How Scope of Practice Affects Rising Health Care Costs with Kimberly Horvath, JD

How Scope of Practice Affects Rising Health Care Costs with Kimberly Horvath, JD

The AMA Update covers a range of health care topics that affect the lives of physicians, residents, medical students and patients. Hear from medical experts on COVID-19, medical education, advocacy, burnout, vaccines and more, from private practice and health system leaders to scientists and public health officials.

Scope of practice expansion, which allows nonphysician providers to practice independently, is costing large health systems millions annually, two studies of health care data show. Kimberly Horvath, senior attorney with the AMA’s Advocacy Resource Center, joins us to discuss the study’s findings and what they mean for practice leaders and policymakers. AMA Chief Experience Officer Todd Unger hosts.


  • Kimberly Horvath, Senior Counsel, AMA Advocacy Resource Center

Unger: Hello and welcome to the AMA Update video and podcast. Today we discuss two studies that show the impact of scope-of-practice expansion in large health systems. Joining me in our Chicago studio is Kimberly Horvath, senior attorney for the AMA’s Advocacy Resource Center. I’m Todd Unger, Chief Experience Officer of the AMA. Kim, we are so happy to have you back in the studio.

Horváth: It’s great to be here.

Unger: Well, we look forward to talking about these two different studies. The first comes from the Hattiesburg Clinic in Mississippi, where the health system has expanded its care teams to include non-physician providers over the past 15 years. And in primary care, these providers practice independently alongside physicians. Why don’t we start talking about what happened when the Hattiesburg leadership looked at how it works?

Horváth: Yeah. So, as an ACO, Hattiesburg Clinic gets a lot of data from CMS. So they dug into that data and found that care provided by non-physicians, particularly physician assistants and nurse practitioners, was more expensive than care provided by physicians. Specifically, the data showed that on the primary care side per member per month, the increased cost per patient was $43 higher for those who saw a nonphysician primary, again compared to a physician.

And if you extrapolate that, it has led or could lead to additional costs, about $10.3 million in annual expenses. Such big numbers. When they risk-adjusted that number because non-physician patients were generally less complex, so when they then risk-adjusted for the complexity of the patient, they found that the cost per member per month would actually be $119, or $28.5 million per year more.

So what they did is they wanted to dig in a little bit more and they found that the reason for those costs is increasing — and that’s found in other studies, but it wasn’t a surprise, it was increased use of the service. They ordered more tests. Rather, they sent the patient to a specialist. Their patients were more likely to use the emergency department. This is all that has led to an increase in costs.

Hattiesburg Clinic also wanted to look at quality of care. And so they did some quality measures and looked at quality measures. And physicians outperformed nonphysicians in 9 out of 10 quality measures and also scored higher on patient satisfaction surveys.

Unger: Okay, so that’s a pretty significant difference by a number of very, very important measures. And when the Hattiesburg leadership looked at these results, what did they decide to do with this information?

Horváth: Yes, these findings prompted management to re-engineer and refocus the clinic’s model of care. Now the physician is the primary care physician for all patients in the primary care model. And no one sees exclusively non-physicians. They can see a non-physician at each subsequent visit. But the doctor will always be the primary care doctor for that patient.

It took them about one year to transition it, to make sure patients knew it, and to make sure all health professionals in the system knew it. But they also made sure to emphasize that non-physicians are still really important. I need them. In fact, they hired more of them. They want them as part of the care team model. They didn’t want them to be primary care leaders. They needed to make sure that doctors were leading the health care team.

Unger: Well, that’s a very, very clear example and support of why the AMA advocates physician-led care teams. But they’re not the only health system with data to support this idea. We have a second study, this time from Stanford. And it had data that was based on data from the Veterans Health Administration. So let’s talk about it. What do we find in that study?

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Horváth: Yeah, so the study compared the care provided by nurse practitioners in the emergency room to doctors. And it was under the Veterans Health Administration, so a closed system. It found that nurses increased the cost of emergency department care by 7%, or about $66 per patient. The authors also looked at the productivity of nurses compared to physicians and found that using the current emergency department nurse staffing model would result in a net cost of $74 million per year, meaning nurses are actually more expensive. employ than doctors, even accounting for the difference in their wages.

The authors of the study cited similar reasons for increased costs, greater use of resources, greater likelihood of ordering tests, seeking specialist consultations, and more. And they also found that — and this is important, despite using more resources, even though patients are kept in the emergency room longer because it takes time for all these tests to come back and have these additional consultations, the patients that the nurse saw, they’re really done. with worse outcomes in the ED compared to those seen by a physician.

Unger: So this is really interesting. So we have pretty similar results to what we saw in Hattiesburg. And I think that probably goes against maybe some of the common notions given the information that you put out there, which is actually more expensive. So you have to really think and look at this data. And while there are similar results, I want you to describe something special about this Stanford study in terms of how it was done.

Horváth: Yes, studying a productivity profession is really a top-level kind of study. Other studies that have looked at cost and quality of care often do so in a correlational analysis. The Stanford study used high-quality causal analysis, that is, a very high-quality study. Also, many other studies in this literature actually look at nurse practitioners practicing in a physician-led team with physician supervision or collaboration.

This study was conducted within the VA, in fact, during a period when nurses practiced truly independently. They were not supervised or cooperative with the doctors in the ED. And it really confirms that coverage expansion can lead to higher health care costs. It also helps demonstrate more clearly the importance of physician-led care.

Unger: So many problems with expanding the scope across the country at different levels of the state. And I know that a lot of the discussion will often focus on the training experience, the years of education between doctors and non-doctors. This discussion that we’re having today is different because we’re talking about costs and real differences in costs and patient outcomes, so to speak. When you use data like this, does it have a different effect when you go talk to legislators about issues around scope?

Horváth: Yes, absolutely. I mean, we will definitely incorporate this information when we reach out to legislators, state medical associations, and specialty societies. It’s really helpful to reject the notion that – we often hear that non-physicians are providing us with high quality care at a lower cost. These studies clearly show that this is not true.

They are also really great examples of the importance of physician-led care, as they both concluded that physician-led care provides the highest quality care at the lowest cost. And both also prove that nurse practitioners and physician assistants are once again important members of the health care team. But they just don’t have the same skills as doctors.

Unger: So when it comes to other health systems, I know many of them are watching the studies coming out of these two places very closely. For those who haven’t done their own analysis but have many non-medical providers, what steps should they take to really take a deep look at their own data?

Horváth: Yeah, we would encourage them to do their own studies. Specific ACOs, but health systems in general, have data like the Hattiesburg Clinic. Look. Put a microscope on those health care costs. It is an important control point for both the healthcare team model and the cost and quality of care delivered to patients, which is ultimately what matters in the high-quality care we provide to patients.

Unger: Kim, thank you so much for being here today. Studies are, of course, complex. And it’s great that you are here to understand them. I really appreciate it. You can learn much more about the AMA’s scope of practice and efforts in this by looking at the AMA Recovery Plan for America’s Physicians on the AMA website. You can find it at

We’ll be back soon with another AMA update. In the meantime, you can check out all of our videos and podcasts at Thank you for joining us today. Please be careful.

Disclaimer: The views expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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