Cost of Health Services Regulation
Working Paper Series
Health Professional
Certification and
Licensure
Health Professionals Regulation
Working Paper No. P-6
Prepared by
Christopher J. Conover
with
Emily P. Zeitler
Center for Health Policy, Law and
Management
Duke University
Under contract to the
April 2006
Draft: Do Not Circulate without Author
Permission
Agency for Healthcare Research and Quality
With funding from ASPE/DALTCP
The authors thank Anne Farland, Matthew Piehl, and
Catherine Wu for excellent research assistance with this
paper.
1
Section I. Introduction
Background
Rationale
The principal rationale for certification and licensure is to ensure a minimum level of
competency for all health professionals subject to such requirements.
Statutory Authority
All states retain the authority to establish licensure or certification standards for a
large variety of health professionals. In contrast to other domains of regulation, the
federal government has never threatened to preempt or compete in this domain of
regulation.
Key Elements
There are three types of professional licensure used for health professionals: a)
mandatory licensure; b) certification; and c) registration (Van Hemel 2001).
Scope
Currently, “all 50 states and the District of Columbia require licensure for allopathic
physicians (M.D.s), osteopathic physicians (D.O.s), dentists, registered nurses, practical
nurses, dental hygienists, pharmacists, optometrists, physical therapists, podiatrists,
chiropractors and administrators of nursing homes. Physicians’ assistants, midwives,
psychologists, social workers, opticians, physical therapy assistants, audiologists and
speech pathologists are also frequently regulated by licensure laws” (Macdonald, Meyer
and Essig 1992: 16-4).1 Some states also have regulations regarding voluntary
certification or registration for health professionals. Although there have been critics who
have argued for the complete elimination of licensure or its replacement by voluntary
certification (Kessel 1958; Friedman 1962; Gellhorn 1976; Baron 1983), no state has
tried to completely eliminate licensure (Macdonald, Meyer and Essig 1992).
Enforcement
The courts have generally given states wide latitude in determining which professions
to license and the scope of practice permitted for those who obtain licenses (Miller and
Hutton 2000).
Research Questions
This working paper covers two major topic areas framed within four research
questions, all of which are related to the impact of certification and licensure regulation
of health professionals in the U.S. Our primary goal was to identify, review, and evaluate
1
Cooper, Henderson and Dietrich (1998) provide a reasonably current comprehensive summary of the
licensure requirements, autonomy, and scope of practice of PAs, NPs, CNMs, CRNAs, CNSs,
chiropractors, acupuncturists, naturopaths, optometrists, and podiatrists.
2
the published literature to answer the research questions with the intent of developing an
interim estimate of the costs and benefits of certification and licensure regulation; our
secondary goal was to identify areas where no evidence exists or where the evidence has
important limitations and then describe the type of data that would be needed to more
fully address the question.
The questions are listed below by topic area, along with a brief description of our
analytical approach, including outcomes of interest.
Costs of Certification and Licensure Regulation for Health
Professionals
Question 1a. What is the amount of government regulatory costs related to
certification and licensure regulations for health professionals? This includes federal
costs to monitor and enforce any applicable Medicare Conditions of Participation that
may apply to professional practices (e.g., those having in-house laboratory facilities) and
state costs to monitor and enforce professional certification and licensure requirements.
Question 1b. What is the amount of industry compliance costs related to
certification and licensure regulations for health professionals? This includes all
administrative costs and enforcement penalties borne by medical practices subject to
Medicare conditions of participation and state-imposed professional certification and
licensure requirements.
Question 2c. What is the net impact of certification and licensure regulations for
health professionals on health expenditures? While protection of public health is the
ostensible rationale for certification and licensure, it inevitably also serves to protect
professionals from competition, thereby increasing their earnings. Hence licensure has
been criticized as benefiting professionals at the expense of consumers insofar as it
contributes to higher costs, less innovation and reduced consumer choice.
These conditions and requirements may add to costs in two ways: first, by increasing
barriers to entry and second by possibly increasing the level of staffing/services offered
above what the free market would have provided (otherwise such regulation would
represent a needless expense). Given the pervasive extent of non-profit ownership among
hospitals, it is conceivable that regulation could improve efficiency, thereby lowering
hospital costs. Our search allowed for the possibility that professional accreditation and
licensure regulation could decrease, increase or have no impact on health expenditures.
Benefits of Certification and Licensure Regulation for Health
Professionals
Question 2a. What is the impact certification and licensure regulations for health
professionals on patient outcomes? In theory, licensure can ensure a minimum level of
quality, which is particularly valuable in alleviating uncertainty if patients are not in a
good position to judge quality (Arrow 1963; Leffler 1978). Even if one concedes that
licensure permits professionals to earn more income, some have argued that the ability to
earn rents helps deter malfeasance, hence contributing to higher quality (Svorny 1992). It
further has been argued that since the quality improvement aspects of licensure are
probably positive, one cannot say a priori whether licensure results in a net benefit or
harm to consumers (Phelps 2003).
3
While this form of regulation theoretically should improve quality, conceptually it is
difficult to say with certainty what level of quality would have been offered absent such
regulation. Moreover, regulation may divert resources away from patient care into
administration/compliance, reducing quality in the process. For all these reasons, our
search allowed for the possibility that professional accreditation and licensure regulation
could decrease, increase or have no impact on patient outcomes.
Limitations of Working Paper
4
Section II. Methods
Literature Search and Review
Sources
Peer-Reviewed Literature
We performed electronic subject-based searches of the literature using the following
databases:
 MEDLINE® (1975-June 30, 2004) and CINAHL® (1975-June 30, 2004)
which together cover all the relevant clinical literature and leading health
policy journals
 Health Affairs, the leading health policy journal, whose site permits full text
searching of all issues from 1981-present
 ISI Web of Knowledge (1978-June 30, 2004) which includes the Science
Citation Expanded®, Social Sciences Citation Index®, and Arts & Humanities
Citation Index™ covering all major social sciences journals
 Lexis-Nexis (1975-June 30, 2004) which covers all major law publications
 Public Affairs Information Service (PAIS), including PAIS International and
PAIS Periodicals/Publishers (1975-June 30, 2004) which together index
information on politics, public policy, social policy, and the social sciences in
general. Covers journals, books, government publications, and directories.
 Dissertation Abstracts (1975-June 30, 2004)
 Books in Print (1975-June 30, 2004)
A professional librarian assisted in the development of our search strategy,
customizing the searches for each research question. In cases where we already had
identified a previous literature synthesis that included items known to be of relevance, we
developed a list of search terms based on the subject headings from these articles and
from the official indexing terms of MEDLINE and other databases being used. We
performed multiple searches with combinations of these terms and evaluated the results
of those searches for sensitivity and specificity with respect to each topic. We also
performed searches on authors known or found to have published widely on a study
topic. In addition to performing electronic database searches, we consulted experts in the
field for further references. Finally, we reviewed the references cited by each article that
was ultimately included in the synthesis. We did not hand search any journals. This
review was limited to the English-language research literature. A complete listing of
search terms and results is found in Appendix A.
“Fugitive” Literature
In some cases, relevant “fugitive” literature was cited, in which case we made every
effort to track it down. We also performed systematic Web searches at the following
sites:
 Health law/regulation Web sites
 Health industry trade organizations
 State agency trade organizations and research centers
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Major health care/health policy consulting firms
Health policy research organizations
Academic health policy centers
Major health policy foundations
These searches varied by site. In cases where a complete publications listing was
readily available, it was hand-searched. In other cases, we relied on the search function
within the site itself to identify documents of potential relevance. Because of the volume
of literature obtained through the peer-reviewed literature, including literature syntheses,
we avoided material that simply summarized existing studies. Instead, we focused on
retrieval of documents in which a new cost estimate was developed based on collection of
primary data (e.g., surveys of state agencies) or secondary analysis of existing data (e.g.,
compilation of agency enforcement costs available from some other source). We
excluded studies that did not report sufficient methodological detail to permit replication
of their approach to cost estimation.
Inclusion Criteria
We developed the following inclusion criteria:
 Sample: wherever results from nationally representative samples were
available, these were used in favor of case studies or more limited samples.
 Multiple Publications: whenever multiple results were reported from the same
database or study, we selected those that were most recent and/or most
methodologically sound.
 Outcomes: we selected only studies in which a measurable impact on costs
was either directly reported or could be estimated from the reported outcomes
in a reasonably straightforward fashion.
 Methods: we only selected studies in which sufficient methodological detail
was reported to assess the quality of the estimate provided.
Where possible, we limited the review to studies using from 1975 through June 30,
2004 reasoning that any earlier estimates could not be credibly extrapolated to the present
given the sizable changes in the health care industry during the past two decades. Other
exclusions were as follows:
 Unless we had no other information for a particular category of costs or
benefits, we excluded qualitative estimates of impact.
 Estimates of impacts derived from unadjusted comparisons were discarded
whenever high quality multivariate results were available to control for
differences between states or across time.
 Estimates that focused on measuring system-wide impact generally were
selected over narrower estimates (e.g., per capita health spending vs. cost per
inpatient day) on grounds that savings achieved in one sector may have
induced higher spending elsewhere in the system; hence narrower
comparisons might inadvertently lead to an inappropriate conclusion.
6
Section III. Results
Empirical Evidence
Licensure has been studied for longer than any other form of regulation examined in this
report. In part for this reason, all the available evidence relates to the stringency of
licensure requirements rather than comparing states with and without licensure.
 Industry Compliance Costs: Burden of Documentation. Only one study was
uncovered that offered estimates of the cost of compliance based on time spent
documenting care. This study indicated that a physician seeing 20 Medicare
patients a day would have to spend two to three hours daily on documentation to
comply with Medicare requirements (Emord 1998). This burden was broken
down into costs of compliance with fraud and abuse regulations and costs of
compliance with other COPs, the latter of which is monetized here.
 Indirect Costs: Increased Cost of Physician Services. On the physician side,
demonstrating the impact of licensure is complicated by the fact that all states
require licensure; hence there is not the same opportunity to rely on inter-state
differences to calculate effects on either cost or quality.
 There is a wide body of somewhat dated literature that attempted to
demonstrate the linkage between licensure and the shortage of physicians that
few would dispute existed decades ago. But while licensure may have been a
contributing factor in this shortage, it would be difficult to disentangle the
effects of licensure from other actions taken by the AMA to, for example,
restrict medical school admissions.2 Moreover, there is not strong evidence
that a physician shortage still exists. Indeed, some argue that perverse
incentives existing in health care professionals training policy have led to a
surplus in the supply of some physician specialties (McEldowney and Berry
1995).
 Another line of argument has been to calculate the rate of return to medical
training to determine whether there are “excess” returns to physicians relative
to other occupational choices: there are numerous studies that explored this
(e.g., Feldman and Scheffler 1978), but these have been criticized as being
biased upward for not taking into account that physicians work more hours
than most other professions; moreover, a review of this evidence concluded
that “the search for cartel returns resulting from AMA supply controls has not
been particularly successful” (Leffler 1978: 172). We did find one study that
examined data from 1965 showing that physician utilization is lower in states
that require basic science certification or citizenship requirements (i.e., higher
entry costs), suggesting that licensure restrictions were more restrictive than
optimal from a consumer perspective (Svorny 1987). But the author did not
calculate the loss of consumer surplus associated with this reduction in use,
nor would it necessarily apply today given the large increase in subsequent
physician supply.
2
A thorough discussion of this is contained in Langwell and Moore 1982, pp. 28-30.
7
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3
A study of state mental hospitals showed that more restrictive licensure
policies regarding foreign medical graduates were associated with higher
costs, but no difference in quality (Windham et al. 1978).
Indirect Costs: Higher Dental Costs Due to Supply Restrictions. Several studies
have shown that licensure increases the cost of dental services.
 Using state-level data, Shepard 1978 found that fees were 14.9 percent higher
in states in which the absence of reciprocity agreements limited entry,
concluding that national dental costs were $700 million higher in 1976 than
they would have been without such restrictions--7.5% of dental expenditures
that year.3
 House (1979, cited in Gaumer 1984) used individual-level data to show that
fees were 5 to 10 percent higher in states with reciprocity agreement
limitations.
 Boulier (1980) also concludes that removal of licensure restrictions would
increase consumer surplus.
 Kleiner and Kudrle (1997) use individual-level data on 464 Air Force recruits
along with detailed statutory information on stringency of dental licensure
requirements for the period 1960-1987 to show that stricter licensing
requirements did not improve dental health, but did result in higher dental
prices (a state changing from the lowest level of restrictiveness to the highest
would see dental prices increase 14 to 16 percent).
 Conrad and Emerson (1981) show that regulations that limit the number of
hygienists per dentist inhibit the delegation of tasks to dental hygienists and
result in higher dental fees.
Indirect Costs: Increased Cost of Optometry Services. A study of optometrists
concluded that the combination of restrictions on employment and branch offices
along with continuing education requirements raised the price of eye exams by
20.6 percent (Begun and Feldman 1981).
Indirect Costs: Increased Cost of Hospital Staff. In a study of hospital labor
markets for the period 1960-1975, Sloan and Steinwald (1980) found that
mandatory licensure was associated with 5-6 percent higher wages for LPNs and
any sort of licensure was associated with 13 percent higher wages for medical
technologists; mandatory licensure increased RN wages by 4.9% using 1960-1975
data, but the effect was not significant for the 1966-1975 period.
Indirect Benefits: Increased Availability of Alternative Providers.
 A comprehensive study of physician assistants, nurse practitioners and
certified nurse midwives found that favorable practice environments were
strongly associated with a greater supply of such practitioners (Sekscenski et
al. 1994); this is supported in a more recent study of nurse midwives (Declerq
et al. 1998).
 A study of complementary and alternative medicine (CAM) showed that use
of such services was significantly higher in states with at least 2 CAM
practice statutes or a liberalized physician practice law that expands their
scope of practice to CAM (Sturm and Unutzer 2001).
Calculated from NHE data for 1976 reported in Gibson, Waldo and Levit (1983).
8
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Indirect Benefits: Higher Quality. We found relatively few studies documenting
an increase in quality attributable to licensure.
 A study of family physicians in Quebec found that those achieving a higher
score on their certification exam demonstrated a sustained relationship (over
4-7 years) with better use of acute and chronic disease management (Tamblyn
et al. 2002).
 An early study found that dental licensure improved quality, as measured by
reduced probability of adverse outcomes, reduced variability in service quality
and higher patient satisfaction (Holen 1978, cited in Kleiner and Kudrle
1997), but this study failed to include treatment price or a number of other
pertinent control variables; in contrast, a more recent and methodologically
superior study based on the dental health of Air Force personnel concluded
that licensure does not improve quality, as neither malpractice rates nor
complaints against dentists are lower in states with stricter licensure
requirements (Kleiner and Kudrle 1997).
Net Assessment
We combined the evidence cited above as follows:
 Government Regulatory Costs. We could not locate an aggregate expenditure
figure for accreditation and licensure activities across all states, so we estimated
this based on the average 2002 cost per capita for state medical board activities in
New Mexico ($0.50) and California ($1.13) as lower and upper bounds and
averaged these for our expected value.
 Industry Compliance Costs. We assumed compliance costs were at least as high
as agency expenditures for our lower bound and three times as high for our upper
bound, again averaging these figures for our expected value.
 Industry Compliance Costs: Burden of Documentation. Emord’s estimate of the
average documentation time required for Medicare patients is between 6 and 9
minutes per patient (Emord 1998). Using these values as the lower and upper
bounds, respectively, we multiplied by the total number of Medicare eligibles in
2002 and then monetize this time using the average hourly value of a hospital
worker as the lower bound and the hourly value of a physician as the upper
bound. We assume that 70 percent of the time losses documented in the Emord
study were not related to fraud and abuse. This resulted in an annual cost estimate
of $216 million ($170, $229).
 Indirect Costs: Higher Dental Costs Due to Supply Restrictions. In addition, we
calculated and added the regulatory impact on dental costs using the 7.5 percent
figure from Shepard as an upper bound, one quarter of this value as a lower
bound, averaging these two as an expected value.
 Indirect Costs: Increased Cost of Optometry Services. We estimate total
expenditures for optometrists based on average annual earnings and total
employment as reported by Bureau of Labor Statistics. We estimate office
overhead using weights from the CMS Medicare Economic Index, using as an
9
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upper bound the ratio of non-MD salary: MD salary (126%) and as a lower bound
the average fringe benefit rate for non-physician compensation (35%). We use the
20.6 percent cost increase reported by Begun and Feldman as an upper bound, one
quarter of this amount as a lower bound (on grounds that subsequent competition
through major retail outlets such as Sears may have eroded this economic rent)
and apply these to the estimated share of such expenditures subject to regulation.
Based on figures reported by Benham (1972), roughly one quarter of states had a
total prohibition on advertising by optometrists, so we use 25 percent as the lower
bound, assume 75 percent as an upper bound and average the two for our
expected share.
Indirect Costs: Increased Cost of Hospital Staff. We then calculated total wage
expenditures on a) RNs; b) LPNs; and c) medical technologists based on the total
number working in each category times their average respective hourly wages as
reported by Bureau of Labor Statistics multiplied by 2000 annual hours. We then
applied the regulatory cost impact figures reported by Sloan and Steinwald as
follows: a) for RNs we used 0% as our expected value and lower bound since they
found no significant effect for 1966-1975; we used their 4.9% estimate from the
full period of analysis as our upper bound; b) for LPNs and medical technologists,
we used their 1966-1975 results for our expected values and their 95% C.I. for
lower and upper bounds. By 1975, 91 percent of SMSAs had mandatory licensure
for RNs and LPNs, compared to slightly more than half in 1960 (Sloan and
Steinwald 1980). Therefore, we use this 91% as a lower bound and 100% as the
upper bound, averaging these for the expected value. Medical technologists were
subject to mandatory licensure in 4 of 22 SMSAs in 1975, so Sloan and Steinwald
base their results on the impact of any sort of licensure, but do not report its
prevalence. We therefore use 50 percent as a lower bound and 100 percent as an
upper bound.
Social Welfare Losses: Efficiency Losses from Tax Collection. To account for the
efficiency losses associated with raising taxes to pay for government regulatory
costs, we multiply the latter times the marginal cost of income tax collections (see
Table B-1 for how these costs are calculated).
Social Welfare Losses: Efficiency Losses from Regulatory Costs. All industry
compliance costs are presumed to be roughly equivalent to an excise tax, i.e.,
raising prices and reducing demand/output correspondingly. We therefore
multiply these costs times the marginal excess burden associated with output
taxes, using 21% (15%, 28%) as the expected value of MEB (see Table B-1 for
details of how MEB is calculated).
These computations resulted in an estimated regulatory cost of $6,549 million (3,414,
15,754). Benefits, i.e., higher earnings for selected health professionals, amount to $4,740
(1,981, 12,981).
Acronyms
RNs
LPNs
Registered Nurses
?
10
PAs
NPs
CMW
SMSAs
Physicians’ Assistants
Nurse Practitioners
Certified Nurse Midwife
References
MEDICARE/MEDICAID CONDITIONS OF PARTICIPATION
Background
Key Elements.
Acronyms
COPs
Conditions of Participation (Medicare/Medicaid)
11
Listing of Included Studies
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12
17. Cole, James W. "A Centralized Verification System." Physician Executive 24, no. 5 (September
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13
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14
54. Kelly, K. "Nurse Practitioner Challenges to the Orthodox Structure of Health Care Delivery:
Regulation and Restraints on Trade." 10 (1985): 195.
55. Kessel RA. "Price Discrimination in Medicine." Journal of Law and Economics 1 (1958): 20-53.
56. Kleiner, Morris M. and Robert T. Kudrle. Does Regulation Improve Outputs and Increase Prices?:
The Case of Dentistry. Cambridge, MA: National Bureau of Economic Research, 1997.
Working Paper No. 5869.
57. Kralewski, Bryan Dowd, and Janet Silversmith. "Managing Patient Care Cost in Minnesota Medical
Group Practices." Minnesota Medicine (February 2004): 48-54.
58. Krol, Robert and Shirley Svorny. " Regulation and Economic Performance: Lessons From the
States." The Cato Journal 14, no. 1.
59. Kudrle, R. T. "Does Regulation Affect Economic Outcomes? the Case of Dentistry." 43 (2000): 547.
60. Lambert, David Aaron. "Political and Economic Determinants of Mental Health Regulations."
Brandeis U., The F. Heller Grad. Sch. For Adv. Stud. In Soc. Wel.; 0541, 1986.
61. Langwell, Kathryn M. and Sylvia F. Moore. A Synthesis of Research on Competition in the
Financing and Delivery of Health Services. Rockville, MD: Department of Health and
Human Services, National Center for Health Services Research, 1982. DHS Pub No. (PHS)
83-3327.
62. Leffler, K. "Physician Licensure: Competition and Monopoly in American Medicine." J of Law and
Economics 21, no. 1 (1978): 165.
63. Leiken, Alan M. and Edmund J. McTernan. "Cost Containment and the Future Utilization of Health
Manpower." Health Care Strategic Management 3, no. 12 (December 1985): 11-13.
64. Macdonald, Michael, Kathryn Meyer, and Beth Essig. "Health Care Law: A Practical Guide.". 7th.
New York: Matthew Bender, 1992.
65. Marder, William D. and Richard J. Willke. "Comparisons of the Value of Physician Time by
Specialty." in Regulating Doctors' Fees: Competition, Benefits, and Controls Under
Medicare, 260-281. Editor H. E. III Frech. Washington, DC: The AEI Press.
66. Mason, C. A. "Will Mandated Continuing Education Improve Dentistry & at What Cost?" 30, no. 3
(May 1999-June 1999): 5.
67. McCarthy, Thomas R. "The Competitive Nature of the Primary-Care Physician Services Market."
Journal of Health Economics 4, no. 2 (June 1985): 93-117.
68. McEldowney, Rene P. and Arnold Berry. "Physician Supply and Distribution in the USA." Journal
of Management in Medicine 9, no. 5 (1995): 68-74.
69. Miller, Robert D. "Problems in Health Care Law.". 8th. Gaithersburg, Maryland: Aspen Publishers,
Inc., 2000.
70. Morrisey, Michael A. "State Health Care Reform: Protecting the Provider." American Health Care:
Government, Market Processes, and the Public Interest, 229-66. Roger D. Feldman. New
Brunswick: Transaction Publishers.
71. Morrison, Richard Drury. "The Causes and Consequences of Health Occupational Regulation:
15
History, Theory and Evidence With Special Reference to the Regulation of Social Workers
in Virginia." Virginia Commonwealth University; 2383, 1988.
72. Netten, Ann and Jane Knight. "Annuitizing the Human Capital Investment Costs of Health Service
Professionals." Health Economics 8 (1998): 245-55.
73. Nicholson, Sean and Nicholas S. Souleles, "Physician Income Expectations and Specialty Choice."
NBER Working Paper Series #8536 (2001). Cambridge, MA: National Bureau of
Economic Research, 2001.
74. Norcini, J. J., H. R. Kimball, and R. S. Lipner. "Certification and Specialization: Do They Matter in
the Outcome of Acute Myocardial Infarction?" Academic Medicine 75, no. 12 (December
2000): 1193-8.
75. O'Neill, Liam. "Surgeon Characteristics Associated With Mortality and Morbidity Following Carotid
Endarerectomy." Neurology 55, no. 6 (September 2000): 773-81.
76. Olchanski, Vladislav and others. "Primary-Care-Physician Supply: Policy Analysis on the State
Level." Clinical Performace and Quality Health Care 6, no. 3 (July 1998): 129-37.
77. Parboosingh, John. "Credentialing Physicians: Challenges for Continuing Medical Education." The
Journal of Continuing Education in the Health Professions 20, no. 3 (Summer 2000): 18890.
78. Paul, D. P. 3rd. "The Potential Impact of the North American Free Trade Agreement on American
Dental Licensure: A European Community Model." 18, no. 1-2 (2000): 87-98.
79. Phelps, Charles E. "Health Economics.". 3rd. Boston: Addison Wesley, 2003.
80. Rankin, J. W. and B. A. Hubbard. "Private Credentialing of Health Care Personnel: a Pragmatic
Response to Academic Theory ." 10 (1984): 189.
81. Richards, Edward P. "The Police Power and the Regulation of Medical Practice: a Historical Review
and Guide for Medical Licensing Board Regulation of Physicians in ERISA-Qualified
Managed Care Organizations." Annuals of Health Law 8, no. 201 (1999).
82. Rosenbaum, Sara. "The Impact of United States Law on Medicine As a Profession." JAMA 289, no.
12 (2003): 1546-56.
83. Safriet, B. J. "Closing the Gap Between Can and May in Health-Care Providers' Scopes of Practice:
a Primer for Policymakers." 19 (1992): 301.
84. Safriet, Barbara J. "Health Care Dollars and Regulatory Sense: The Role of Advanced Practice
Nursing." Yale Journal on Regulation 9, no. 2 (Summer 1992): 417-88.
85. Saponaro, J. M. "Determining the Immunity "Measuring Stick": the Impact of the Health Care
Quality Improvement Act and Antitrust Laws on Immunity Aspects of Granting Privileges
to Physicain Assistants." 47 (1999): 115.
86. Schneider, Donald P. and William J. Foley. "A Systems Analysis of the Impact of Physician
Extenders on Medical Cost and Manpower Requirements." Medical Care 15, no. 4 (April
1977): 277-97.
87. Sekscenski, E. S. and others. "State Practice Environments and the Supply of Physician Assistants,
Nurses, Practitioners, and Certified Nurse-Midwives." New Engl J Med 331, no. 19
16
(November 1994): 1266-71.
88. Shepard, Lawrence. "Licensing Restrictions and the Cost of Dental Care." Journal of Law and
Economics 21, no. 1 (1978): 187-201.
89. Sloan, FA and B Steinwald. "Hospital Labor Markets.". Lexington, MA: DC Health, 1980.
90. Sloan, Frank A. and William B. Schwartz. "More Doctors: What Will They Cost?" JAMA 249 , no.
6 (February 1983): 766-69.
91. Stano, Miron . "An Analysis of the Evidence on Competition in the Physician Services Market."
Journal of Health Economics 4, no. 3 (September 1985): 197-211.
92. Sturm, Roland. and Jurgen. Unutzer. "State Legislation and the Use of Complementary and
Alternative Medicine." Inquiry 37 (Winter 2000-Winter 2001): 423-29.
93. Sullivan, Robert B. and others. "The Evolution of Divergences in Physician Supply Policy in Canada
and the United States." JAMA 276 , no. 9 (September 1996): 704-9.
94. Svorny, Shirley. "Physician Licensure: A New Approach to Examining the Roles of Professional
Interests." 25(July 1987): 497-509.
95. ________. "Should We Reconsider Licensing Physicians?" Contemporary Policy Issues 10 (January
1992): 31-39.
96. Svorny, Shirley V. "The Changing Role of Licensure in Promoting Incentives for Quality in Health
Care." American Health Care: Government, Market Processes, and the Public Interest, 36584. Roger D. Feldman. New Brunswick: Transaction Publishers.
97. Tamblyn, Robin and others. "Association Between Licensure Examination Scores and Practice in
Primary Care." 288, no. 23 (December 2002).
98. Taskforce on Health Care Workforce Regulation and others. Reforming Health Care Workforce
Regulation: Policy Considerations for the 21st Century. Pew Health Professions
Commission, 1995.
99. Tierney, John T., William J. Waters, and Donald C. Williams. "Controlling Physician Oversupply
Through Certificate of Need." American Journal of Law and Medicine 6, no. 3 (Fall 1980):
335-60.
100. Trandel-Korenchuk, Darlene. "Nursing and the Law.". 5th. Gaithersburg, Maryland: Aspen
Publications, 1997.
101. Van Hemel, Peter J. "A Way Out of the Maze: Federal Agency Preemption of State Licensing and
Regulation of Complementary and Alternative Medicine Practitioners." 27 (2001): 329.
102. Wedig, Gerard J. "Ramsey Pricing and Supply-Side Incentives in Physician Markets." Journal of
Health Economics 12, no. 4 (December 1993): 365-84.
103. Weiner, Jonathan P. "Forecasting the Effects of Health Reform on US Physician Workforce
Requirement: Evidence From HMO Staffing Patterns." Journal of the American Medical
Association 272, no. 3 (July 1994): 222-30.
104. Weissert, Carol S., Jack H. Knott, and Blair E. Stieber. "Education and the Health Professions:
Explaining Policy Choices Among the States." Journal of Health Politics, Policy, and Law
17
19, no. 2 (Summer 1994): 361-92.
105. White, William D. "Physicians and the Changing Health Care Marketplace." Quarterly Review of
Economics and Finance 39, no. 4 (Winter 1999): 439-44.
106. Windham, S and others, "Evaluation of the Use of Foreign Medical Graduates in State Mental
Hospitals." (1978). Cambridge, MA: Abt Assoc., 1978.
107. Wise, L. C. "Tax-Deductible Education Expenses." 23, no. 5 (May 1993): 56-61.
108. Zweifel, Peter. "Protecting the Medical Profession: a Commentary." in Regulating Doctors' Fees:
Competition, Benefits, and Controls Under Medicare, 75-91. Editor H. E. III Frech.
Washington, DC: The AEI Press.
18
Listing of Excluded Studies
Key for Reasons for Exclusion
1. Studies with no original data
2. Studies with no outcomes of interest
3. Studies performed outside U.S.
4. Studies published in abstract form only
5. Case-report only
6. Unable to obtain the article
1. American Medical Association. "Physician Licensure: An Update of Trends." May 1902.
[http://www.ama-assn.org/ama/pub/printcat/2378.html]. 2 March 1912.
2. Ameringer, Carl F. "State Medical Boards and the Politics of Public Protection.". Baltimore: The
Johns Hopkins University Press.
3. Batalden, Paul and others. "General Competencies and Accreditation in Graduate Medical
Education; an Antidote to Overspecification in the Education of Medical Specialists."
Health Affairs (September 2002-October 2002).
4. Benham, Lee. "Licensure and Competition in Medical Markets." in Regulating Doctors' Fees:
Competition, Benefits, and Controls Under Medicare, 75-91. Editor H. E. III Frech.
Washington, DC: The AEI Press.
5. Bloom, Bernard S. and Osler L. Peterson. "Physician Manpower Expansionism: a Policy Review ."
Annals of Internal Medicine 90, no. 2 (February 1979): 249-56.
6. Boaz, Rachel Florsheim. "Free-Standing Subsidized Family Planning Clinics: the Manpower Cost
of Patient Services." Inquiry 10 (March 1973): 14-25.
7. Butter, Irene and others. "Effects of Manpower Utilization on Cost and Productivity of a
Neighborhood Health Center." Milbank Memorial Fund Quarterly 50, no. 4 (October
1972): 421-52.
8. Carroll, Sidney L. and Robert J. Gaston. "Occupational Licensing and the Quality of Service: an
Overview." Law and Human Behavior 7, no. 2/3 (1983): 139.
9. Cole, James W. "A Centralized Verification System." Physician Executive 24, no. 5 (September
1998-October 1998): 52-56.
10. Cooper, James K., Karen Heald, and Michael Samuels. "Affecting the Supply of Rural Physicians."
American Journal of Public Health 67, no. 8 (August 1977): 756-9.
11. Cooper, Richard A. and Linda H. Aiken. "Human Inputs: The Health Care Workforce and Medical
Markets." J of Health Politics, Policy and Law 26, no. 5 (October 2001): 925-38.
12. Cooper, Richard A. and others. "Economic and Demographic Trends Signal an Impending Physician
Shortage." Health Affairs 21, no. 1 (January 2002-February 2002): 140-154.
13. Cromwell, J. "Barriers to Achieving a Cost-Effective Workforce Mix: Lessons From Anesthesiology
19
." Journal of Health Politics, Policy, and Law 24, no. 6 (December 1999): 1331-61.
14. Escarce, Jose J., Daniel Wozniak Gregory D. Polsky, and Phillip R. Kletke. "HMO Growth and the
Geographical Redistribution of Generalist and Specialist Physicians, 1987-1997." Health
Services Research 35, no. 4 (October 2000): 825.
15. Fournier, Gary M. and Melayne Morgan McInnes. "Medical Board Regulation of Physician
Licensure: Is Excessive Malpractice Sanctioned?" Journal of Regulatory Economics 12
(1997): 113-26.
16. Friedland, Bernard Valachovic Richard. "The Regulation of Dental Licensing: The Dark Ages?"
American Journal of Law and Medicine 17, no. 249 (1991).
17. Grumbach, Kevin. "Fighting Hand to Hand Over Physician Workforce Policy." Health Affairs 21,
no. 5 (September 2002-October 2002): 13-27.
18. Hadley, Jack . "Theoretical and Empirical Foundations of the Resource-Based Relative Value
Scale." in Regulating Doctors' Fees: Competition, Benefits, and Controls Under Medicare,
97-125. Editor H. E. III Frech. Washington, DC: The AEI Press.
19. Hirth, Richard A. and Michael E. Chernew. "The Physician Labor Market in a Managed CareDominated Environment." Economic Inquiry 37, no. 2 (April 1999): 282.
20. Hogan, Daniel B. "The Effectiveness of Licensing: History, Evidence and Recommendations." Law
and Human Behavior 7, no. 2/3 (1983): 117.
21. Jacobson, Peter D. "Regulating Health Care: From Self-Regulation to Self-Regulation?" J of Health
Polit Pol & Law 26, no. 5 (October 2001): 1167-77.
22. Jessee, William F. "MGMA submits comments on regulatory burdens to MedPAC." 2004.
[http://www.mgma.com/press/medpaccomments.cfm]. 27 July 2004.
23. Kralewski, Bryan Dowd, and Janet Silversmith. "Managing Patient Care Cost in Minnesota Medical
Group Practices." Minnesota Medicine (February 2004): 48-54.
24. Krol, Robert and Shirley Svorny. " Regulation and Economic Performance: Lessons From the
States." The Cato Journal 14, no. 1.
25. Leiken, Alan M. and Edmund J. McTernan. "Cost Containment and the Future Utilization of Health
Manpower." Health Care Strategic Management 3, no. 12 (December 1985): 11-13.
26. Marder, William D. and Richard J. Willke. "Comparisons of the Value of Physician Time by
Specialty." in Regulating Doctors' Fees: Competition, Benefits, and Controls Under
Medicare, 260-281. Editor H. E. III Frech. Washington, DC: The AEI Press.
27. McCarthy, Thomas R. "The Competitive Nature of the Primary-Care Physician Services Market."
Journal of Health Economics 4, no. 2 (June 1985): 93-117.
28. Morrisey, Michael A. "State Health Care Reform: Protecting the Provider." American Health Care:
Government, Market Processes, and the Public Interest, 229-66. Roger D. Feldman. New
Brunswick: Transaction Publishers.
29. Netten, Ann and Jane Knight. "Annuitizing the Human Capital Investment Costs of Health Service
Professionals." Health Economics 8 (1998): 245-55.
20
30. Nicholson, Sean and Nicholas S. Souleles, "Physician Income Expectations and Specialty Choice."
NBER Working Paper Series #8536 (2001). Cambridge, MA: National Bureau of
Economic Research, 2001.
31. O'Neill, Liam. "Surgeon Characteristics Associated With Mortality and Morbidity Following Carotid
Endarerectomy." Neurology 55, no. 6 (September 2000): 773-81.
32. Olchanski, Vladislav and others. "Primary-Care-Physician Supply: Policy Analysis on the State
Level." Clinical Performace and Quality Health Care 6, no. 3 (July 1998): 129-37.
33. Parboosingh, John. "Credentialing Physicians: Challenges for Continuing Medical Education." The
Journal of Continuing Education in the Health Professions 20, no. 3 (Summer 2000): 18890.
34. Richards, Edward P. "The Police Power and the Regulation of Medical Practice: a Historical Review
and Guide for Medical Licensing Board Regulation of Physicians in ERISA-Qualified
Managed Care Organizations." Annuals of Health Law 8, no. 201 (1999).
35. Rosenbaum, Sara. "The Impact of United States Law on Medicine As a Profession." JAMA 289, no.
12 (2003): 1546-56.
36. Safriet, Barbara J. "Health Care Dollars and Regulatory Sense: The Role of Advanced Practice
Nursing." Yale Journal on Regulation 9, no. 2 (Summer 1992): 417-88.
37. Schneider, Donald P. and William J. Foley. "A Systems Analysis of the Impact of Physician
Extenders on Medical Cost and Manpower Requirements." Medical Care 15, no. 4 (April
1977): 277-97.
38. Shepard, Lawrence. "Licensing Restrictions and the Cost of Dental Care." Journal of Law and
Economics 21, no. 1 (1978): 187-201.
39. Sloan, Frank A. and William B. Schwartz. "More Doctors: What Will They Cost?" JAMA 249 , no.
6 (February 1983): 766-69.
40. Stano, Miron . "An Analysis of the Evidence on Competition in the Physician Services Market."
Journal of Health Economics 4, no. 3 (September 1985): 197-211.
41. Sullivan, Robert B. and others. "The Evolution of Divergences in Physician Supply Policy in Canada
and the United States." JAMA 276 , no. 9 (September 1996): 704-9.
42. Svorny, Shirley V. "The Changing Role of Licensure in Promoting Incentives for Quality in Health
Care." American Health Care: Government, Market Processes, and the Public Interest, 36584. Roger D. Feldman. New Brunswick: Transaction Publishers.
43. Taskforce on Health Care Workforce Regulation and others. Reforming Health Care Workforce
Regulation: Policy Considerations for the 21st Century. Pew Health Professions
Commission, 1995.
44. Tierney, John T., William J. Waters, and Donald C. Williams. "Controlling Physician Oversupply
Through Certificate of Need." American Journal of Law and Medicine 6, no. 3 (Fall 1980):
335-60.
45. Trandel-Korenchuk, Darlene. "Nursing and the Law.". 5th. Gaithersburg, Maryland: Aspen
Publications, 1997.
21
46. Wedig, Gerard J. "Ramsey Pricing and Supply-Side Incentives in Physician Markets." Journal of
Health Economics 12, no. 4 (December 1993): 365-84.
47. Weiner, Jonathan P. "Forecasting the Effects of Health Reform on US Physician Workforce
Requirement: Evidence From HMO Staffing Patterns." Journal of the American Medical
Association 272, no. 3 (July 1994): 222-30.
48. Weissert, Carol S., Jack H. Knott, and Blair E. Stieber. "Education and the Health Professions:
Explaining Policy Choices Among the States." Journal of Health Politics, Policy, and Law
19, no. 2 (Summer 1994): 361-92.
49. White, William D. "Physicians and the Changing Health Care Marketplace." Quarterly Review of
Economics and Finance 39, no. 4 (Winter 1999): 439-44.
50. Zweifel, Peter. "Protecting the Medical Profession: a Commentary." in Regulating Doctors' Fees:
Competition, Benefits, and Controls Under Medicare, 75-91. Editor H. E. III Frech.
Washington, DC: The AEI Press.
22
Appendix A. Evidence Tables
Table P-6. Cost of Accreditation and Licensure of Health Professionals (millions of 2004 dollars)
Range
Cost Category
Public Administration
Federal
State
Expected
Minimum
Benefits
Maximum
561.0
222.6
338.4
668.4
222.6
445.9
928.8
222.6
706.2
Compliance Expenditures
Administrative costs for licensure
CME requirements, time costs
Medicare Conditions of Participation
Higher medical professional incomes
Indirect Costs
Higher costs due to supply restrictions
Improved MD quality
3,469.7
1,122.0
2,122.3
225.4
2,204.6
668.4
1,358.6
177.6
6,674.6
2,786.4
3,649.7
238.5
4,739.6
4,739.6
-
1,981.2
1,981.2
-
Social Welfare Losses
Efficiency losses from tax collection
Efficiency losses from regulatory costs
GRAND TOTAL
1,020.3
294.3
726.0
9,790.6
530.9
206.8
324.1
5,385.1
Expected Minimum
-
-
Maximum Notes
-
12,981.2
12,981.2
-
4,739.6
4,739.6
4,739.6
4,739.6
-
1,981.2
1,981.2
1,981.2
1,981.2
-
12,981.2
12,981.2
12,981.2
12,981.2
-
3,576.0
1,713.8
1,862.2
24,160.6
9,479.3
3,962.3
25,962.3
[A]
[B]
[C]
[D]
[E]
Notes:
[A] The public administration costs are calculated by finding the cost per capita [P1] of accreditation and licensure and
multiplying by the total US population [P2].
[B] Compliance costs were calculated by multiplying the cost of public administration by the ratio of compliance costs to agency
expenditures [P3].
[C] Patient and consumer losses were calculated as follows: for RNs, LPNs and medical technologists, the number of each kind
of professional ([P6]; [P10]; [P14]) was multiplied by the respective portion of average salary attributable to licensure
([P7]*[P8], etc). Each of these products were adjusted for the respective percentage of areas with mandatory licensure
([P9]; [P13]; [P17]) to yield the percentage of aggregate wages for each profession that can be attributed to accreditation
and licensure. The costs of dental services attributable to licensure and accreditation were also included ([P4]*[P5]) as well
as the costs of optometric services attributable to accrediation and licensure {[P18]*[P19]*(1+[P20])*[P21]*[P22]}.
[D] Estimated by multiplying direct costs (efficiency losses) times the estimated ratio of transfer costs to efficiency costs.
[E] All losses borne by health industry are presumed to be roughly equivalent to excise taxes, I.e., raising prices and reducing
demand/output. The marginal excess burden (MEB) is intended to measure the deadweight loss associated with such
reduced output. The figures shown equal industry compliance costs and external costs of uninsured times MEB [P27].
23
Parameters:
Expected Minimum Maximum
[P1] Licensing boards/regulatory oversight gross cost,
$928.81
929
929
[P2] Federal share of cost
24%
24%
24%
[P3] State funding for hospital licensure/accreditation,
107.45
53.73
214.908
[P4] State funding for NH licensure/accreditation, 2000
149.91
149.91
149.9094
[P5] State funding for other licensure/accreditation,
110.45
56.73
217.908
[P6] Ratio of compliance to agency expenditures
2
1
3
CME hours per year required
20
15
30
Active physicians, 2004 (000's)
781
781
781
Value of MD time per hour
76
76
76
CME hours per year required, RNs
10
5
20
Active RNs, 2004 (000's)
2,421
2,421
2,421
Value of RN time per hour
39
39
39
[P7] Cost of dental services, 2002
$70,100
$70,100
$70,100
[P8] Increase in dental costs due to licensure
4.7%
1.9%
7.5%
[P9] Number of RNS
2,217,990 2,217,990
2,217,990
[P10] Average RN salary
23.45
23.45
23.45
[P11] Increase in RN costs due to licensure
0.0%
0.0%
4.9%
[P12] Percent of areas with mandatory licensure
95.5%
90.9%
100.0%
[P13] Number of LPNs
683,790
683,790
683,790
[P14] Average LPN salary
15.31
15.31
15.31
[P15] Increase in LPN costs due to licensure
4.3%
2.5%
6.0%
[P16] Percent of areas with mandatory licensure
95.5%
90.9%
100.0%
[P17] Number of medical technologists
135,220
135,220
135,220
[P18] Average salary
17.25
17.25
17.25
[P19] Increase in technologist costs due to licensure
9.8%
6.5%
13.0%
[P20] Percent of areas with mandatory licensure
75.0%
50.0%
100.0%
[P21] Number of optometrists
25,441
25,441
25,441
[P22] Average optometrist salary
88,945
88,945
88,945
[P23] Overhead cost
80.8%
35%
126.3%
[P24] Impact of restrictions on exam costs
12.9%
5.2%
20.6%
[P25] Percent of areas with regulation
50.0%
25.0%
75.0%
Disciplinary actions
[P26] Marginal tax overhead costs
52%
31%
185%
[P27] Marginal excess burden
21%
15%
28%
24
[a]
[b]
[c]
[d]
[e]
[f]
[g]
[h]
[I]
[j]
[k]
[l]
[m]
[n]
[o]
[p]
[q]
[r]
[s]
[t]
[u]
[v]
[w]
[x]
[y]
[z]
[aa]
Parmeter Notes:
[a] Based on straight-line extrapolation of figures for 1998 and 1999 reported in Table 33 of [S6].
[b] Based on figures for 1999 reported in Table 33 of of [S6].
[c] Expected figure reported in [S7]. Lower bound equals half of expected and upper bound equals twice the expected figure.
[d] Expected figure reported in [S7]. Lower bound equals half of expected and upper bound equals twice the expected figure.
[e] Expected figure reported in [S7]. Lower bound equals half of expected and upper bound equals twice the expected figure.
[f] For the ratio of compliance to agency expenditures, it was assumed that compliance costs were at least as high as agency
expenditures for the lower bound and three times as large for the upper bound. The average of these two is the expected
value.
[g] Cost of dental services in 2002 as projected in [S3].
[h] Using evidence from [S4], the upper bound of the regulatory impact on costs of dental services is a 7.5% increase and the
lower bound is one quarter of this value. The expected impact is the average of these two.
[I] Since 2002 labor statistics were not yet available, the average growth trend from 1998-2001 as determined according to the
Bureau of Labor Statistics' National Occupational and Employment Wage Estimates was applied to 2001 numbers to yield
the number of registered nurses in 2002.
[j] Average hourly salary of an RN from BLS 2001 data multiplied by the chain-weighted GDP index percentage change
according to [S3].
[k] In [S5], mandatory licensure of RNs had no significant effect on wages from 1966-1975, so 0% is the lower bound and
expected value. However, from 1960-1966, mandatory licensure was associated with a 4.9% increase in wages; this is the
upper bound.
[l] According to [S5], by 1975, 91% of SMSAs had mandatory licensure for RNs and LPNs. Therefore, 91% is the lower bound
and 100% is the upper bound. The expected value is the average of these two.
[m] Since 2002 labor statistics were not yet available, the average growth trend from 1998-2001 as determined according to the
Bureau of Labor Statistics' National Occupational and Employment Wage Estimates was applied to 2001 numbers to yield
the number of LPNs.
[n] Average hourly salary of an LPN from BLS 2001 data multiplied by the chain-weighted GDP index percentage change
according to [S3].
[o]
Mandatory licensure was associated with a 5-6% increase in wages for LPNs according to [S5]. The upper bound is the high
end of this range, and the lower bound is half of the low end of the range. The expected value is the average of the two
bounds.
[p] By 1975, 91% of SMSAs had mandatory licensure for RNs and LPNs [S5]. Therefore, 91% was used as the lower bound,
and 100% for the upper bound. The expected value is the average of the two bounds.
[q] BLS estimates
[r]
[s] Sloan and Steinwald [S5] found in 1980, that any kind of licensure was associated with 13% higher wages. This is the upper
bound. The lower bound is half that, and the expected value is the average of the two.
[t] In 1975, medical technologists were subject to mandatory licensure in 4/22 SMSAs, and results are based on any kind of
licensure, not on prevalence [S5]. Thus, 50% is used as the lower bound and 100% as the upper bound with the expected
value as the average of the two.
[u] Since 2002 labor statistics were not yet available, the average growth trend from 1998-2001 as determined according to the
Bureau of Labor Statistics' National Occupational and Employment Wage Estimates was applied to 2001 numbers to yield
the number of optemtrists in 2002.
[v] Average annual salary of an optometrist from BLS 2001 data multiplied by the chain-weighted GDP percentage change
according to [S3].
[w] Office overhead costs are estimated using weights from the CMS Medicare Economic Index, with the upper bound resulting
from the ratio of non-MD salary to MD salary and as a lower bound the average fringe benefit rate for non-physician
compensation. Expected is the average. I don't really understand this, so I just copied from the write-up...
[x] As reported in [S1], regulatory restrictions on optometrists led to a 20.6% increase in the cost of an eye exam; this is the
upper bound. The lower bound is one quarter of this amount based on the emergence of competition through major retail
outlets that may have eroded this economic rent. Expected value is the average of the upper and lower bounds.
[y] Based the reports of [S2], 25% of states had total prohibition on advertising in 1972. This is the lower bound, and we
assume that 75% is our upper bound . The average of the two is the expected value.
[z] Marginal cost of tax collections is the sum of administrative, compliance and marginal excess burden (deadweight loss): it
represents the total amount of resources lost to society per dollar of revenue collected.
[aa] Marginal excess burden is the efficiency loss associated with a small increase in income taxes. It represents the share of the
revenues collected that are lost due to reduced output as measured by general equilibrium models. The figures shown are
weighted averages for personal and corporate income taxes using the best available estimates from the literature for each.
Sources:
[S1] Begun, J., and R. Feldman. 1981. A Social and Economic Analysis of Professional Regulation in Optometry. PHS81-3295.
National Center for Health Services Research: DHHS.
[S2] Benham, Lee. 1972. The Effect of Advertising on the Price of Eyeglasses. in The foundations of regulatory economics:
Regulation and deregulation: Industries and issues .Robert B. Ekelund, Jr., ed, 3-18. The Foundations of Regulatory
Economics, 3. Cheltenham, UK.
[S3] Heffler, Stephen, Sheila Smith, Sean Keehan, M. Kent Clemesn, Greg Won, and Mark Zezza. 2003. Health spending
projections for 2002-20012: Spending on hospital services and prescription drugs continues to drive health care's share of
the economy upward. Health Affairs Web Exculsive: 54-65.
[S4] Shepard, Lawrence. 1978. Licensing restrictions and the cost of dental care. Journal of Law and Economics 21, no. 1: 187201.
[S5] Sloan, FA, and B Steinwald. 1980. Hospital Labor Markets . Lexington, MA: DC Health.
[S6] Milbank Memorial Fund, National Association of State Budget Officers, and Reforming States Group. 1998-1999 State Health
Care Expenditure Report. March 2001. Available at http://www.milbank.org/1998shcer/ (accessed July 6, 2003).
[S7] Walshe, Kieran, and Charlene Harrington. 2002. Regulation of Nursing Facilities in the United States: An Analysis of
Resources and Performance of State Survey Agencies. 42, no. 4: 475-86.
25
Appendix B. Search Strategies
Database: Ovid MEDLINE(R) <1975-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
1 (cost$ or burden$ or impact$ or outcome$).mp.
1741238
2 exp "Costs and Cost Analysis"/
161688
3 exp Certification/ec, sn, td [Economics, Statistics & Numerical Data, Trends] 821
4 exp Licensure, Dental/ec, sn, td
64
5 exp Licensure, Nursing/ec, sn, td
192
6 exp Licensure, Medical/ec, sn, td
200
7 exp Licensure, Pharmacy/ec, sn, td
11
8 licensure/ec, sn, td
293
9 (licensur$ or certification$).ti.
5418
10 (cost$ or burden$ or impact$ or outcome$).ti. and 9
92
11 3 or 4 or 5 or 6 or 7 or 8
1530
12 11 and (1 or 2)
250
13 10 or 12
327
14 ..l/ 13 lg=en
308
15 ..l/ 14 yr=1975-2004
163
16 ..l/ 14 yr=2005-2010
125
Database: CINAHL <1975-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
#
S12 S7 or S9
Query
Limiters/Expanders
Limiters - English Language;
Published Date from: 20050101-
26
Results
63
20101231
Search modes - Find all my search
terms
S11 S7 or S9
Limiters - English Language;
Published Date from: 1975010120041231
Search modes - Find all my search
terms
57
S10 S7 or S9
Search modes - Find all my search
terms
129
S9
S8 and (S1 or S2)
Search modes - Find all my search
terms
48
S8
S3 or S4
Search modes - Find all my search
terms
572
S7
S5 and S6
Search modes - Find all my search
terms
86
S6
TI cost* or burden* or impact* or Search modes - Find all my search
outcome*
terms
S5
TI licensur* or certification*
Search modes - Find all my search
terms
5056
S4
(MH
"Licensure+/EC/SN/TD/UT")
Search modes - Find all my search
terms
393
S3
(MH "Certification+/EC/TD/SN")
Search modes - Find all my search
terms
181
S2
(MH "Costs and Cost Analysis+")
Search modes - Find all my search
terms
54882
S1
cost* or burden* or impact* or
outcome*
Search modes - Find all my search
terms
444626
Database: ISI Web of Science <1975-2004>
Search Strategy #1ALL: hpcl
#5
275
#4 AND #3
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=1975-2004
# 4 761,131 (ts=(cost* or burden* or impact* or benefit*)) AND Language=(English)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=1975-2004
#3
954
#2 AND #1
27
104004
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=1975-2004
# 2 544,717 (ts=health*) AND Language=(English)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=1975-2004
#1
9,071
(ts=(certification* or licensur*)) AND Language=(English)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=1975-2004
Database: ISI Web of Science <2005-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
#5
335
#4 AND #3
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=2005-2010
# 4 725,431 (ts=(cost* or burden* or impact* or benefit*)) AND Language=(English)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=2005-2010
#3
1,008 #2 AND #1
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=2005-2010
# 2 492,984 (ts=health*) AND Language=(English)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=2005-2010
#1
5,873 (ts=(certification* or licensur*)) AND Language=(English)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=2005-2010
Database: Lexis-Nexis <1975-2004>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
[(((certification* OR licensur*) and TITLE (health*) and TITLE(cost* OR
burden* OR impact* OR benefit*)) and Date(geq(1975) and leq(2004)))]
(36)
Database: Lexis-Nexis <2005-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
[(((certification* OR licensur*) and TITLE(health*) and TITLE(cost* OR
burden* OR impact* OR benefit*)) and Date(geq(2005) and leq(2010)))]
(31)
28
Database: PAIS <1975-2004>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
Set
S1
Search
Databases
all((certification* OR licensur*) AND health*)Limits
applied
PAIS
Results
48*
Database: PAIS <2005-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
Set
S1
Search
Databases
all((certification* OR licensur*) AND health*)Limits
applied
PAIS
Results
48*
Database: Dissertation Abstracts <1975-2004>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
Set
Search
Databases
Results
S3
all((certification* OR licensur*) AND health*) AND
all(cost* OR burden* OR impact* OR outcome* OR
satisf*)Limits applied
ProQuest
Dissertations & 310*
Theses (PQDT)
S2
all(cost* OR burden* OR impact* OR outcome* OR
satisf*)Limits applied
ProQuest
Dissertations & 256610*
Theses (PQDT)
S1
all((certification* OR licensur*) AND health*)Limits
applied
ProQuest
Dissertations & 975*
Theses (PQDT)
Database: Dissertation Abstracts <2005-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
Set
Search
Databases
Results
S3
all((certification* OR licensur*) AND health*) AND
(cost* OR burden* OR impact* OR outcome* OR
satisf*)Limits applied
ProQuest
Dissertations & 328*
Theses (PQDT)
S2
cost* OR burden* OR impact* OR outcome* OR
satisf*Limits applied
ProQuest
Dissertations & 305683*
Theses (PQDT)
29
Set
S1
Search
Databases
all((certification* OR licensur*) AND health*)Limits
applied
Results
ProQuest
Dissertations & 405*
Theses (PQDT)
Database: Books in Print <1975-2004>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
QUERY
# OF RESULTS
kt="certification$" and kt="health" and py>=1975 and
py<=2004 and la=english or kt="licensur$" and kt="health"
and py>=1975 and py<=2004 and la=english
137
Database: Books in Print <2005-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
QUERY
# OF RESULTS
kt="certification$" and kt="health" and py>=2005 and
py<=2010 and la=english or kt="licensur$" and kt="health"
and py>=2005 and py<=2010 and la=English
43
Database: Health Affairs <1975-2004>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
Searching journal content for certification* or licensur* (any words) in full
text, from Jan 1981 through Dec 2004.
Displaying results: 328
Database: Health Affairs <2005-2010>
Search Strategy #1ALL: hpcl
--------------------------------------------------------------------------------
Searching journal content for certification* or licensur* (any words) in full
text, from Jan 2005 through Dec 2010.
Displaying results: 186
30
Appendix C. Web Sites Used in P-6 Literature Search
Health Law/Regulation Web Sites
We began searching at Web sites known to specialize in health law and regulation
generally or specific topics included in this review:
 American Health Lawyers Association
http://www.healthlawyers.org/ (no documents found)
 Findlaw.com—health law
http://www.findlaw.com/01topics/19health/index.html (no documents found)
 Health Care Compliance Association
http://www.hcca-info.org/ (no documents found)
 HealthHippo
http://hippo.findlaw.com/hippohome.html (no documents found)
 National Health Care Anti-fraud Association (NHCAA)
http://www.nhcaa.org/ (no documents found – member-only site)
Health Industry Trade Organizations
Health Professionals Regulation
For health professionals regulation, we searched the following industry and state
agency trade organization Web sites:
General
 Federation of State Medical Boards (FSMB)
http://www.fsmb.org/ (no documents found)
Physicians/Dentists
 American Medical Association (AMA)
http://www.ama-assn.org/ (no documents found—member-only site)
 American College of Physicians/American Society of Internal Medicine (ACPASIM)
http://www.acponline.org/ (no documents found)
 American Dental Association (ADA)
http://www.ada.org/ (no documents found—member-only site)
Midlevel Practitioners
 American Academy of Physician Assistants (AAPA)
http://www.aapa.org/ (no documents found)
 American Optometric Association
http://www.aoanet.org/ (no documents found)
 American College of Nurse Practitioners (ACNP)
http://www.nurse.org/acnp/ (no documents found)
 American Association of Nurse Anesthetists (AANA)
http://www.aana.com/ (no documents found)
31

American College of Nurse-Midwives (ACNM)
http://www.midwife.org/ (no documents found)
Mental Health
 Policy Information Exchange PIE Online
http://mimh200.mimh.edu/mimhweb/pie/database/GetArticle.asp?value=3443
 American Psychiatric Association
http://www.psych.org/ (no documents found)
 American Psychological Association (APA)
http://www.apa.org/ (no documents found)
 American Managed Behavioral Healthcare Association (AMBHA)
http://www.ambha.org/ (no documents found)
 National Alliance for the Mentally Ill (NAMI)
http://www.nami.org/ (no documents found)
Other Allied Health
 American Nurses Association (ANA)
http://www.nursingworld.org/ (no documents found)
 American Pharmaceutical Association (APA)
http://www.aphanet.org/ (no documents found)
State Agency Trade Organizations and Research Centers
For state agency trade organizations and health policy research centers specializing in
state health policy issues not accounted for above, we searched the following Web sites:
Executive branch
 National Governors Association (NGA)
http://www.nga.org/ (no documents found)
 National Association of State Budget Officers (NASBO)
http://www.nasbo.org/ (no documents found)
 Association of State and Territorial Health Officers (ASTHO)
http://www.astho.org/pubs/HIPAA5FINAL.pdf
 National Association of Health Data Organizations (NAHDO)
http://www.nahdo.org/default.asp (no documents found)
 National Association of State Auditors, Comptrollers and Treasurers (NASACT)
http://www.nasact.org/ (no documents found)
Legislative branch
 National Conference of State Legislatures (NCSL)
http://www.ncsl.org/ (no documents found)
 Council of State Governments (CSG)
http://www.csg.org/csg/default (no documents found)
 National Academy of Public Administration (NAPA)
http://www.napawash.org/ (no documents found)
32
State Health Policy Research Centers
 National Academy of State Policy
http://www.nashp.org/ (no documents found)
 Pew Center on the States
http://www.stateline.org/ (no documents found)
 State Health Policy Web Portal Group
http://www.hpolicy.duke.edu/cyberexchange/Whatstat.htm#States
Rather than search 50 individual sites, we queried by e-mail the directors of all
centers included in this group for relevant reports/studies their centers had
conducted or that had been conducted by agencies in their states
Health Care/Health Policy Consulting Firms
For major health care/health policy consulting firms, we searched the following sites.
Some of these specialize in human resource consulting, but were included in the event
they had done industry-wide studies of regulatory costs:








Buck Consultants Inc.
http://www.buckconsultants.com/ (no documents found)
Deloitte & Touche
http://www.deloitte.com/vs/0%2C1616%2Csid%25253D2000%2C00.html
documents found)
Ernst & Young LLP
http://www.ey.com/global/content.nsf/US/Home (no documents found)
Hewitt Associates LLC
http://was.hewitt.com/ (no documents found)
Milliman USA Inc.
http://www.milliman.com/ (no documents found)
PricewaterhouseCoopers LLP
http://www.pwcglobal.com/ (no documents found)
Towers Perrin
http://www.towers.com/towers/default.asp (no documents found)
Watson Wyatt Worldwide
http://www.watsonwyatt.com/ (no documents found)
(no
Health Policy Research Organizations
. For major health policy research organizations, including “think tanks” and some
advocacy groups, we searched the following sites:




Abt Associates
http://www.abtassoc.com/ (no documents found)
Alliance for Health Reform
http://www.allhealth.org/ (no documents found)
AcademyHealth
http://www.academyhealth.org/index.html (no documents found)
The Advisory Board Company
33



















http://www.advisoryboardcompany.com/ (no documents found – member-only
site)
American Enterprise Institute (AEI)
http://www.aei.org/ (no documents found)
Battelle
http://www.battelle.org/ (no documents found)
Brookings Institution
http://www.brook.edu/ (no documents found)
Cato Institute
http://www.cato.org/pubs/regulation/reg15n4c.html
http://www.cato.org/pub_display.php?pub_id=1105&full=1
http://www.cato.org/new/10-04/10-04-04r.html
http://www.cato.org/pubs/pas/pa246.pdf (new)
Center for Budget and Policy Priorities (CBPP)
http://www.cbpp.org/ (no documents found)
Center for Health Affairs (Project HOPE)
http://www.projecthope.org/ (no documents found)
Center for Health Care Strategies (CHCS)
http://www.chcs.org/ (no documents found)
Center for Study of Health Systems Change (CSHSC)
http://www.hschange.com/ (no documents found)
Employee Benefits Research Institute (EBRI)
http://www.ebri.org/ (no documents found)
Heritage Foundation
http://www.heritage.org/ (no documents found)
Institute of Medicine (IOM)
http://www.iom.edu/ (no documents found)
Lewin Group
http://www.Quintiles.com/Specialty_Consulting/The_Lewin_Group/default.htm
(no documents found)
Mathematica Policy Research (MPR)
http://www.mathematica-mpr.com/HEALTH.HTM (no documents found)
National Bureau of Economic Research (NBER)
http://www.nber.org/ (no documents found)
National Health Policy Forum
http://www.nhpf.org/ (no documents found)
RAND Health
http://www.rand.org/health_area/ (no documents found)
Research Triangle Institute (RTI)
http://www.rti.org/ (no documents found)
Urban Institute
http://www.urban.org/ (no documents found)
Major Health Policy Foundations.
searched the following sites:
For major health policy foundations, we
34






California Healthcare Foundation
http://www.chcf.org/ (no documents found)
Commonwealth Fund
http://www.cmwf.org/ (no documents found)
Robert Wood Johnson Foundation
http://www.rwjf.org/index.jsp
Henry J. Kaiser Family Foundation
http://www.kff.org/ (no documents found)
United Hospital Fund
http://www.uhfnyc.org/ (no documents found)
35