A guide to understanding state restrictions on NP practice

Two ways restrictive regulations can impact medical groups’ NP utilization

Supervision requirements deter physicians from NP utilization

Many physicians doubt NPs' clinical preparedness and consider them a burden and a risk. State requirements can exacerbate this sentiment by imposing complex and time-intensive NP supervision requirements.

Excessive review burden and liability

Many states specify how often a collaborating physician must review NP activities. For example, in Missouri, collaborating physicians must review 10% of NP-provided care services and 20% of cases in which the NP wrote a prescription–both on a biweekly basis.

Demonstrating compliance with such requirements can take up substantial physician time. In addition, physicians who are required to sign off on NP decisions may be more concerned about legal exposure.

Restrictions on physician mobility

Several states require physicians to provide on-site supervision to NPs. In Alabama, the collaborating physician must be present at an NP's practice site for at least 10% of the NP's scheduled hours. This can disrupt the physician’s schedule, particularly in rural areas.

Limited scope restrains medical groups from maximizing NP skillset

Even when physicians are open to collaboration, state regulations can limit where and how medical groups deploy NPs to meet clinical and strategic goals.


Limited geographic flexibility

Several states, such as Georgia, require NPs to practice within a specified distance of their collaborating physician, restraining use of NPs in areas experiencing a physician shortage.


Narrow scope of inpatient practice

Some states, including California and Ohio, prohibit NPs from admitting patients to the hospital. In many states, such as Missouri, NPs are subject to the credentialing institution’s bylaws—as a result, traditional medical staff and hospitals often limit the scope of an NP’s practice to varying degrees within a state.


Patient care disruptions

In states that require heavy physician involvement, patients may receive unnecessary and fragmented care. For example, after an NP in Missouri sees a new patient or makes major care plan changes, a physician must see the patient within two weeks. This can confuse patients, create opportunity for error, and occupy valuable appointment slots with duplicative work.

In states where NPs may prescribe only limited quantities or types of medication, such as Kentucky, medical groups may struggle to ensure timely patient access to needed medications.


Cap on NP recruitment

Several states limit the number of NPs each physician may work with. Although most medical groups have not yet felt the impact of this limitation, these restrictions affect their ability to develop new team care models that require a larger NP workforce.

How does your state’s environment compare?

State regulations vary drastically. In Washington state—where NPs may practice independently of physicians—a medical group can allow NPs to run full-service clinics to provide access to a rural population. By contrast, NPs in Florida cannot fill that role because they require physicians sign-off on treatment plans and cannot prescribe controlled drugs.



NP Practice Appendix

Learn More

Barton Associates's free tracker allows users to visually compare scope-of-practice in each state. In addition, a report by the National Governor Association offers a more detailed comparison of state regulations.

Continue Reading

Our blog post offers strategies to help medical groups minimize the effects of these regulations using NP hiring and deployment strategies.

Supervision requirements deter physicians from NP utilization

Many physicians doubt NPs' clinical preparedness and consider them a burden and a risk. State requirements can exacerbate this sentiment by imposing complex and time-intensive NP supervision requirements.

Excessive review burden and liability

Many states specify how often a collaborating physician must review NP activities. For example, in Missouri, collaborating physicians must review 10% of NP-provided care services and 20% of cases in which the NP wrote a prescription–both on a biweekly basis.

Demonstrating compliance with such requirements can take up substantial physician time. In addition, physicians who are required to sign off on NP decisions may be more concerned about legal exposure.

Restrictions on physician mobility

Several states require physicians to provide on-site supervision to NPs. In Alabama, the collaborating physician must be present at an NP's practice site for at least 10% of the NP's scheduled hours. This can disrupt the physician’s schedule, particularly in rural areas.

Limited scope restrains medical groups from maximizing NP skillset

Even when physicians are open to collaboration, state regulations can limit where and how medical groups deploy NPs to meet clinical and strategic goals.


Limited geographic flexibility

Several states, such as Georgia, require NPs to practice within a specified distance of their collaborating physician, restraining use of NPs in areas experiencing a physician shortage.


Narrow scope of inpatient practice

Some states, including California and Ohio, prohibit NPs from admitting patients to the hospital. In many states, such as Missouri, NPs are subject to the credentialing institution’s bylaws—as a result, traditional medical staff and hospitals often limit the scope of an NP’s practice to varying degrees within a state.


Patient care disruptions

In states that require heavy physician involvement, patients may receive unnecessary and fragmented care. For example, after an NP in Missouri sees a new patient or makes major care plan changes, a physician must see the patient within two weeks. This can confuse patients, create opportunity for error, and occupy valuable appointment slots with duplicative work.

In states where NPs may prescribe only limited quantities or types of medication, such as Kentucky, medical groups may struggle to ensure timely patient access to needed medications.


Cap on NP recruitment

Several states limit the number of NPs each physician may work with. Although most medical groups have not yet felt the impact of this limitation, these restrictions affect their ability to develop new team care models that require a larger NP workforce.

How does your state’s environment compare?

State regulations vary drastically. In Washington state—where NPs may practice independently of physicians—a medical group can allow NPs to run full-service clinics to provide access to a rural population. By contrast, NPs in Florida cannot fill that role because they require physicians sign-off on treatment plans and cannot prescribe controlled drugs.



NP Practice Appendix

Learn More

Barton Associates's free tracker allows users to visually compare scope-of-practice in each state. In addition, a report by the National Governor Association offers a more detailed comparison of state regulations.

Continue Reading

Our blog post offers strategies to help medical groups minimize the effects of these regulations using NP hiring and deployment strategies.