Physicians win big in states over scope-of-practice issues

Cooperation between national, state and specialty medical societies paid off this year as dozens of scope-of-practice bills were defeated.

By Jay Greene, amednews staff. July 2, 2001. Clarification

The 2001 state legislative sessions proved a banner year for physicians as they defeated a slew of scope-of-practice bills that sought to give additional independent practice rights to advanced-practice nurses, expand optometrist prescribing and surger y rights and enable psychologists to prescribe medications. While a handful of state legislatures with scope bills remain in session at press time, physicians scored well in more than a dozen states, including big victories in Maryland, Georgia, Mississip pi, South Carolina and Florida.

They found success with strategies that linked grassroots lobbying with collaborative efforts between state medical associations, specialty societies and the AMA. The theme was to educate legislators on the educational differences between physicians an d nonphysicians.

"Finally enough physicians realize that scope of practice is bigger than just their own specialty. They are speaking out for the benefit of good patient care. It is starting to pay off with victories in many fields," said Michael Brennan, MD, secretary of state affairs with the American Academy of Ophthalmology.

Dr. Brennan also attributed success this year to physicians taking time out of their busy office and academic schedules to become involved in advocacy campaigns.

Physicians have defeated the scope of practice bills in more than 12 states.

"This year was notable [for ophthalmologists] because the stakes were higher," said Dr. Brennan, an ophthalmologist in Burlington, N.C. Eight states had bills that could have allowed optometrists to give injections, he said.

Optometry bills -- most designed to allow glaucoma treatment -- were defeated in 14 states. Legislatures in Pennsylvania, New York, Oregon and Massachusetts were still in session at press time. While all states allow optometrists to perform some diagno stic procedures and prescribe therapeutic medications, 13 states do not permit optometrists to prescribe controlled substances for treatment of some types of glaucoma.

A close call

One of the more contentious scope battles was in Maryland. State medical society officials needed Gov. Parris N. Glendening's veto to stop nurse practitioners from being listed alongside of primary care physicians on HMO panels.

"The bill did not contain adequate safeguards to prevent the pressuring of patients into using nurse practitioners [by HMOs]," said Albert Blumberg, MD, president of the Maryland State Medical Society. "We do not believe the training of nurse practitio ners is an adequate substitute for that of a primary care physician."

Other bills that were defeated in Maryland included giving nurse psychotherapists prescriptive authority with physician collaboration, allowing pharmacists to collaborate with physicians and modify prescriptions and enabling certified registered nurse anesthetists greater independent practice authority.

"Even though we won a lot of battles, the nurse practitioner issue took up a lot of time, energy and personal resources," said Dr. Blumberg, a Baltimore radiologist. "We have to be constantly vigilant and active because nonphysicians will be back next year."

Georgia physicians defeated bills to allow psychologists and optometrists prescribing rights. "We had another quite successful year," said David Cook, general counsel for the Medical Assn. of Georgia. "The optometrist bill went further than ever this y ear, but we still defeated it."

Psychologist prescribing bills were defeated in eight other states -- Connecticut, Hawaii, Illinois, Louisiana, Missouri, New Mexico, Tennessee and Texas.

In 1998, the U.S. Territory of Guam enacted legislation that grouped psychologists with physician assistants as "allied health professionals" and authorized them to obtain limited prescription authority under certain conditions. To date, however, no ps ychologists have applied for prescribing rights.

"We were very pleased to have been able to influence the legislative process," said Richard Harding, MD, president of the American Psychiatric Assn., in Columbia, S.C. "Psychologists are very good at dealing with human behavior, but they are not physic ians," Dr. Harding said.

Dr. Harding said that while no states allowed psychologists prescribing power, bills in some states include language that would set up a council to review possible medications that psychologists could prescribe.

"This is a foot in the door that we don't think should be allowed," Dr. Harding said. "Giving prescribing rights to nonphysicians is bad medicine. It is very complicated to prescribe psychotropic medication to the elderly and children, especially when other drugs are involved."

In Mississippi, a bill that would have allowed nurse practitioners to diagnose, treat and prescribe medications for patients without direct supervision of physicians was defeated in committee.

Florida physicians worked to defeat several scope bills, including one that would have allowed nurse practitioners to prescribe controlled substances. Fourteen states permit advanced-practice nurses to independently prescribe controlled substances, sai d the National Conference of State Legislatures.

Not all of the battles ended in victory. Despite opposition from physician groups, pharmacists added five more states to the 29 that permit collaborative practice arrangements with physicians, said the NCSL. Those five states allowing pharmacists to in itiate or modify medications under certain protocols are Idaho, Louisiana, Nebraska, Ohio and Tennessee. (See Clarification)

Clarification

This story overstated the number of states that have either laws or regulations that would permit collaborative agreements between pharmacists and physicians. According to the National Conference of State Legislatures, the number is 29 and does not inc lude Tennessee. As of Aug. 20, 2001, regulations had not been written in Louisiana. AMNews regrets the error.