Stanford Study Challenges the AMA's Fight Against 'Scope Creep'

Nurse practitioners hold full practice authority in 27 states, the District of Columbia, and two U.S. territories. In those places, NPs manage patient care, including prescribing medications and controlled substances, without physician oversight. The American Medical Association opposes that expansion, calling it "scope creep." A large Stanford study now undercuts the safety argument at the center of that fight.

The AMA's Position

Fighting scope creep is one pillar of the AMA's Recovery Plan for America's Physicians, alongside reforming prior authorization, supporting telehealth, cutting physician burnout, and reforming Medicare payment. The AMA defines scope creep as the "expansion of the medical services and procedures nonphysician health professionals are allowed to perform," and argues that letting NPs or physician assistants diagnose and treat without physician oversight is a step in the wrong direction.

"Patients deserve care led by physicians, the most highly educated, trained and skilled health care professionals," the AMA states, framing physician-led teams as the way to lower costs and improve care.

What the Stanford Study Found

Stanford Medicine researchers ran the largest study of its kind on prescribing in states where NPs have full prescriptive authority. They analyzed more than 73,000 primary care physicians and nurse practitioners and their prescribing for Medicare patients aged 65 and older from 2013 to 2019, measuring inappropriate prescribing against the American Geriatrics Society's Beers Criteria.

"Older adults account for a huge proportion of all prescriptions written," said senior author David Studdert, LLB, ScD, a professor of health policy and law. "They are also especially vulnerable to adverse drug events from inappropriate prescribing."

The finding was direct: "Nurse practitioners were no more likely than physicians to prescribe medications inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians."

How NPs View Scope Limits

Seana Rutherford, MSN, APRN, FNP-C, CWS, holds privileges at Cleveland Clinic's Fairview Hospital and owns her own practice. She was not surprised by the results. "I'm passionate about our profession," she said. "Physicians are my peers. It's been hard-earned respect from these guys."

Reduced authority creates real inefficiencies. A 2021 analysis of electronic health records and claims data found that when states granted NPs greater authority, some practiced more autonomously, but the change did not shift the volume or allocation of patients to NPs within large practices. In other words, more authority alone did not push NPs to open their own practices. Combined with the physician shortage, the limits states place on independent NP care can restrict access to care.

Rutherford has felt those limits in Ohio, a reduced-practice state, where she can write a prescription in the hospital but not in her own office.

What Greater Authority Could Mean

The AMA warns that expanding APRN scope would raise costs and reduce safety. "Expanding the scope of practice of APRNs to allow independent practice and prescriptive privileges will increase utilization of diagnostic services, antibiotic prescribing, and opioid prescribing," former AMA President Susan R. Bailey, MD, told the Nebraska APRN Technical Review Committee, arguing all of it threatens cost and patient safety.

Stanford's researchers see it differently. "If expanding patient access while ensuring quality and safety system-wide is the goal," they wrote, "fixation on the question of whether NPs or other nonphysician providers should be allowed to prescribe may be less impactful than identifying and addressing deficient performance among all clinicians who prescribe, regardless of practitioner type or practice location."

Rutherford lands in the same place: focus on patient safety, no matter who delivers the care. She wants a shared safeguard built into the system, like a hard stop in the hospital or pharmacy software that checks prescriptions from NPs and physicians alike.