What Is Prescriptive Authority?

Prescriptive authority is the legal right to prescribe drugs. Full prescriptive authority affords the legal right to prescribe independently and without limitation. Physicians have full prescriptive authority. For nonphysician providers, the degree of prescriptive authority varies. Some have full prescriptive authority; however, for many, prescriptive authority is restricted. Limitations are generally tied to oversight by a doctor of medicine (MD) or doctor of osteopathy (DO) as part of the provider’s scope of practice.

Recall that there are two components of prescriptive authority: (1) the right to prescribe independently and (2) the right to prescribe without limitation. The provider who prescribes independently is not subject to rules requiring physician supervision or collaboration. The provider who prescribes without limitation may prescribe any drugs, including controlled drugs, with the exception of Schedule I drugs which have no current medical use.

Full practice authority is sometimes interpreted differently for advanced practice registered nurses (APRNs) and physician assistants (PAs) because supervisory requirements vary for the two professions. (See Box 1.1 for information on other professions seeking and obtaining prescriptive authority). PAs are required to practice and prescribe under the supervision of a physician. All PAs, including those in a solo practice, must have a supervising physician who can be reached by telephone or other means of telecommunication. (See Guidelines for State Regulation of Physician Assistants available at https://www.aapa.org/Workarea/DownloadAsset.aspx?id=795 for additional information.) If the PA-physician arrangement does not limit drugs that may be prescribed and if the law allows the PA to prescribe Schedule II to V drugs, the PA may enjoy a type of quasi-full prescriptive authority. Indeed, some have referred to this as full prescriptive authority; however, the issue of supervision still applies. Hence, PAs do not have the legal right to prescribe independently of a supervisory arrangement. Even for those in solo practice, there is always the possibility of dissolution of the PA-physician arrangement. In the event this occurs, the PA must affiliate with another physician or physician group in order to continue prescribing.

Whether APRNs possess full prescriptive authority depends on their legal right to prescribe without a supervisory or collaborative requirement. APRNs are educated to practice and prescribe independently without supervision; however, some state laws require that they practice in collaboration with or under the supervision of a physician. In these situations, some physicians limit the types of drugs that the APRN can prescribe. State laws may place additional restrictions with regard to controlled drugs.

Table 1.1 provides prescriptive authority status for PAs and the four categories of APRNs—clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, and certified nurse practitioner. Information regarding the right to prescribe controlled drugs is available at http://www.deadiversion.usdoj.gov/drugreg/practioners.

Prescriptive Authority Regulations

Prescriptive authority is determined by state law. As a result of differences from state to state, advanced practice providers may have full prescriptive authority in some states yet face significant restrictions in other states. The stark differences particularly affect providers who serve in locum tenens staffing positions or who have practices in two contiguous states.

The regulation of prescriptive authority is under the jurisdiction of a health professional board. This may be the State Board of Nursing, the State Board of Medicine, or the State Board of Pharmacy, as determined by each state.

Although the federal government controls drug regulation, it has no control over prescriptive authority. However, several organizations have appealed for changes that would place scope of practice and prescriptive authority under federal regulation in an effort to expand prescriptive authority and the scope of practice of advanced practice providers. The Institute of Medicine (IOM), for example, advocated for federal regulation in their report, The Future of Nursing: Focus on Scope of Practice. After noting problems with the “patchwork of state regulations,” they wrote:

The federal government has a compelling interest in the regulatory environment for health care professions because of its responsibility to patients covered by federal programs. … Equally important is the responsibility to all American taxpayers who fund the care provided under these programs to ensure that their tax dollars are spent efficiently. … Scope-of-practice regulations in all states should reflect the full extent not only of nurses but of each profession’s education and training.

The Case for Full Prescriptive Authority

Advanced practice providers complete rigorous programs of study, largely in accredited programs that meet stringent national standards. Although there are differences in each program, all include common components. For example, they require extensive education focused on assessment, diagnosis, and management of health problems. Diagnostic reasoning, critical thinking, and procedural skills are evaluated in both didactic and clinical courses. National examinations validate the ability to provide safe and competent care. Licensure ensures that providers comply with standards of practice that promote the public health and safety. In short, advanced practice providers are prepared to fully implement the advanced practice role in their profession.

Limited prescriptive authority creates numerous barriers to quality, affordable, and accessible patient care. For example, restrictions on the distance of the APRN or PA from the physician providing supervision or collaboration may prevent outreach to areas of greatest need. A requirement to obtain the physician’s cosignature on prescriptions can increase patient waits. Despite the use of terms such as collaborative arrangement, these relationships create a situation in which one partner holds the power. In the event of dissolution of the arrangement, the ultimate loss is commonly assumed by the advanced practice provider rather than the physician.

In 2010, the Association of American Medical Colleges commissioned a report projecting the future of the physician workforce. The report, The Complexities of Physician Supply and Demand: Projections from 2013 to 2025, was released in 2015. Several of the key findings have important implications for nonphysician providers.

These findings echo the dire circumstances reported in the 2013 Department of Health and Human Services report, Projecting the Supply and Demand for Primary Care Practitioners through 2020, which concluded that full utilization of nurse practitioners and PAs can reduce the physician shortage.

In this scenario in which physician demands are excessive, requiring oversight for other providers may be untenable. To adequately meet the demands for future health care needs, APRNs and PAs will need broader practice privileges than some states currently allow. This includes an imperative to afford full prescriptive authority.

Prescriptive Authority and Responsibility

The possession of full prescriptive authority requires a somber responsibility. Whether you are reading this book as a student or as a practicing provider, it is essential to recognize the full obligation this requires. The safe and competent practice of prescribing and managing medications requires a sound understanding of drugs and the conditions that they are used to manage. It is our goal to help you lay that foundation. In the coming chapters, you will read about rational drug selection, writing prescriptions, and promoting positive outcomes. Then we will delve into the heart of pharmacology through a study of pharmacokinetics and pharmacodynamics as we prepare you for the study of individual drug categories.