What does it mean to practice at the "Top of License"?

The United States faces a healthcare workforce shortage, which is projected to worsen. Estimates show a shortage of over 85,000 physicians by 2036, with the U.S. only meeting 87% of overall physician demand. Rural areas are likely to be hit particularly hard, with projections showing that by 2036, there will only be enough physicians to meet 44% of rural demand. If people cannot access healthcare due to provider shortages, they are more likely to forego primary and preventative care, leading to worse health outcomes. Workforce shortages span a multitude of specialty areas, with internal medicine, family medicine, and geriatrics being hit the hardest.

Driving this worsening shortage are structural issues such as physician burnout, student debt, low pay for primary care roles, and violence against physicians, driving longer patient wait times, compromising care, and reducing access. One solution that some states are implementing is allowing physician assistants (PAs) and nurse practitioners (NPs) to practice at the top of their license (TOL). TOL practice is when healthcare professionals work at the highest level of their education, skills, and licensure to provide patient care, allowing them to perform all the medical care they are trained for. For example, if they are trained to do a primary care check-up and some testing, they should be allowed to do both tasks, not just the primary care check-up.

NPs are registered nurses with advanced training in administering patient care, and can cover 60 to 80 percent of primary and preventive care. PAs are licensed clinicians who work in a variety of specialties, including primary care, in care teams overseen by a physician. Both NPs and PAs undergo medical training that enables them to care for patients in a variety of settings, and they are able to complete their training more quickly than a physician, leaving them with less student debt and a shorter timeline to practice. This medical training allows them to practice primary and preventative care that physicians may not have time for, freeing physicians to focus on tasks they are not able to delegate, as they are beyond the training of NPs and PAs.

Due to states controlling medical licensing and scope of practice, there are varying regulations regarding what NPs and PAs are allowed to practice. States allowing TOL practice for NPs have been found to increase access to primary care clinicians with no drop in quality of care when tasks are delegated to NPs and PAs by physicians. Specific tasks include screenings, administrative duties, immunizations, diagnosing and treating common illnesses, and some prescribing of drugs. In these states, 90% of patients say PAs make it easier to make a medical appointment, add value to healthcare teams, and believe PAs are dedicated to meeting patients' needs.

Not only does allowing TOL practice increase access, but studies suggest it also increases provider supply, healthcare access and utilization, and quality of care. As a result, top-of-license practice for NPs and PAs is often examined as part of broader discussions about healthcare workforce capacity, access to care, and provider well-being. Thirty states allow NPs full authority to practice and 8 states have enacted laws to give PAs more autonomy when practicing. States such as New Hampshire are leading the way, with the state granting more freedom for both NPs and PAs. The debate over TOL practice will continue on a state-by-state basis in the coming years, and states may consider the impacts it will have on both patients and providers.