Easing scope-of-practice laws and streamlining graduate medical education (GME) funding would make U.S. healthcare more competitive and efficient, the Trump administration said Monday.
“Reduced competition among clinicians leads to higher prices for healthcare services, and reduces choice… Government policies have reduced competition by restricting the available supply of providers and restricting the range of services they offer,” said a senior administration official, speaking on the condition of anonymity, during a call with reporters to discuss a new report called “Reforming America’s Healthcare System Through Choice and Competition.”
President Trump called for the report, issued jointly by the departments of Health and Human Services, Labor, and Treasury, in an executive order issued in October 2017; the order asked for the report to be issued “within 180 days of the date of this order, and every 2 years thereafter.”
Although scope-of-practice (SOP) laws may be justified in cases where there is substantial risk of consumer harm, “Oftentimes, too, SOP restrictions limit provider entry and ability to practice in ways that do not address demonstrable or substantial risks to consumer health and safety,” according to the report. “When this happens, these undue restrictions are likely to reduce healthcare competition and harm consumers — including patients, and taxpayers more generally.”
“For example, advanced practice registered nurses (APRNs), physician assistants (PAs), pharmacists, optometrists, and other highly trained professionals can safely and effectively provide some of the same healthcare services as physicians, in addition to providing complementary services,” the report continued. It made the following recommendations:
- States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice at the top of their license, utilizing their full skill set.
- The federal government and states should consider accompanying legislative and administrative proposals to allow non-physician and non-dentist providers to be paid directly for their services where evidence supports that the provider can safely and effectively provide that care.
- States should consider eliminating requirements for rigid collaborative practice and supervision agreements between physicians and dentists and their care extenders (e.g., physician assistants, hygienists) that are not justified by legitimate health and safety concerns.
The report also addressed the role of foreign-trained physicians, saying that while efforts should be made to expand domestic medical training, “easing the licensing pathway for highly qualified, foreign-trained doctors is one step that could be taken in the short run to expand the supply of medical practitioners, and thus, constrain the price of physician services and lower overall healthcare costs for American consumers.”
Currently, “there is likely an inadequate supply of physicians in the United States,” the report noted. “Moreover, there is an uneven distribution in physician supply (both geographically and across specialties), GME training slots, and in government support for GME. Yet there is inadequate information to assess overall physician needs, and for different specialties in different geographic areas.”
To address this problem, “as requested in the FY 2019 President’s Budget, the federal government should more efficiently spend taxpayer resources by streamlining federal Health and Human Services spending on graduate medical education into a single graduate medical education grant program,” the report authors suggested. “The new grant program would be funded out of the Treasury and jointly operated by the administrators of [the Centers for Medicare & Medicaid Services] and HRSA [the Health Resources and Services Administration]. This proposal is estimated to save $48.1 billion between 2019 and 2028.”
The report also called for HRSA to continue its work on assessing physician supply, and to assess the agency’s workforce development programs and identify gaps between existing programs and future workforce needs.
The authors particularly attack state “certificate of need” (CON) laws, which require healthcare providers to seek approval before opening certain types of facilities. “Not only may CON laws impose costly barriers to provider entry, but by interfering with market forces that normally determine the supply of facilities and services, they can suppress supply, misallocate resources, and shield incumbent healthcare providers from competition from new entrants. In addition, incumbent firms may use CON laws to thwart or delay entry or expansion by new or existing competitors.”
The report recommended that states repeal their CON laws “or, at a minimum, significantly scale back the scope of their CON regimes, for example, by ensuring that competitors of CON applicants cannot weigh in on these applications.”
“CON laws were put in place 40 years ago when there was a very different healthcare landscape,” an official (also speaking on condition of anonymity) said on the press call. “We think there’s a variety of anti-competitive restrictions at the state level and CON represents one of the worst, and the administration wants to get on the right side of this issue. So, to the extent we have the ability to set out a vision and to work with state policy makers to loosen up restrictions on the provider side of the market, we are excited and hopeful to do that.”