, pathology, etc. PA providers in New York saw the profession in that 

State as growing with these increased opportunities. 

Offsetting this growth is the closure of some education programs New York. PAs expect to see 

stabilization in the number of graduates over the coming years. There is a feeling that new 

graduates are more aggressive in finding new opportunities for practice as they begin their 

careers than had been the case with past PA graduates. 

NP informants in New York suggest that there may be job market saturation for NPs in the State. 

Educators observe that graduates are leaving New York in order to find employment. Some NP 

informants there expressed concerns that the profession is out-pricing itself and that increased 

wage compression will create demand for physicians. If an experienced NP is priced at just 

below the wage level for an inexperienced physician, the employer may consider hiring a 

physician who is more legally autonomous and can provide care at a higher level. The balance 

between affordability and extent of professional practice must be maintained. 

Also in New York, informants expressed concern about the lower numbers of young people who 

are entering nursing. Since NPs are often experienced nurses looking for expanded practice 

opportunities, the reduced numbers of incoming nurses is likely to affect future supply. More 

supports for nursing staff which encourages new recruits including such things as more 

autonomy for nurses at patient bedsides, more release time for advanced or continuing nursing 

education, and fewer mandates requiring compliance by nursing staff would be helpful. 

Summary of the Statutes and Regulations 

The discussion that follows summarizes the statutes and regulations related to professional 

practice for the three professions as presented by the various informants contacted during the 

field work. 

Nurse Practitioners 

California 

• Licensed in California Business and Professional Code 

• Regulated by the Board of Registered Nurses in the State Department of Consumer 

Affairs 

• Title Protected 1985 

• Professional practice same as that for RNs but expanded by standardized procedures in 

law contained in written supervisory agreement that is site specific. 

• National certification required 

• Supervisory relationship with physicians but collaborative practice as well 

• Effective in 1997 can “furnish or order” Schedule III (under patient specific protocols) to 

V controlled substances except for NPs in solo practice 

214
• Maximum of four NPs to one supervising physician 

• Medicaid in the State reimburses Family and Pediatric Nurse Practitioners as primary 

care providers. 

• Effective in 2001, the NPs name will appear on drug containers along with the 

supervising physician’s name. 

Illinois 

• Until1998, NPs were regulated as a special class of registered nurses. In that year, the 

legislature passed the Advanced Practice Nursing Act. 

• Licensure available to NPs beginning in 2001. 

• Practice is limited to direction from physician but no employment relationship is required 

• Periodic review of records is required 

• Title protected 

• The last State to enact specific legislation regarding Nurse Practitioners 

• National certification and master’s degree required for licensure. 

• Now regulated by Advanced Practice Nursing Board 

• Collaborative agreement with physician determines prescriptive authority but it is 

delegated authority only. NPs may prescribe, dispense and administer Schedule III to V 

controlled substances. 

New York 

• NPs are certified to practice in the State since 1989 and are regulated by the Department 

of Education and the Board of Nursing (this is unique among State’s regulatory authority) 

• National certification is an option but not required 

• Nurse Practitioners are defined as independent practitioners 

• Collaborative relationship with physicians based on written agreement between the 

physician and NP 

• Collaborative agreement addresses practice coverage, record review and practice 

protocols and must be kept at the practice site for inspection by the State as requested 

• Review of patient records must occur not less than every 3 months 

• Nurse Practitioners are qualified as primary care gatekeepers under the State’s Medicaid 

Managed Care Law 

• NPs must obtain a certificate to prescribe in the State after demonstration that they have 

completed an educational program with a pharmacy component. 

• NPs have authority to prescribe Schedule II to V controlled substances in the State 

North Carolina 

• A joint subcommittee of the Board of Nursing and the Board of Medicine regulates NPs. 

215
• Since 1993, third party reimbursement has been available to NPs 

• Rules changed in 1994 to allow NPs to prescribe controlled substances and to expand 

prescriptive privileges for refills of legend drugs. At that time, the previous formulary 

was discarded in favor of practice specific drug and device agreements between physician 

and NP. Controlled substances may be prescribed for a period of only 30 days. NPs can 

procure, prescribe, order, compound and dispense drugs in the State. 

• Since 1999, an NP can sign any form that would require the signature of a physician. 

• The statutes contain some collaborative language but a supervising physician is still a 

legal requirement. 

• Review of records is achieved periodically through a Quality Improvement Process 

between the NP and supervising doctor. 

Ohio 

• NPs are regulated by the Board of Nursing 

• Licensed since 1997 as a distinct category of Advanced Practice Nurse. Prior to that time 

they were allowed to use titles obtained from educational program completion but were 

regulated as registered nurses. 

• Certificate of authority to practice as NP issued when all conditions for certification are 

met. 

• Standard care arrangements with physicians are a requirement to practice along with a 

regular review of patient care outcomes. 

• Effective 2001, all new NPs must have a master’s degree. 

• Prescriptive authority for controlled substances in Schedule III to V since 2000 but 

limited to a formulary of drugs and devices. Schedule II may be prescribed under very 

limited conditions such as to terminally ill patients. Prescriptive authority governed by a 

Joint Commission of the Boards of Nursing, Medicine, and Pharmacy. 

• Since 1997, Medicaid reimbursement is available to Family, Pediatric, Adult and 

Women’s Health NPs. 

Oregon 

• NPs are title protected 

• NPs are issued a certificate of special competency to practice 

• A master’s degree is required 

• Considered independent providers. 

• Prescriptive Authority for Schedule II to V from an exclusionary formulary. NPs may 

write prescriptions but may dispense medications only in geographically remote areas. 

• Mandated third party reimbursement. 

• Medicaid reimbursement at 100 percent of physician fee schedule (unusual) 

216
• Fair practice legislation in the State permits hospitals to grant admitting privileges to NPs 

but hospitals may and often do enforce a co-admission requirement (MD must also 

admit.) 

• NPs can sign death certificates in the State. 

Texas 

• NPs are approved to practice in the State. 

• Statutory language is both supervisory and collaborative depending on the setting in 

which services are to be provided and on whether prescriptive authority is being 

exercised. 

• The Board of Nursing in the State regulates NPs but the Board of Medical Examiners 

influences their prescriptive authority. 

• Effective in 2003, a master’s degree will be required for NPs (this is consistent with 

Federal legislation implementing the same requirement.) 

• A written practice agreement between physician and NP must be maintained on site. 

• A physician cannot collaborate with more than three NPs in the State. 

• Hospital privileges are defined in law as clinical privileging conditions. 

• Prescriptive authority is limited to legend drugs in the State. The supervisory agreement 

with the physician defines the privilege that is site specific and includes medically 

underserved areas, health professional shortage areas, facility based sites and private 

medical practices. 

Certified Nurse Midwives 

California 

 Regulated by the Board of Registered Nursing with a Midwifery Committee in the State 

Department of Consumer Affairs. 

 Title protected. 

 Receive a certificate to practice when qualified by education, national certification and 

licensure as a nurse in the State. 

 The Medical Board of California under different rules and regulations regulates nonnurse midwives in the State. 

 Professional practice for CNMs in the State includes obstetrical, postpartum, and family 

planning services. 

 Mode of practice is indirect supervision by a physician under standardized procedures 

and protocols developed between CNM and collaborating physicians and facilities. 

 CNMs who meet specific additional criteria may prescribe Schedule III (only under 

patient specific protocols) to V controlled substances and legend drugs. 

 No more than four nurse midwives may collaborate with one physician at any time. 

 Mandated reimbursement by third party payers in the State. 

217
Illinois 

 CNMs are regulated as advanced practice nurses in the State. 

 Master’s degree is required effective in 2001. 

 Delegated prescriptive authority for Schedule III to V controlled substances. CNMS may 

receive and dispense samples through the authority given them in their collaborative 

agreement. 

New York 

 CNMs are regulated under different statutory and regulatory guidelines than NPs in the 

State of New York. 

 They are licensed by a Board of Midwifery in the Department of Education with a 

broadly defined professional practice that includes not only obstetrical and postpartum 

care but also well-woman gynecological care. 

 Statutory language is collaborative and consultative. It is possible for CNMs to practice 

independently in the State. 

 CNMs can refer directly for other health care services as needed by their patients. 

 Direct entry midwives are licensed under the same practice act in the State but are subject 

to different regulations. 

 Public Health Law in the States require that women have direct access to care from 

ob/gyn physicians and nurse midwives. 

 Medicaid provides 100 percent reimbursement of physician fee schedule to CNMs in the 

State. 

 CNMs have prescriptive authority to prescribe Schedule II to V and legend drugs in the 

State. 

North Carolina 

 A Midwifery Joint Committee that includes members of the Board of Nursing, the Board 

of Medicine and CNMs regulates CNMs under the Nurse Midwifery Act of 1983. 

 CNMs in the State operate under a professional practice as defined by the professional 

association. 

 The statutes contain collaborative language but CNMs must have supervising physicians 

in the State. 

 Legislation in 1993 required that third party payers reimburse CNMs for services. 

 1994 Legislation gave CNMs prescriptive authority for legend drugs and controlled 

substances in Schedules II to V. This privilege is defined in the supervisory agreement 

between the CNM and the physician. 

 Medicaid reimbursement for services is at 100 percent of the physician fee schedule. 

218
Ohio 

 Since 1997, CNMs are authorized to practice in the State as a category of advanced 

practice nurse. 

 CNMs are regulated by the Board of Nursing with no specific midwifery representation. 

 National certification is required for authorization to practice. 

 A master’s degree is required effective in 2001. 

 Collaborative language is included in the statutes. 

 CNMs practice under standard care arrangements in the State, which are written 

protocols developed by the CNM and the collaborating physician. 

 Professional practice includes well women gynecological care as well as obstetrical and 

postpartum care. 

 Regular review by the physician of care outcomes is required. 

 There is a legal prohibition for hospitals to discriminate against midwives if maternity 

services are provided at the facility. 

 Legislation in 2000 gave CNMs prescriptive authority for legend drugs and Schedule II 

to V controlled substances. 

 There is mandated third party reimbursement in the State for nurse midwifery services if 

an employer provided health benefits to workers. 

 It is presently illegal in the State to provide services for compensation as a DEM. 

Oregon 

 CNMs are a category of nurse practitioner. 

 National certification is not required but licensure as a nurse is. 

 CNMs provide independent care in consultation or collaboration with other providers. 

 Prescriptive authority, hospital admitting privileges and insurance reimbursement are all 

governed by NP statutory and regulatory limitations. CNMs may prescribe legend drugs 

and controlled substances in Schedule III to V and may dispense those drugs in 

geographically remote locations. 

 A master’s degree is required in the State. 

 Regulated by the Board of Nursing with no specific midwifery representation. 

 The title of Nurse Practitioner is protected in the State, title used is dictated by education. 

 CNMS are issued a certificate of special competency when requirements for licensure are 

met. 

 A 1993 statute governs direct entry midwifery. 

Texas 

 CNMs are approved for practice according to the statutory language and authorized to 

practice in regulation. 

219
 They are required to use the title specified on their authorization and may not call 

themselves Advanced Practice Nurses. 

 The Board of Nursing regulates them with involvement by the Board of Medicine when 

prescriptive authority is involved. 

 Regulations speak of independence or collaboration for nursing aspects of care but 

require that protocols or written physician authorization provide authority for medical 

aspects of care. These protocols need not be detailed. 

 Midwifery Act of 1993 provides for the regulation of non-nurse midwives by the Texas 

Board of Midwifery 

 A 1999 State law provides due process privileges when hospitals extend privileges to 

Advanced Practice Nurses. 

 Prescriptive authority is limited to legend drugs in eligible sites such as HPSAs, MUAs, 

primary care locations and health facilities except that Nurse Midwives can provide one 

or more doses of controlled substances during intrapartum care if so directed by a 

physician. 

Physician Assistants 

California 

3⁄4 Enabled to practice in the State since 1971. 

3⁄4 Regulated by a Physician Assistant Committee of the Medical Board of California in the 

State Department of Consumer Affairs. 

3⁄4 Separate legislation to cover osteopathic physician assistants (this legislation will soon 

sunset in the State.) 

3⁄4 Title protected since 1996 

3⁄4 Since 1997, PAs are licensed in the State. 

3⁄4 Must practice under continuous supervision of a physician. 

3⁄4 Physician may only supervise two PAs at any one time. 

3⁄4 Physician assistants may transmit a drug order in the State for legend drugs and under 

patient specific orders from the supervising physician for controlled substances in 

Schedule II to V. 

Illinois 

3⁄4 Initial PA legislation enacted in 1976 

3⁄4 Since 1987, PAs are licensed in the State 

3⁄4 National certification is required. 

3⁄4 A seven member Physician Assistant Committee makes regulatory recommendations to 

the Medical Licensing Board in the Illinois Department of Professional Regulation 

3⁄4 As of 1997 ratio of 1 physician to two PAs in force but there is no limit on alternate 

supervising physicians 

220
3⁄4 In 1994, legislation required written guidelines for practice to be developed between the 

PA and the supervising physician. 

3⁄4 Delegated prescriptive authority for Schedules III to V. PAs may prescribe, dispense and 

administer if so delegated 

New York 

3⁄4 PAs are registered in the State (RPA-C) but are issued a license. 

3⁄4 Professional practice for PAs in the State is defined by the individual PA and the 

supervising physician in accordance with the education and training of both. 

3⁄4 PAs are supervised under indirect supervision in all locations 

3⁄4 PAs are reimbursed at 100 percent of the Medicaid fee schedule for physician services. 

3⁄4 PAs may prescribe legend drugs and controlled substances in Schedule II to V. 

3⁄4 A physician may only supervise 2 PAs in private practice. Greater ratios are allowed in 

special settings. 

North Carolina 

3⁄4 PA profession born in North Carolina at Duke University in late 1960s. 

3⁄4 PAs in the State are licensed by and registered with the North Carolina Medical Board. 

3⁄4 A change in rules governing PAs occurred in 1993 easing some of the restriction on 

practice. 

3⁄4 PAs are not listed on MCO panels and are considered medical assistants in hospitals 

rather than as part of the medical staff. 

3⁄4 Supervision requirement for PAs requires that all outpatient charts be reviewed within 7 

days. 

3⁄4 Payment for services performed by a PA within professional practice is mandated in law. 

3⁄4 Prescriptive authority is defined in the supervisory agreement reached by the physician 

and PA and may include not only legend drugs but also Schedule II to V controlled 

substances with Schedule II and III being limited to a 30 day supply only. 

3⁄4 Since 1993, a seat on the North Carolina Medical Board is available to a PA. 

Ohio 

3⁄4 PAs in the State are issued a certificate of registration which is a license to practice. 

3⁄4 A Physician Assistant Committee that is appointed by the medical board regulates PAs in 

the State. 

3⁄4 National certification is required 

3⁄4 State regulations require that a standard utilization plan be approved for the PA and the 

supervising physician. Any further extension of that standard plan must be filed with the 

board for approval as a supplemental utilization plan. 

221
3⁄4 PAs practice under continuous supervision in the State but may not practice more than 60 

minutes travel time from their supervising physician. 

3⁄4 A physician may not supervise more than 2 PAs at any one time. 

3⁄4 PAs may not prescribe, dispense, or order medication in the State but they may carry out 

physician’s orders for medication. 

3⁄4 Medicaid reimburses PA services at 85 percent of the physician fee schedule in the State. 

Oregon 

3⁄4 PAs are licensed in the State and title protected. They are obligated to register as a PA if 

they are employed as a PA. 

3⁄4 A PA committee of the Board of Medical Examiners regulates PAs in the State. 

3⁄4 The physician and the PA define the professional practice options for the PA in the State 

but the Board of Medical Examiners must approve the written agreement between the 

parties. Under certain circumstances remote supervision is permitted to extend care to 

medically disadvantaged areas as long as direct communication is available. This 

privilege must be specifically applied for. 

3⁄4 Physicians may supervise two PAs (up to four in underserved areas) and PAs may have 

four supervising physicians. 

3⁄4 Prescriptive authority is defined in the written agreement between physician and PA and 

may include Schedule III to V prescription drugs. PAs may administer and dispense 

drugs in emergency situations. 

3⁄4 A regular review of the PAs work is required. 

Texas 

3⁄4 PAs are licensed in the State 

3⁄4 The Texas State Board of PA Examiners regulates PAs. 

3⁄4 The PA and physician must notify the boards of their employment agreement and include 

their names, addresses, licenses and phone numbers on the notification. 

3⁄4 A physician may supervise up to 3 PAs or their full-time equivalent. 

3⁄4 Prescription authority is limited to legend drugs in the State and must be authorized 

through delegation of the physician or through standing medical orders and is limited to 

the primary practice site and certain underserved locations. 

3⁄4 PAs may supply drugs in properly labeled containers in public health clinics. 

222
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