Case Study: Alabama

This case study summarizes the Alabama laws governing oral health providers, physician assistants and nurse practitioners. As in many other states, the laws in Alabama include supervision requirements, practice limitations and restrictions on the authority to prescribe medication. The summary below includes the relevant elements of Alabama laws governing each profession as well as legislative changes to those laws since enactment.

Alabama Oral Health Providers

Since 1959 the Alabama Legislature has recognized the licensing of dental hygienists, established examination and qualification requirements, and set out supervision and practice conditions for dental hygienists. Dental hygienists in Alabama must work under the direct supervision of a licensed dentist. By 1993 dental hygienists were authorized to assist a licensed dentist, as well as “develop and mount oral X-rays; remove calcareous deposits, accretions or stains from the teeth, perform any intra-oral procedures allowed” by the Board of Dental Examiners of Alabama. Dental hygienists have not be given the authority to prescribe medications in Alabama.

In 2013, the permitted dental services that were listed in earlier law were replaced with a provision allowing dental hygienists to only perform the duties as allowed by the dental board. The Legislature in 2013 also recognized expanded duty dental assistants and authorized the dental board to develop license and practice requirements. The law also specifically prohibits expanded duty dental assistants from performing any irreversible procedure, such as surgery. The dental board’s rules for expanded duty dental assistants are pending.

Another law affecting oral health providers in Alabama was enacted in 2005 when the Legislature required that “allied dental personnel who assist dentists during oral conscious sedation procedures” be certified in cardiopulmonary resuscitation and that at least one other person, including a dental assistant, be present in addition to the dentist during a sedation procedure.

Alabama Physician Assistants

The assistant to physician (PA) position was recognized and certified by the Alabama Legislature in 1971. The Legislature noted a shortage of skilled health personnel, an uneven geographic allocation of health care services, and a need to enable physicians to delegate certain health care services for its recognition and development of the PA profession. The law also set out definitions for the PA system, the services PAs could perform, and the powers and duties of Alabama Board of Medical Examiners regarding PAs.

In 1998, the certification scheme for PAs was changed to a licensing and registration model. The Alabama Legislature made clear that the licensing and registration of PAs is required and specifically disallowed the independent unsupervised practice of PAs. The revised law established penalties for practicing without a PA license; application and licensing requirements; license renewal; a process for licensing those PAs who were certified; and remedies for the denial, suspension or revocation of a PA license. In 2008 the Legislature expanded the medical board’s investigation powers during license denials, suspensions and revocations by allowing criminal background checks of PAs under investigation. The medical board also required PAs to submit to a physical, mental or laboratory examination when there is probable cause that the PA is unable to perform the needed skills.

An Alabama PA is required to have a “direct continuing and close supervisory relationship” with a licensed physician. While there need not be direct on-site supervision, there must be professional oversight and direction as required by the medical board. The PA is permitted to provide the medical services that are listed in the PA’s written job description and while under the supervision of a physician as approved by the Alabama Board of Medical Examiners. A PA also has the authority to prescribe and administer medication that is listed in the PA’s job description. The medical board may decide the different medications that PAs can prescribe and under certain circumstances allows the prescribing of Schedule III-V controlled substances. In 2013 the Legislature authorized the medical board to develop a permitting system to allow PAs to prescribe Schedule II controlled substances.

Alabama Nurse Practitioners

The Alabama Legislature first recognized and regulated nurse practitioners (NPs) in 1995 when it declared that the recognition and regulation of NPs and the collaborative practices between NPs and physicians was “essential to protect and maintain the public health and safety.” The Alabama Board of Nursing was given the authority to establish the qualifications for and adopt the rules governing NPs. Both the nursing board and the medical board have the authority to regulate and approve the collaborative agreements between NPs and physicians as well as the protocols under which NPs practice.

NPs in Alabama generally must practice in collaboration with a licensed physician and under written protocols signed by the collaborating physician. The nursing board may establish rules exempting an NP from the written protocol and collaboration requirements. While direct, on-site supervision of NPs is not required, the physician must provide professional oversight and direction. NPs may also prescribe and administer medications as authorized in the written protocol with the collaborating physician and approved by the nursing and medical boards.

Very little has changed in the licensing and regulation of NPs in Alabama since the profession was first recognized by the Legislature. Most notably, in 2013 the Legislature granted NPs who have a Qualified Alabama Controlled Substances Registration Certificate and a valid U.S. Drug Enforcement Administration registration number the authority to prescribe, administer and dispense the Schedule III, IV and V controlled substances that are approved by the medical board.

Alabama’s laws governing midlevel oral health providers, physician assistants and nurse practitioners are not as expansive as other states such as Alaska and Massachusetts. As this policy surveillance case study illustrates, however, policymakers in Alabama have demonstrated a willingness to add to the professional responsibilities and duties of midlevel oral health providers, physician assistants and nurse practitioners throughout the years