Scope-of-practice regulations and PA inter-state relocation
Publication id: nepal-2025-pa-scope-interstate
Status: verified
Citation: Nepal, T., & Shakya, S. (2025). Scope-of-Practice Regulations and Physician Assistant Inter-State Practice Relocation. Journal of Labor Research. Download PDF
Facts¶
Policy hook¶
Physician assistants (PAs) face scope-of-practice restrictions that vary by state. Some states grant “optimal” scope-of-practice laws providing full practice authority and independent prescribing rights, while others maintain restrictive supervision requirements. The question is whether expanding PA autonomy influences their location decisions and improves workforce distribution, particularly in underserved rural areas.
Main finding¶
Physician assistants are approximately 3 percentage points more likely to relocate their practice to states with optimal scope-of-practice laws compared to restrictive states. More importantly, optimal scope-of-practice laws produce substantially larger retention effects in rural areas than non-rural areas, suggesting that practice autonomy is particularly valued by PAs considering rural practice locations.
Data and setting¶
National Plan and Provider Enumeration System (NPPES) database, 2016–2023, covering over one million physician assistants across all 50 US states. Five states enacted optimal scope-of-practice laws during the study period: North Dakota (2019), Utah and Wyoming (2021), and Iowa and Montana (2023). Analysis compares PAs’ interstate relocation patterns before and after these policy changes.
Research design (plain language)¶
Linear probability model applied to panel data tracking physician assistant practice locations from 2016–2023. Difference-in-differences framework exploits staggered adoption of optimal scope-of-practice laws across states. Heterogeneity analysis separately examines rural and non-rural responses. Robustness checks include relaxing the optimal scope-of-practice definition and randomized inference tests to confirm statistical significance.
One caveat¶
The differential retention effect is substantially stronger in rural areas than non-rural areas, indicating that spatial context mediates policy impact. Generalizability to earlier time periods (before 2016) is unclear due to data availability. The analysis cannot determine whether higher relocation rates reflect PAs seeking expanded autonomy or whether other state-level factors correlate with both scope expansion and PA attraction.
PDF or DOI¶
Why it matters¶
Scope-of-practice restrictions are a major barrier to PA practice in the United States. This paper provides direct evidence that expanding PA autonomy influences relocation decisions—practitioners are more likely to practice in states that remove restrictive oversight requirements. Critically, the stronger rural effect suggests that practice autonomy is particularly valuable for addressing rural physician shortages. For policymakers considering scope expansion, the findings support a workforce-development rationale: removing restrictions doesn’t just allow existing PAs to practice more independently; it actually attracts PAs to practice in areas (rural regions) that desperately need them. The result aligns with policy goals of improving geographic access to care. However, the effect size (3 percentage points) is modest, suggesting that scope expansion should be paired with other rural recruitment tools—loan forgiveness, housing subsidies, education pipeline development—to achieve substantial workforce redistribution.