AMA Advocacy Insights webinar series: Protecting patients from inappropriate scope of practice expansions

Webinar (series)
Protecting patients from inappropriate scope of practice expansions
May 17, 2023

Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety. 

Learn more in this webinar about the importance of these issues to organized medicine from the AMA, the Medical Association of Georgia and Washington State Medical Association. We’ll discuss the unique challenges states encounter when facing multiple scope bills, how to overcome these issues and ways physician advocates can get involved.


  • Sandra Adamson Fryhofer, MD, chair, AMA Board of Trustees


  • Kim Horvath, JD, senior attorney, AMA Advocacy Resource Center
  • Derek Norton, interim director, Government Relations, Medical Association of Georgia
  • Sean Graham, director, Government Affairs, Washington State Medical Association

Dr. Fryhofer: Hello, everyone and welcome to this new edition of our AMA Advocacy Insights webinar series. I'm Dr. Sandra Fryhofer, AMA board chair. And I'll be your host for today's session. These webinars are designed to help keep physicians informed and engaged on issues impacting physicians, our patients and our entire health care system.

Today's topic focuses on inappropriate and unsafe scope expansion by nonphysicians. We'll talk about the ever more aggressive efforts by nonphysicians to expand their scope of practice and how this puts our patients at risk. And we have a great expert panel to help us understand where we are, where we're headed and what's next on this issue that's top of mind for so many physicians.

Why is this topic important to physicians and the practice of medicine? And why is this issue key to our advocacy efforts? Every year, in nearly every part of the country, bills are being introduced that try to inappropriately expand scope of practice for nonphysicians, including physician assistants, nurse practitioners, pharmacists, optometrists, psychologists and other non-physician health professionals. In fact, legislation has been introduced in about two dozen states already this year that would change practice requirements for PAs, including amendments to provisions or totally removing requirements for physician supervision or collaboration.

Take, for example, Senate Bill 175 in South Dakota. This bill, introduced in January, would have allowed PAs to practice medicine totally on their own, including diagnosing and treating patients, ordering and performing x-rays and other diagnostic testing, and prescribing controlled substances, all without any physician involvement.

Thankfully, this legislation was defeated just like two previous bills before it. AMA Scope of Practice Partnership, also known as SOPP, has been instrumental in defeating these types of scope expansion bills and so many more. SOPP has partnerships from 109 state, national, medical specialty and osteopathic organizations. Since 2007, SOPP has awarded more than $3.5 million in grants to its members to fund advocacy tools and campaigns.

We are strong, growing and committed. In my home state of Georgia, and thanks to a grant from AMA Scope of Practice Partnership, the Medical Association of Georgia was able to boost its advocacy work and successfully defeated two state bills that would have allowed CRNAs—that's certified registered nurse anesthetists—to practice without any physician supervision. Our state medical society was also able to get a bill passed that strengthens Georgia's Truth in Advertising laws and increases health care transparency in our state.

The Washington State Medical Association also received a grant from SOPP for their 2023 legislative session. They use this funding to strengthen on the ground lobbying efforts during a very busy legislative session. Multiple scope bills from a variety of nonphysician groups were introduced. Their session is just wrapping up. And they were also largely successful. We're seeing increasing threats from unsafe scope expansions by nonphysicians in nearly every state.

Patients are at risk when nonphysicians are allowed to practice outside their level of training and expertise. This is why AMA has increased its financial support of SOPP this year, raising our annual contribution from $50,000 now to $300,000 a year. The magnitude of this investment underscores the urgency of this issue. At the state level during a busy 2022 legislative session, AMA advocacy, along with our federation partners, achieved more than 35 victories opposing inappropriate and unsafe scope expansions by nonphysician health care providers. Numerous bills have already been defeated in 2023. And we'll talk about some of those today.

On the federal level, scope expansion is expected to be a primary advocacy focus of nonphysician groups and this Congress this year. AMA has already organized a sign-on letter to the House Ways and Means Committee and to the Energy and Commerce Committee expressing strong opposition to H.R. 2713, the Improving Care and Access to Nurses Act, also referred to as the ICAN Act.

This legislation, which seeks to expand scope of practice for nonphysician health care providers, would endanger the quality of care received by patients covered by Medicare and Medicaid. AMA, as well as multiple evidence-based studies, strongly supports a team-based approach to patient care in which each member of the team fulfills a clearly defined role based on his or her expertise and training.

Physician-led teams are best for our patients. A recent study out of Stanford shows nurse practitioners practicing independently achieve worse health outcomes and use more health care resources than physicians. NPs also exhibit lower productivity than do physicians. Their patients have longer length of stays and higher costs. They achieve less favorable results. The Stanford study also found use of current staffing allocation of nurse practitioners in emergency departments results in a net additional cost of $74 million per year compared to staffing the emergency department with only physicians.

In Hattiesburg, Mississippi, a study found care provided by nonphysicians working on their own patient panels led to higher costs, more referrals, higher emergency department use and lower patient satisfaction as compared to care provided by physicians.

Study after study supports the truth we know. Physician-led care teams lead to better and safer care for our patients. NPs are not a replacement for physicians. PAs are not a replacement for physicians. An AMA survey confirms an overwhelming number of Americans want a physician involved in their care. In fact, 95% of U.S. voters say having a physician involved in their diagnosis and treatment is important to them.

AMA is responding and leading. AMA will always defend patients, physicians and the practice of medicine from inappropriate and unsafe scope expansions. The panel of experts we have with us today will tell us more about where these battles are unfolding and where we've had success.

Let's first welcome Kim Horvath, senior attorney at the AMA. Kim is instrumental in leading our scope advocacy efforts and has nearly two decades of advocacy experience in the health care space. She's a sought after expert on a range of legislative issues.

And as AMA board chair and as a member of the SOPP steering committee, let me add my own personal accolades for Kim. She's an absolutely amazing resource for AMA and the physicians of our nation. And the success of SOPP can largely be attributed to her. So Kim, welcome and thank you.

Our next panelist is Derek Norton, CEO of Topspin Strategies. Derek is the interim director of government affairs for my own state medical association, MAG, the Medical Association of Georgia. Derek's also the mayor of the city of Smyrna. I mentioned those recent wins in Georgia, defeating scope expansion bills. Well, Derek and his team were instrumental in those victories. And he'll tell us more about that today. So Derek, welcome.

Also with us today is Sean Graham, director of government affairs for the Washington State Medical Association. Sean joined WSMA in 2013 and has helped physicians in Washington State successfully advocate on a number of health care issues that impact patient care, including scope. Sean previously worked in a number of capacities in the Washington State Senate. So welcome, Sean.

Many thanks to each of our panelists for being here. We've got a lot to cover in one hour. And I want to leave plenty of time for your questions so let's get started. First question. Kim, I'm going to start with you. Can you give us a broad overview of the type of scope of practice legislation we've been seeing so far this year?

Horvath: Yeah. Thanks so much, Dr. Fryhofer. And thanks so much for the kind introduction as well. So we've seen a ton of activity so far at the state level this year and really no surprise. Before we started 2023, we did a survey of the state medical associations and national specialty societies to gauge their interest in scope of practice and what they saw coming for the upcoming legislative session. And just like previous years, about 86% of state and specialty societies identified scope of practice as a top legislative priority. And I think that was a precursor to what has happened so far this legislative session, which is lots and lots of bills.

So in terms of trends of what we're seeing, we're continuing to see, of course, nurse practitioner scope expansions. But I think we're seeing a really increase in number of, for example, physician assistant bills. You mentioned about two dozen states in which we've seen bills that would expand the scope of practice of physician assistants, either redefining collaboration or essentially removing physician supervision or collaboration of physician assistants, sometimes replacing it with collaboration with an employer or a hospital which is, of course, not the same as with a physician.

We've also seen about 20 states that would have had bills that would allow pharmacists to test, treat and prescribe for medications for things in which a clear waive test can be determined to be used to determine whether somebody has something like strep throat or a urinary tract infection but then allowing the pharmacist not just to test for that but then to prescribe medication for it.

We've also seen about a dozen states that have had bills that would allow psychologists to prescribe and a number of states that would allow optometrists to either perform surgery or prescribe medications. So again, no shortage in number of bills. We've seen hundreds of bills this year.

On the proactive side though, I will say we have seen an uptick in truth in advertising laws, including states like Georgia, which have expanded their existing truth in advertising laws to cover things like title, specialty title. So we've seen an uptick in those bills.

We've also seen some bills in states where they've been a little more proactive in trying to preserve physician-led team care. And the AMA actually has model AMA legislation, again supporting physician-led teams. So some states are using that as a basis to proactively push through physician-led team legislation.

So far, in terms of where we are with the legislative session, about 20 states have adjourned for the year. So that still leaves quite a few states obviously that are in session. Many more will be finishing up at the end of May and then, of course, a whole bunch over the summer.

But there are many states that will continue to meet in their state legislatures for the remainder of the year. And there are a number of states that even if they aren't in legislative session, they will be having meetings, either working groups with legislators during the summer into the fall. So this work on this issue doesn't end even if the legislative sessions have adjourned for the year. And we continue to work hand in hand with the state medical associations during that time, continuing to build out our resources to help them and just there as needed in this fight.

Dr. Fryhofer: Well, the work of SOPP is so important. And you just described challenges in every corner. Every time you turn around, there's some sort of new issue that's coming across our desk. So Derek and Sean, your legislative sessions are now finished for the year. Can you give us an overview of the types of scope of practice bills you faced in your respective states and how you're addressing them? Derek, let's hear from you first.

Norton: Sure. Thank you, Dr. Fryhofer. I'm so glad to be with you today. And you're right. Thankfully, we finished our legislative session at the end of March. It was a high energy session this year with a ton of activity in the health care space.

On the scope front, we dealt with several issues. First and foremost was the CRNA independent practice fight which was a huge battle this year in Georgia. We were up against the newly appointed, very powerful and motivated rules committee in the Senate, whose wife is not only a CRNA but she was the current president of the CRNA State Association. So you can imagine what we were facing there. We spent a lot of time educating legislators on correcting misinformation done by the CRNAs.

And I'll tell you that the $50,000 grant that we received with the Medical Association of Georgia from the Scope of Practice Partnership went a long way towards efficating and educating in that space. We're so appreciative of the part that the SOPP played in this fight. And I'm pleased to report that we were successful this year in ultimately defeating this proposal.

We won the battle in the Senate Health Committee by two votes, a committee on which the rules chairman sits. And we won the House Committee vote by a wider margin of 13 to six. And I think one of the keys to success on this issue and others was keeping the focus on patients and patient safety. That really resonated with legislators, and particularly on this issue.

We also faced a proposal to increase prescriptive authority for APRNs, PAs and NPs to be able to order schedule II drugs. And we were successful through the process narrowing the legislation to what they could prescribe, and how many days they could prescribe it and the age of those they could prescribe to. But ultimately, after being able to scale back the original bill, we were also able to prevent it from being called up and so it ultimately died this session.

Some additional scope issues, among others that we dealt with this session, were Senate Bill 164, which would have created a license for APRNs, another proposal that would have provided for the licensure and regulation of community midwives, and a bill that would have allowed physical therapists to order diagnostic imaging and use ultrasound. And I'm happy to report that all of those proposals were defeated.

We also were proactive with the Health Care Practitioner Truth and Transparency bill that addressed title misappropriation. And I think we're going to discuss that a little bit later. So that gives you a snapshot of some of the things we were dealing with in Georgia this year.

Dr. Fryhofer: Well, Derek, you just had an onslaught of issues. And it was a fight with a capital F for sure. And thank you so much for your hard work. I know you probably had many sleepless nights just wondering what was going to happen the next day. But thank you for working so hard for the patients of Georgia and the physicians who care for them. So Sean, what's been happening in Washington State?

Graham: Yeah. Thanks for the opportunity to be here and the ability to commiserate with everybody about our work on scope of practice. And I know that we're all in this together. I don't pretend the WSMA has all the answers when it comes to scope. If anything, the opposite might be true.

There's a lot of bills that are annually proposed in Washington State because a lot of bills have passed here in the past. And for many of you, we might be a little upstream from where you're at so you can think about this as kind of a preview of your future life. But as is usually the case, we had a long list of scope of practice bills in the 2023 legislative session.

We also had a new wrinkle. After 20 years of having a chair of the House Health Care committee who was a former nurse and who had become, over her tenure in that chair position, really kind of weary of scope of practice, she retired and so we had a new dynamic in the legislature. And a lot of nonphysician practitioners perceived that there was an opportunity to address their scope of practice issues that might have been sidelined for a number of years.

And like a lot of other states, we have a legitimate workforce and access to care issues in Washington State. We know that most of those scope of practice proposals that are considered won't positively impact those workforce and access. But legislators don't always understand that math.

So in terms of the bills that we opposed this year, the primary bills, ARNPs, which are licensed and have pretty broad autonomy in Washington State, are proposing to be reimbursed at parity with physicians for the services that they provide. Physician assistants, as mentioned, want to move away from supervision and towards collaborative practice with a physician or an employer or a hospital.

Naturopaths, which are licensed in Washington State, had a proposal to increase their scope of practice to include prescriptive authority for all drugs, schedules II through V. Psychologists here proposed a new ability for prescriptive authority. And as mentioned, we also saw a bill from the pharmacists that would allow independent ability to diagnose and treat certain conditions. Those bills were all fortunately defeated.

The one bill that we opposed which ended up passing into law, unfortunately, was around optometric scope of practice. Optometrists here had proposed an increase in their prescriptive authority, the ability to perform injections, broad surgical procedures, as well as lasers. What ultimately passed into law was a narrower version of that bill that did allow for prescriptive authority injections and some limited surgery but no laser procedures.

We also had a scope of practice bill that we supported here in Washington State working with the anesthesiologists to propose to license anesthesiologist assistance. That bill got some consideration and will be reintroduced again next year. And then there's another host of bills that we might have had some concerns with that we were able to work through around medical assistants, athletic trainers, music therapists—yes, music therapists—behavioral health specialists, like undergrad degree support specialists and certified peers, and then international medical graduates, in addition to the scope bills in our state that we don't tend to engage on as directly, examples around dry needling and dental therapy.

So also want to say thank you to the AMA Scope of Practice Partnership. As noted, we were able to have some additional on the ground support on these scope of practice issues this year. And I know that we would have had very different outcomes without the grant, without the support from the AMA.

Dr. Fryhofer: Well, Sean, you have really had your hands full. It sounds like they've been coming after physicians in Washington State with both barrels. So thank you for all your hard work. And it sounds like you had some good wins. I'm sorry about that optometrist bill. Has the governor signed that bill yet?

Graham: Unfortunately, it was signed into law last week. And we had, working with the AMA and physicians in Washington State and beyond, had mounted a strong campaign, hundreds and likely into thousands of messages into the governor requesting a veto. But unfortunately, it was signed into law.

Dr. Fryhofer: That really is unfortunate for the safety of our patients. So I'm going to stick with you for another moment, Sean. You mentioned a lot of bills on a lot of different areas of scope of practice. So how did this volume of bills impact your advocacy? And what advice do you have for states facing a similar volume and variety of legislation from various nonphysician groups?

Graham: Yeah. It's tough. So our legislative session start annually in January. And if you talk to us or if you heard one of our staff meetings in November, we always have grand plans of how we're going to be focused on scope of practice. We're going to limit engagement. We're going to ignore the noise. And then the second week of session, we're neck deep in scope. We're sweating out a committee vote on a bill about psychiatric pharmacists or whatever.

The reality—I think what we've kind of come to terms with is that we can't skimp on scope. If we don't do it, no one will. No one else is going to defend the profession. And there's probably no one who's going to look out for patient safety in the way that we will.

So a couple of things that we've done. I mean the first is to accept it, bake it into the agenda, know that you're going to have to allocate a significant portion of your resources on scope of practice, and make sure your position leadership knows the calories that you're going to be burning on scope and how it impacts other parts of the agenda.

We also want to, to Derek's point, we want to make sure that legislators know that our opposition to scope of practice bills is based in patient safety concerns and not turf wars. I think there tends to be an impression of legislators that this is all just about bottom line and making sure that physicians can make money. Our concern—the physicians that I hear from over the years and who engage on these issues are purely interested in ensuring that patients are receiving high quality, safe care.

The other thing that we've done in Washington State is collaborate really closely with physician specialties. A lot of physician specialties and physician organizations in Washington State have their own contract lobbyists. And so as things have evolved, I kind of think about scope of practice in two buckets.

One is those issues that are more specialty specific as opposed to others that might be more general. So the optometry bill that was proposed here this year, we're going to work closely with the ophthalmologists. We're going to follow their lead and support them in opposing those bills as opposed to legislation around naturopaths or ARNPs that might impact the house of medicine more generally where we're going to be the lead on that and helping to organize physician organizations and opposition.

The other things that we've done here, just briefly, hired a contract lobbyist to focus just on scope of practice, so thanks again to the AMA for the grant funding there, and proactively work out the scope issues that you can during interim. I often feel that's easier said than done.

We don't want to be negotiating on a bad bill until and unless we have to. But the last thing that I'd say is making sure that legislators are aware of the breadth of scope of practice issues that you're fighting. A lot of times we might have a tendency to focus on these kind of on a one-off basis and not take a step back, realize the totality of the bills that are being considered.

I think it creates an opportunity to talk with legislators and leadership of the caucuses and to point out all the different bills that we're fighting and to impress on them that you got to pick and choose. You can't make us fight all of these and overextend our resources. So I, again, don't pretend that we have the answers necessarily but that's some of the kind of tactics that we've utilized.

Dr. Fryhofer: Well, you have certainly been working very hard. And it sounds like also education is a big part of that. Losing that legislature that had been there for such a long time sounds like that was a big loss for you, so educating the people there on the difference between physician training and these nonphysicians is important as well as focusing on the patient safety issues. So thank you so much for that.

Derek, I know MAG's been working hard and proactively on the truth in advertising bill while simultaneously and fervently opposing several scope expansion bills. So tell us about this dynamic. I know it was challenging by having both things going. Did it seem to be helpful? Tell us what you went through.

Norton: No. It wasn't helpful. It was difficult, to be honest, really because, as I mentioned before, we were fighting directly with the powerful Senate Rules Committee chairman on the CRNA issue. And we didn't want that fight to bleed over into our effort to get the truth and transparency legislation across the finish line. So it was a delicate dance.

I can't stress enough how important our strategic partnerships became, particularly with the Georgia Society of Anesthesiologists and the Georgia Alliance for Patient Protection—their acronym is GAPP—as the session progressed.

Just as a little bit of background, GAPP was formed as a local version of the national group that many of you all might be familiar with, the Physicians for Patient Protection, or PPP, group. They've been active in Indiana and other states. But they have a mission to ensure physician-led care for all Georgians and promote truth and transparency regarding health care credentials.

So ultimately, I'm pleased to announce that we passed Senate Bill 197. And the governor signed it into law last week. I was there. I got the pen in my coat pocket. And so we're very pleased with this result.

Dr. Fryhofer: That is great news. And I would think that the truth of advertising, talking about the differences between training was probably helpful in getting the legislators to focus on the different education and training that physicians have as compared to nonphysicians.

So next, I want to talk about balancing priorities. And certainly, the Washington State Medical Association and the Medical Association of Georgia each had a number of legislative priorities this year. In Washington State, WSMA has led efforts to reform prior authorization, ensuring access to reproductive health care services and addressing gun violence. So Sean, can you tell us more about those issues and how did your advocacy fit within your overall legislative agenda?

Graham: Yeah. It's a good question. I would estimate that our work on scope comprised about a third of the resources that we were expending through the legislative session. And on balance, it was a really successful session for the Washington State Medical Association.

As you noted, we saw a bill passed here around prior authorization reform to standardize and modernize prior authorization, expedite turnaround times for determinations, as well as build on the federal rule through CMS that folks are probably aware of that requires integrated electronic processes for prior auths, so we're very pleased to see that move through this year, and then also worked on a package of bills around abortion and reproductive care access, seeking to make sure that there are liability protections in place for patients and physicians.

We want to protect physician licenses. We want to ensure access to abortion medication. And then the last big bucket in terms of our priority issues, what we were helping to proactively bring forward this year, was around addressing gun violence, requiring background checks and waiting periods for firearm purchases, affecting an assault weapons ban and imposing some liability for gun manufacturers.

And then there's a host of other issues that we worked on this legislative session—telemedicine, consolidation, the ability of physician groups to enter into partnerships is a big issue in our state. We have a health care cost transparency board that I know some other states do too that folks are looking to beef up and build out an enforcement component of and then any number of insurance mandates and regulations that were considered this year.

Well, as you know, AMA now has a gun violence task force. And many of the items that you just mentioned are part of our AMA Recovery Plan for America's Physicians. So now we're all just kind of working together to try to work on these state by state battles. But Sean, again, thank you for sharing that with us.

Derek in Georgia, and thanks to continued advocacy, MAG has led the way for surprise billing revisions, network adequacy and candor. So please share more details about these victories in Georgia and what is candor.

Norton: Sure. Glad to. Scope was certainly front and center and at top of our legislative priorities list. Sean, you said a third of your time was spent on it. I would say 50% or higher in Georgia. We just had so much coming at us. And we expended tremendous resources on those issues.

The three other issues that were front and center in our legislative priorities list, like you mentioned surprise billing, revisions, network adequacy, and candor, H.B. 295 by representative Lee Hawkins, who is a dentist, chairman of the Health and Human Services committee in the House, and one of our best relationships at the Capitol. He brought this bill forward. And we worked with him.

Bethany, my predecessor in this role, worked with him a lot on it. Revises Georgia's current surprise billing laws by clarifying what constitutes an unfair claim settlement practice by an insurer. It expands the timeline for filing requests for independent dispute resolution and for the IDR entity to come to a decision from 30 days to 60 days and grants additional flexibilities to the Department of Insurance to administer the program, including fines for noncompliance. And we're pleased to have been able to get this bill across the finish line this session.

Senate Bill 20 dealt with network adequacy. This was brought by one of our physician legislators, Kay Kirkpatrick. And it authorizes the Department of insurance to set and enforce network adequacy standards. It really just gives the insurance commissioner in Georgia the tools he needs to increase network adequacy in our state. And also pleased to say that this bill passed and was signed into law earlier this month, actually on the same day as the truth and transparency legislation.

And then Sharon Cooper, who's a long time ally in the House but formerly the Health and Human Services chair, and comes to all the MAG events and her husband was a physician, She brought H.B. 470, which was the candor legislation. It's a dispute resolution bill that would have provided an additional and alternate process for patients, physicians, and facilities to resolve unanticipated outcomes.

We got this through the House. I think it was unanimous. But for whatever reason, it didn't fall high enough on the Senate's priority list and so it was not pulled up for a vote, but it still remains. We're a two-year biannual here in Georgia and so it'll be eligible for consideration, having already passed the House this year, in the Senate next year.

Dr. Fryhofer: Well, I know all of those key contacts you mentioned. And we've worked hard over the years within the state of Georgia to develop relationships with those key contacts. So thank you for that hard work.

So Derek and Sean, how did each of your state organizations encourage physician engagement on the scope bills? And do you have any tips for physicians who want to be active advocates on these issues? So Derek, let's start with you on that one.

Norton: Sure. You know, I've been doing this for about 20 years or more. And I've worked with other groups and associations along the way. And I've seen many organizations attempt to have an impact on legislative activity from the grassroots level. But I have never seen anything like how physicians in Georgia engage to move the needle on important bills.

They stepped up in a huge way again this year. And it reminded me a lot of the grassroots effort, gosh, I don't know, maybe five or six years ago now—I can't believe it's been that long—when we were in the middle of the surprise billing fight in Georgia. And MAG was at odds at that time with the powerful Insurance Committee chairman in the House, who's now the Rules chair. But we couldn't keep his bill, which we opposed in that instance, from reaching the House floor for a vote.

But when it did reach the floor, the emails and texts and phone calls to all legislators by our Georgia physicians—and these were not form letters. These were individual, well thought out responses and communications—made a huge difference. And we were able to defeat his bill during that battle on the House floor. And just like that battle, this year, the same type of effort and outreach from those same physicians, specialty societies and county medical societies this year helped us defeat the CRNA independent practice legislation.

And as far as tips for physicians who want to be engaged on these issues and advocate successfully, it comes down to just simply getting to know your legislators, not when they're in session and have 10,000 issues coming at them rapid fire but in the offseason, either just right after session is over with or in the months preceding the next legislative session.

I encourage all physicians to go meet with your legislator at the local coffee shop, get to know them, tell them that you're interested in what they're doing and that you want to share what's important to you. Let me tell you a physician constituent coming to speak with one of these citizen legislators who don't necessarily know anything about the health care space—these are part time legislators in Georgia who are bankers and farmers, and you name it, whatever else, your perspective on health care issues is very meaningful to them.

And if you can develop that relationship, and have their cell phone and they have yours, and then when legislation is moving at the capital, they use you as a resource, there's nothing more valuable than that to you as an individual physician, your society and the House of Medicine in general. So that's my advice. Just take the time out of everybody's busy schedules and reach out. They're very approachable. And you'll be well served by doing that.

Dr. Fryhofer: Well, certainly, the patients of Georgia and the physicians who care for them are very fortunate to have a very strong medical association looking after us. And Derek, thank you for your hard work.

And I remember when I went through the Georgia Physicians Leadership Academy. Getting to know your congressperson, your legislator and having their cell phone was so important. And it really, I mean, I think this particular session just proves how important that is. So Sean, how have you gotten more physicians involved in these efforts in Washington State?

Graham: Yeah. I think it's a similar dynamic. And Derek said most of it better than I can. A lot of the tools that WSMA would utilize I think are pretty common in terms of promoting these issues in our messaging, utilizing calls to action through emails.

In any given session, we have hundreds, again, if not thousands of messages that are generated that way that go into legislators in addition to independent messaging that physicians may do or that may come through their physician specialty organizations. We organize an annual legislative summit, an opportunity for folks to come to the Capitol and have meetings with their legislators, talk about WSMA's priorities.

But to Derek's point, I think that what is most important is building those relationships over the interim. I imagine the dynamic in Washington is typical elsewhere. You're going to get 15 minutes best case scenario with a legislator during session. And there might be a lot to fit into the conversation. By contrast, over the interim, you can regularly meet with them in the community for an hour.

Invite them to your practice even. Have them come see where you work and have a sense of what your work environment looks like. Build those relationships in the interim. I think it can be hugely helpful to have physicians reaching out to their legislators during session even if they don't have an existing relationship.

But what's really going to get the attention of a legislator is when they can remember, "Oh yeah, I've met that person. We've connected on multiple occasions. I have trust in them. I have confidence in the information that they're providing me during legislative session."

And I know folks are busy. Physicians are busy. You know who else is busy? Nonphysicians. And dentists make time. And optometrists make time. Chiropractors make time. It's imperative that the physician community does as well.

And the only thing that I would note—this just came to me. Run for office, y'all. I've been at WSMA for 10 years. And I was actually just coming on, unfortunately, as the last physician legislator that we had in our state was unelected. And there have been a number who have ran unsuccessfully since. We've tried to support them where we can.

We're fortunate to have a physician in Congress in Washington State—I should mention that—a pediatrician, Dr. Kim Schrier. But at the state legislature, we haven't had a physician in 10 years. And more broadly, there's been a lot of attrition of health care providers in our state legislature. If you went back a couple of years, there was quite a few different types of health care providers.

And at current, I don't believe we have a practicing health care provider in our Washington State legislature. So out of 147 legislators, we've got a nonpracticing dentist and two nonpracticing pharmacists and that's really it.

So to Derek's point, legislators come from all walks of life. They're not versed in health care. They are really looking to physicians in their community to provide them information on these issues, ideally through the legislative interim and to be building those relationships year round.

Norton: Let me add something to what Sean just said, Dr. Fryhofer, if you don't mind. The value of having physician legislators behind the ropes, I just can't stress that enough.

And in Georgia, we've been blessed. Prior to this session, we had five physician legislators. And up to last year, the chair of the Senate Health and Human Services committee and the chair of the Senate Insurance committee were both physicians. And I don't know that that's been the case anywhere else in the country. We have four now. We have two in the House and two in the Senate. But the program that Dr. Fryhofer mentioned before, our Physician Leadership Academy in Georgia, we encourage physicians to run for office.

And I don't know about other states out there but Georgia experiences incredible turnover for legislators every year. Here I think 50 out of our 236 members of the legislature were new. So identifying those seats and being able to have a crystal ball and look out a couple of years or four years and understand that some of these more seasoned legislators are going to be retiring, identifying positions in those districts and trying to encourage them early to run—they've got all kinds of support from Medical Society and their peer groups. And so if they can make the time, it's just an incredible asset to have them in the legislature.

Dr. Fryhofer: And we've also had a few physician spouses that are in the legislature. So if the physicians are too busy to run, get your spouse to run. How's that? Sean, did you want to say something in addition?

Graham: No. Just that I'm jealous of you all in Georgia. We are fortunate to have a couple physician spouses here. But yeah. I would give a lot to have some physicians in elected office here too in the legislature.

Dr. Fryhofer: OK. Kim, again, thank you so much for your work with SOPP. So how can physicians learn more about AMA's work on scope of practice?

Horvath: Thanks, Dr. Fryhofer. So hopefully, you don't have to look far. I think there are a couple of ways. First off, if you don't already subscribe to Advocacy Update, that's a great way. We try to share some of the state level activity in that resource and including kind of updates on the most current legislative activity.

We often—there are often AMA news articles talking about the work on scope of practice, either at the state level or just more generally about the issue. So that's another place and a place where you can often learn. The AMA website also has some resources if you just want to learn more about the issue.

And then another place that I would encourage, and again kind of speaking about physicians who maybe want to run for office or want to be a physician advocate, the State Advocacy Summit is another place where you can learn not just about scope of practice but all the issues that physicians across the country care about. It is a health policy conference that the unit that I work in, the Advocacy Resource Center, puts on.

Every year it occurs in January. And it's a time when we bring in national experts to talk about a variety of legislative issues. So that's another way we can dive in much more deep and learn about the issues, and get to know people like Derek and Sean who are usually in attendance and other physician leaders in your state. And so that's another opportunity as well.

Dr. Fryhofer: So I think this upcoming SAS, State Advocacy Summit, will be in January in Amelia Island, which is a really nice venue. And it's a little more casual. It's really a great way to learn and get to know other people within the AMA. So thanks so much for that, Kim. And thank you for your leadership in this space.

All of our experts today have been so incredibly knowledgeable and committed to making sure that we're advocating individually and collectively to support and defend physician-led teams to protect our patients and to protect the quality of care our patients receive. And we're extremely grateful for all of your time today. But we want a little bit more of it so we now have some time for questions from you, our audience.

And many of you submitted questions when you registered. And we'll start with those. But again, you can still submit your questions online in the Q&A section. And we'll try to get to those as well if we can. And if we don't have time to get to them today, we'll try our best to address them during future webinars. And Kim, it'd be great if you could help us monitor the Q&A for additional questions. But I'm going to start with some submitted questions.

So I'm going to let y'all, the panel, just jump in if you want to answer it. Here's the first one. Are there opportunities to address scope of practice by collaboration with other professions other than just opposing them?

Graham: I'll do briefly in Washington State I think that this is tough. We have pursued this. I think that there are limits on what we can do in working with those other practitioner groups. Other professions in Washington State are often allied. They'll support each other's scope of practice proposals or at least are neutral on them. There's a sort of detente that they have among them. We do have good relationships with those nonphysician practitioner groups.

We meet on a weekly basis during the session. We help host an interim conference of health care lobbyists. And we do partner on nonscope issues. But to be honest, we haven't had a lot of success on the scope of practice. I think it can be a powerful ally. We have seen it here or there. But it's tough.

Norton: My observations are almost exactly that in Georgia. Very difficult.

Horvath: Yeah. And I'll just add there is things like physician-led care and promoting physician-led care and I think things like the AMA model. And that is another way to kind of—I mean, it is a way to bring everybody together.

Dr. Fryhofer: Next question. How do we advocate for physician rights as compared to nonphysician providers on the hospital level? Who wants to take that one?

Graham: So we've had some experience with this in Washington State. And I'll say where this has come up, I can think of some different examples. A lot of these have taken nonlegislative routes.

Direct advocacy. It's been the case that physicians might have an issue with a health system's policy rather than with state policy, so not something that necessarily required legislation but something that we were able to work with the particular health system and make sure that there's an awareness. The one that comes to mind for me, there's an awareness of the titles that practitioners may be using in the hospitals and making it clear physicians as opposed to nonphysicians who are working in the hospitals.

Dr. Fryhofer: OK. Kim, can you share some recent wins on advocacy efforts from the AMA?

Horvath: Yeah. So we've had—it's been, as I mentioned, about 20 states so far have adjourned for the year. And I wouldn't say this is complete but to give you an idea, we've had about 50 wins so far. And I think it is really, really important.

And I have to credit and make sure that this is understood that the work that we do is definitely not alone. We work hand in hand with the state medical associations, with the national specialty societies, with people like Derek and Sean, and lobbyists across the country on these issues, providing resources to them. But they're the ones, they're the boots on the ground. Right?

And I think kind of understanding, as Derek and Sean talked a little bit about, the political realities of the state is really kind of also the art form that they live in and work in day in and day out. But we do our best to provide the resources to them, the information on the different education and training, the quick one pagers that they might be able to hand out to lawmakers. So I just want to make sure that this is definitely a team effort.

So about 50 wins. Dr. Fryhofer, you already mentioned South Dakota, significant victory in defeating the physician assistant bill for the third year in a row, psychologists prescribing legislation was defeated in Hawaii, Arizona defeated just a number of scope bills from pharmacists bills to a psychologist prescribing bill. They had a CRNA bill that they defeated, optometry bill, an APRN contact bill, just a number of bills in that state. Mississippi defeated 11 scope of practice bills, all 11 scope of practice bills.

And New York defeated scope legislation that was proposed in the governor's budget. So that was removed from the budget. So some really important victories so far. And again, we'll continue to work at the state level to bring those as the state legislatures wrap up.

Dr. Fryhofer: We've received a couple of questions about an increase in dermatology related scope expansion including nonphysicians performing laser procedures, as well as neurotoxins and soft tissue injectables. So how can we bring greater attention to these specialty specific issues?

Horvath: I'll take that one. And Sean, feel free to jump in. But I think that this is really an issue where, again, we can talk about the work that the AMA does providing the very broad overview of the difference in education and training, and what have you. But this is where our work, again, hand in hand with the national specialty societies and that trickling down to the state specialty societies as well, is so important because they can provide the really important information about why certain procedures need to be physician-led.

What can go wrong? Provide us with the examples. Give us any data or studies that you may have culled from within the specialty. But I think that's where the specifics layering into the broad information that we can provide really is important. And I think it really speaks to the necessity and the importance of us all working together.

And I think the AMA can also serve the role as a convener in making sure that the states are aware of some of these, again, some very specialty specific issues but bringing those up to the state level so that they're interested so that they're looking for them and might not have been aware that a bill was dropped, for example, but then can work on that bill once they kind of know that it is something that has maybe happened in other states.

Dr. Fryhofer: So I think this is our—oh, go ahead. I'm sorry. Go ahead.

Graham: Sorry. The only thing that I'd add on a state level is where organizations have the ability to have their own dedicated lobbyists, I think that that's something that's of a lot of value having somebody who's at the Capitol on an a day in and day out basis and who is the voice for your specialty, helping facilitate connections between physicians and legislators, and helping to remind them of these issues. I think that can be hugely helpful to you.

Dr. Fryhofer: So this is going to be our last question. It's been demonstrated that when physicians are not leading the patient care team, both medical errors and costs to our overall health care system increase. Please comment on what's being done to increase awareness of this important issue.

Graham: Kim, you're going to have a better answer on this than I am. I'll defer to you.

Horvath: I think, Dr. Fryhofer, you mentioned some really key studies in your introduction, the Stanford study, the Productivity of Profession study and the Hattiesburg clinic study are just two that are kind of at the forefront of the information that we make sure that states are aware of.

And again, this is kind of where we can serve as a convener but then also providing that information out to the states. We have things like issue briefs that summarize all of the studies that have been out there. So I think that our work that we do, again at the state advocacy level, is really working to amplify kind of that information.

But I think it's also important—and I guess we try to incorporate that information into all of the work that we do, whether it's articles that Kevin O'Reilly is writing for AMA News, making sure that he can highlight, for example, those studies, but also making sure that talking points weave in that information as well and incorporate that. And I think with the help of the SOPP, one of the great things that SOPP has been able to do is help state medical associations create communications campaigns.

And what we have seen through those is a lot of this information is being put into those campaigns. And so it is being used. It's maybe not being used in the wider media, but it is being used in state communications and at the state legislative level. But we will continue to work hard to amplify it because it is really important.

And we would also encourage physicians that might be out there that are interested in doing a study, please do so. The Hattiesburg Clinic study was not necessarily supposed to be a study on scope but it has been tremendously helpful. So encourage physicians who might be in a leadership position to do studies in their health system to please do so.

Dr. Fryhofer: SOPP, AMA Scope of Practice Partnership, is such a great resource for these advocacy efforts. And this discussion has been so informative. But unfortunately, we're out of time for today's session. Many thanks to our panel of experts for your insights and expertise. We thank all of you for defending the practice of medicine from unsafe and inappropriate scope of practice expansions by nonphysicians. Physician-led teams are the right teams to administer the best care safely to our patients.

We've made a great deal of progress based on today's discussion but there's still much work to do. Please continue to stay involved and advocate beside us and stand with us as we work towards solutions that protect our patients. It's been my pleasure to be your host today. And I hope you'll join us for future AMA Advocacy Insight webinars. Until then, thank you for being here.

Thank you for being engaged on issues that most directly impact America's physicians and our patients. And remember AMA is your ally and your partner as we work to create a health care system that's better for patients and the physicians who care for them. Thank you. And have a great rest of your day.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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