How States Can Unleash Their Health-Care Workforce to Fight Coronavirus

F ederal and state governments are stepping up to support their health-care workforces during the COVID-19 (coronavirus) pandemic, the most significant public-health challenge to face our country in generations. Federal agencies and governors are already taking up several measures to allow doctors to practice across state lines, protect them from meritless lawsuits during the crisis, and enhance their ability to use telehealth services. The next step in the process, though — particularly for states — will be to unleash the potential for health-care professionals who don’t have an “M.D.” next to their name: nurses, nurse practitioners, physician assistants, and more.

Doctors are, of course, on the front lines of the COVID-19 crisis. But supporting them is not the only way to expand the health-care workforce’s capacity to deal with any surges in patient demand from the pandemic. According to the Bureau of Labor Statistics data, in 2018, there were 756,800 physicians and surgeons. But there were 118,800 physician assistants (PAs), 240,700 advanced practice registered nurses (APRNs), 728,900 licensed practical nurses (LPNs), and a whopping three million registered nurses (RNs). That’s a workforce of 4.1 million non-physician health-care professionals, 5.5 times the size of the physician and surgeon workforce.

Many of these professionals can perform some of the same tasks as physicians and surgeons, such as giving medication or starting intravenous drips (LPNs), “prescrib[ing] medications, order[ing] medical tests, and diagnos[ing] health problems” (APRNs), assisting with surgeries and giving vaccines (PAs), and operating and monitoring medical equipment (RNs). However, a number of onerous state laws and regulations restrict them. Such policies are particularly inappropriate during a crisis such as COVID-19. For example:

• Most states require continuing education (CE) for RNs and LPNs every two to three years in order to be recertified; many require as many as 30 hours of CE.
• The American Academy of Nurse Practitioners Certification Board (AANPCB) requires nurse practitioners (NPs, one of several kinds of APRNs) seeking recertification to have a minimum of 1,000 hours of clinical practice in a five-year period and 100 contact hours of advanced CE.
• Most states require continuing education for renewal of PA licenses, while others require certification by the National Commission on Certification of Physician Assistants (NCCPA); the NCCPA, for its part, includes in their recertification requirements earning “100 [CE] credits every two years” and paying a maintenance fee.

All of these professionals are also affected by the state-to-state scope of practice laws, from a prohibition on prescribing certain medications they have been trained to prescribe to requirements that physicians supervise them for a whole set of basic items and services.

There are two easy ways state governments can unleash the potential of the health care workforce and ease the burden on front-line physicians and surgeons during the COVID-19 public-health emergency. They can temporarily suspend CE and/or maintenance fee requirements for RNs, LPNs, APRNs, and PAs. And they can temporarily relax scope-of-practice regulations and expand scope-of-practice reciprocity for APRNs and PAs (at minimum).

The first item, suspending CE and fee requirements, should be a layup. Nurses and physician assistants burdened with significant patient demands should not be required to also squeeze in hours of CE if that makes the difference between losing or retaining their licenses. A reasonable law, regulation, or executive order could relax those requirements for existing practitioners in good standing, through the end of a state or federal public-health emergency and for a few months after.

The second item, temporarily relaxing the scope of practice laws and regulations, is slightly more difficult to implement. Fortunately, Maine and Iowa recently passed model legislation expanding PAs’ scope of practice. Maine now allows “a majority of PAs with more than 4,000 hours to practice without a written agreement [with a physician],” and “eliminates the requirement that a PA receive a certificate of registration (in addition to a license) prior to practicing.” Iowa removed a requirement “that a physician visit remote locations staffed by a PA at least once every six months.” These are commonsense changes for any time, but especially during a pandemic.

As for licensing reciprocity, states don’t need to completely reinvent the wheel. According to AANP, twelve states currently have restricted scope of practice for nurse practitioners (NPs), which AANP defines as “career-long supervision, delegation or team management by another health provider in order for the NP to provide patient care.” Sixteen states have reduced practice restrictions less severe than those twelve, and the remaining 22 states (plus D.C.) allow NPs to practice at their full scope. The 28 states that limit their NPs could temporarily match the 22 states by allowing full scope of practice, freeing up both NPs and the physicians tasked with supervising them under current laws and regulations.

While federal and state policymakers have taken encouraging steps to support the health-care workforce thus far, it’s clear from the sheer size of the non-physician workforce that more is possible. Governors and state legislators should listen to what RNs, LPNs, APRNs, and PAs have been telling them for years, and unleash the full potential of these millions of workers at a critical time for our nation’s health system.