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

• Introduction
• Study objectives
• Study components
• Remainder of report

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;
• 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.

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.

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.

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 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.

• 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

• 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