California’s Nurse Practitioners

How scope of practice laws impact care

Joanne Spetz, Healthforce Center at UCSF


Nurse practitioners (NPs) are registered nurses who have completed additional education to prepare them to deliver a broad range of services including the diagnosis and treatment of acute and chronic illnesses. They are one of four categories of advanced practice registered nurses, with the others being certified nurse-midwives, nurse anesthetists, and clinical nurse specialists.

California is 1 of 28 states — and the only western state — that restricts NPs by requiring them to work with physician oversight. A large body of research has linked such restrictions to a lower supply of NPs, poorer access to care for state residents, lower use of primary care services, and greater rates of hospitalization and emergency department visits. Although dozens of studies demonstrate that the quality of NP care is comparable to the quality of physician care, and that there is no difference in care when there is no physician oversight, proponents of scope of practice restrictions continue to argue that oversight is necessary for quality care.

California’s Nurse Practitioners: How Scope of Practice Laws Impact Care describes the regulations that govern scope of practice for NPs in California and in other states, and summarizes recent research on how these laws impact care.

Key findings include:

  • Physician supply in California will meet less than half of demand for primary care in 2030, but this gap can be filled by projected growth in NP and physician assistant supply. Policy leaders point to the elimination of unnecessary barriers to NP care as a means to address this primary care shortfall, especially in rural and underserved areas.
  • Multiple systematic reviews of the literature conclude that NPs provide care of comparable quality to physician care, even when practicing without physician oversight. Findings were similar beyond primary care, including in prescribing, chronic disease management, and ordering diagnostic tests. The findings were also reflected in rural and community health center settings.
  • Physicians currently bill time for overseeing NPs, resulting in practices offering them stipends of anything from $5,000 to $15,000 annually to cover this cost. This cost is passed along to patients, and would be removed if NP oversight hours were reduced or ended. Additionally, limiting the supply of NPs may lead patients to seek more expensive care, again increasing costs.

The full report is available for download under Related Materials.

About This Series
This paper is one of a series that examines the scope of practice of selected California health professions. The series looks at professions discussed by the California Future Health Workforce Commission and its subcommittees and work groups during spring and summer of 2018. Each brief begins by describing the profession, including its legally permissible scope of work, and educational requirements. The brief then outlines how California’s permissible scope of practice compares with that of other states and provides a summary of research studies on the impact of the profession’s scope of practice on access to care, care quality, and costs. Finally, it summarizes demographic characteristics, practice settings, and geographic distribution.

About the Author
Healthforce Center at UCSF prepares health care organizations for success by combining a deep understanding of the issues facing their workforce with the leadership skills to drive progress.