As physician shortages grow more acute in the United States, Canada, and the United Kingdom, advanced practice providers (APPs), including nurse practitioners and physician assistants, are stepping in to fill the gap. Both professions, along with other APPs such as certified nurse midwives, are growing as their scope of practice is increasing in some areas.
The Association of American Medical Colleges projects a US physician shortage of up to 86,000 physicians by 2036. In Canada, the average number of new medical school graduates lags significantly behind those of other developed countries, with Canada producing 7.5 new doctors per 100,000 people, just over half of the average number in developed countries, which is 14.2 new doctors per 100,000 people. Compared to Europe, England has 3.2 physicians per 1,000 people, significantly lower than the EU average of 3.9 physicians per 1,000 people. To reach that average, England would need 40,000 more physicians.
In primary care, physician shortages are worse. The National Center for Health Workforce Analysis estimates a current shortage of 20,800 primary care physicians, which could double by 2036. Canada’s primary care physician shortage is even more acute, with an aging workforce retiring at a time when fewer Canadian medical students are specializing in primary care. The Canadian federal government estimates a shortage of nearly 20,000 primary care physicians by 2031. Shortages of primary care physicians in England mean that the average primary care doctor is caring for 17% more patients in 2024 than in 2015, according to the BBC.
In the absence of an increase in the number of physicians, which is unlikely, national health services and health systems in the US, UK, and Canada are turning to APPs. The influx of APPs raises several issues, including whether and how their scope of practice is increasing, so called top of license initiatives, the potential for a change in medical professional liability risk and risk assessments, and disputes over scope of practice and license expansion between physicians’ groups and APP groups.
To get a sense of how APP scope of practice and risks are evolving, Inside Medical Liability Online spoke with a group of experts in the US, UK, and Canada, including:
- Michael Devlin, Head of Professional Standards and Liaison, The Medical Defence Union (MDU)
- Laura Kline, MBA, CPCU, CIC, Regional Operating Officer of the Northeast Region, The Doctors Company
- Larry Smith, Vice President of Risk Management, Medstar Health
- W. Todd Watkins, BSc (Hon), MD, CCFP, Associate Chief Executive Officer, Canadian Medical Protective Association (CMPA)
- Kristi Wright, Senior Vice President of Claims, Curi
APP Scope of Practice Increases
As the number of APPs grows, their scope of practice has grown in many jurisdictions. In the US, more than half of all states and territories allow full practice authority for nurse practitioners, which means they can diagnose and treat patients, as well as prescribe medications, without the supervision of a physician. In contrast, only six states allow independent practice for physician assistants (PAs)—a status that still requires physician supervision. PA scope of practice tends to be more site-specific, based on where they work, rather than based on state licensing laws, regulations, education, training, and experience, which is more the case with NPs.
In Canada, considerable variance exists for NPs in scope of practice across provinces and territories. For example, NPs possess full hospital privileges in Ontario, Manitoba, the Northwest Territories, British Columbia, and Nunavut, which means they can admit, treat, and discharge patients. However, NPs cannot engage in those activities in Quebec and are restricted in other provinces. The scope of practice of a PA in Canada is tied to their supervising physician’s scope of practice as well as their experience, knowledge, skill, and judgment.
In the UK, the scope of practice for advanced nurse practitioners has extended and expanded at least partly due to demand. In the UK, PAs work under the supervision of a physician. Their scope of practice is defined locally at the health facility where they work within a framework of National Health Service (NHS) guidelines.
Top of License Initiatives
Top of license initiatives involve ensuring that APPs are practicing to the greatest extent allowed by their licenses. These initiatives are designed to promote independent practice in hospitals and ambulatory care facilities to improve healthcare, patient satisfaction, and APP productivity. A research study conducted using a top of license initiative at University of California, Irvine, revealed that utilizing APPs acting at the top of their licenses demonstrated a 53% improvement in productivity, which resulted in an 84% increase in payments and a 79% increase in charges over the prior fiscal year. The initiative had no negative impacts on patient satisfaction, physician productivity, or program expansion.
We advocate for clinicians practicing at the top of their license," said Kline. "Communities need reliable access to care—yet in many areas, care is simply unavailable. A recent study found that in states where nurse practitioners have a greater scope of practice or practice authority, patient populations are healthier."
"In states with restricted or reduced practice authority, there is no significant difference—only in states where nurse practitioners have an expanded scope of practice do populations tend to be healthier," she continued. "I believe more states will grant full practice authority to help address care gaps, typically requiring nurse practitioners to complete a certain number of years or practice hours beforehand."
There is some concern that APPs could be a target for plaintiff’s attorneys. Smith noted a case where a plaintiff attorney zeroed in on an NP’s education. “We recently had a lawsuit around care by a nurse practitioner, and the plaintiff lawyer cited a concern that some of her coursework was done remotely,” said Smith. “The plaintiff was questioning the validity of her training to be competent to be doing what she is doing. The reality is that it is not unusual to have a lot of non-clinical work done remotely.”
“We get the plaintiff’s lawyers who complain about whether or not APPs are qualified to do the work they’ve been asked to do,” he continued. “Then you have the APPs, who are seeking to get more independent responsibility, looking for top of the licenses expansion because they believe that they can make even a more effective contribution to taking care of patients, if that were allowed. APPs want to see less ambiguity about what they are capable, by license, of being able to accomplish. Then on the top, you have the physicians who are also at the top wondering how far the top of license goes for APPs.”
Smith noted that the benefits of more APPs coming into healthcare and top of license initiatives is that healthcare becomes more accessible in an era when many Americans have trouble finding a doctor and getting a primary care appointment. In fact, a research study by the Milbank Memorial Fund found that access to primary care is worsening across the US, with 13.6% of children and 28.7% of adults surveyed lacking a usual source of care. That means they do not have a regular primary care doctor and are at risk of missing preventative care visits and vaccines.
APP Risk Evolves
Although the numbers of APPs continue to rise, the medical professional liability (MPL) risk involved in APPs—specifically NPs and PAs—has not increased, according to a report released in October 2023 by Candello. The in-depth analysis of the percentage of cases involving NPs and PAs remained flat at 9% between 2012 and 2021. Although NPs and PAs are involved in 8.4% of all MPL cases, Candello noted that they are named as defendants in only 2.2% of cases. Significantly, the study found no impact on cases with indemnity payments when an NP or PA was on the care team.
Kline described the Candello study as "an excellent baseline study, showing that physicians are typically named as defendants when a claim is filed. When payouts for PAs and NPs occur, their frequency and severity are lower than many in the industry expected. In our limited APC Program data, we have not yet seen any claims for this new segment." In 2022, TDC Group began underwriting an independent segment of advanced practice providers, including physician assistants, nurse practitioners, certified registered nurse anesthetists, and certified nurse-midwives.
To appropriately manage risk, The Doctors Company has one rate for NPs working in a primary setting and other, separate rates, for NPs working in specialty areas. “So, if you’re an NP doing family practice or family medicine, that’s one rate. If they are in obstetrics, it’s a higher premium. Some of them do surgical work, are working in a surgical practice, so they pay even more. We do the same for PAs,” she said. “This is how we rate our physicians and surgeons.”
Wright noted that Curi has found that the risks associated with APPs are essentially the same as risks involved in MPL for physicians and other clinicians. “Just like other clinicians, we have to be careful to vet them in advance, which is what our underwriting team does through a series of questions,” she said. “That involves reviewing their training, loss history, employment gaps, duty to their employers, level of supervision, skills assessments for core competencies, and so on.”
As the healthcare industry continues to face staffing and clinician shortages, it makes sense for healthcare facilities to use more APPs, Wright continued. To mitigate risk, healthcare facilities should set them up with proper onboarding, training, education, and mentoring as well as reviewing those programs frequently. APPs can be positioned for success when facilities assign a mentor to the APP, assign oversight of the APP compliance program to someone in a leadership role, and support continuing education initiatives, she added.
Healthcare facilities need to carefully analyze their risk exposures around APPs, Wright said. Because APPs often share limits with the entity that they work for, she added. “If they don’t have a separate limit, underwriters need to take the risk of APPs within the entity into account because the entity is not just vicariously liable—they are actually sharing that limit,” she continued. “This isn’t uncommon, and it is not a problem so long as the coverage is priced correctly. It’s important also, on an ongoing basis, say at renewal time, to figure out if anything has changed. Is the APP performing any new functions or procedures? Have they gotten their required continuing education?”
Watkins of the CMPA noted that there was currently no clear indication of increasing or new emerging risks associated with APP risk profiles or how they might be mitigated to achieve the benefits that these newer care models can bring to patient care. In terms of specific steps that hospitals, health systems, and physicians’ groups can take to reduce risk, he said, “It is vital that each care provider in a multidisciplinary team have a clear scope of responsibility, robust professional regulatory oversight, effective communication with other team members, and adequate liability protection.”
“Without these, liability for harm may shift disproportionately to the most responsible clinician and impose a burden of supervision sufficient to defeat the intended benefits of multidisciplinary care,” he continued. “This may be assumed to fall to physicians in settings where they work.” Watkins noted that APPs play an essential role in the delivery of healthcare in all settings across Canda. Risks may arise due to the great number of provider types involved in patient care as risks of critical communication failures can also arise, he said.
Disputes over APP Scope of Practice and License Expansion
APP scope of practice issues can get contentious, with physicians’ groups generally opposing expansions in scope of practice, while APP groups favoring—and in some cases initiating—them. In the US, because licensing issues are a state matter, behind the scenes battles at state legislative sessions occur over APP licensing expansion.
In many cases, physicians’ groups, such as the American Medical Association (AMA), come out against license expansion while professional associations of NPs and PAs promote such legislation. The AMA seeks to block legislation that would, in its opinion, “provide inappropriate expansion of the medical services and procedures nonphysician health professionals are allowed to perform.” The AMA holds that such expansion endangers patient safety, although some research studies have rebutted that premise, including a Stanford University study that found that NPs are as safe as physicians when prescribing medication to older adults.
“It’s really interesting to see that in addition to the clinical evolution, which I think is a positive evolution because we don’t have enough clinical staff to fill the gaps, there are competing interests around APP license expansion,” said Smith. “APPs are promulgating bills in the Maryland legislature, for example, to push their licenses and scopes of responsibility forward. At the same time, physicians’ groups are trying to make sure that the legislature is conservative in terms of continued expansion of scope of APP practice.”
For PAs in the UK, scope of practice controversies have arisen as the British Medical Association (BMA), a trade association for physicians, the Royal College of General Practitioners, and other organizations have raised concern about potential scope creep in PA responsibilities and patient safety risks. Devlin noted that PAs were initially seen as a kind of panacea to fill in the gaps in care that were occurring in the NHS. But controversy has arisen about whether they are getting enough supervision and whether their scope of practice infringes upon matters that should be only handled by physicians, he continued.
For example, the BMA , challenged—and lost—a case over the government’s decision to refer to both physicians and APPs as medical professionals. “This kind of challenge underlines the polarity that exists on this issue, that the BMA is willing to litigate on something that might seem like a fairly small matter, but one that they obviously think is important,” Devlin said.
“Last year, the UK government announced that there would be a review of PAs to look at all of the issues that are being raised, including scope of practice, patient safety, risk, workforce analysis, and introduction of APPs into the workforce,” he continued. “The review is being chaired by a very experienced NHS senior administrator, and I suspect her recommendations will be sensible, proportionate, and achievable. Once that happens, we’ll get some specific guidance about the circumstances where we are happy to have PAs working and the ones where we aren’t so happy to have them working. Our view is that there probably are legitimate questions as to patient safety and risk, as there have been cases where a PA missed a diagnosis that led to an unfortunate outcome.”
Other Issues
Among the variety of issues involving APPs, a few more are worthy of mention, including:
- Continuity of care: APPs create continuity in the care teams in which they operate, ensuring that communication occurs during handoffs between care team members. “APPs are in some ways uniquely situated to make sure that things don’t fall through the cracks,” Smith said. “They’re going to make sure the right people on the team are aware of what they need to know to be effective.”
- Varying board regulations: Because APP licenses vary from state to state in the US, and by province and territory in Canada, it’s important to stay on top of board regulations in each state, territory, and province. “It’s just making sure that the APPs have the annual education that’s required, maintaining updated policies and procedures, and maintaining the collaboration agreements that are required,” said Wright. “Healthcare organizations also need to have signed agreements from the parties involved in conducting spot checks relative to the requirements and then assure the leaders and the organization know what the compliance requirements are so that they are followed.”
- Acceptance of APPs by patients: APPs have become much more accepted by patients. Patients are perfectly happy for them to provide care, Smith said. Where it gets more difficult is when patients are very sick, when they are critical, they want to see the doctor, that’s where there is some resistance to folks who don’t have an MD or DO behind their name, he added.
A Final Word
To date, there’s no hard evidence that APPs present any additional MPL risk, although the trends bear watching. There’s no doubt, however, that they will continue to be a key part of healthcare teams in the future.