AMA Advocacy Insights webinar series: State of the states: What key health care issues are in play this year?

Webinar (series)
State of the states: What key health care issues are in play this year?
Mar 5, 2024

As states are kicking off their legislative sessions this year, what trends are emerging related to three key issues affecting patients and physicians: prior authorization, scope of practice and physician wellness? How do all of these topics impact quality and timely delivery of patient care? How are legislators and regulators shifting their approaches to these issues?  

Hear the latest in this webinar from a panel of AMA attorneys who work hand in hand on these issues and more with state and specialty medical societies.


  • Willie Underwood III, MD, MSc, MPH, chair, AMA Board of Trustees


  • Daniel Blaney-Koen, JD, senior attorney, Advocacy Resource Center, AMA 
  • Emily Carroll, JD, senior attorney, Advocacy Resource Center, AMA 
  • Kimberly Horvath, JD, senior attorney, Advocacy Resource Center, AMA 
  • Michaela Sternstein, JD, vice president, Advocacy Resource Center, AMA 

Dr. Underwood: Morning. Well, good afternoon, if you're outside of the United States. We're here and thank you for joining us today. And thank you for being here for the latest American Medical Association Advocacy Insights webinar series. Hi, I'm Dr. Willie Underwood, board chair of the AMA and urologist in Upstate New York.

It is my pleasure to be the host of this morning's session that we've titled 'The State of the States' because it will examine some of the most important issues playing out in states across the country as the new state legislative sessions kick off. Scope of practice, prior authorization, physician burnout and wellness, each of these issues impact physicians, affect our health care systems and they jeopardize the quality of care that patients receive.

So we need to address them. We need to understand them. We need to talk about them. So what's being done about them? What does effective state-level advocacy look like? What does legislators and regulators need from physicians to better understand these issues? And importantly, what tools, resources, support does the AMA offer to help states and specialty medical societies confront these challenges and improve patient care in their home states?

We'll discuss all of that and much more over the next hour with four experts from our AMA Advocacy Resource Center, which is the hub of where we collaborate closely with national state and specialty societies that influence laws and regulations to best support physicians, you, and your patients, and help shape the health care policy landscape. With us today is Kai Sternstein, the vice president of AMA Advocacy Research Center which is commonly referred as to as the ARC.

Also joining are three senior attorneys from the ARC, Emily Carroll, Kim Horvath and Daniel Blaney-Koen. And I'd like to say, I got to work with them closely for eight years on the council and legislation. And I love them. They're my friends. And I am so excited to be doing this with them today. And they specialize in different health care policy issues for the AMA. They will provide us with inside look at these issues and the states where they are most hotly contested.

Welcome panelists. Let's get started. Kai, let's set the scene. All right. Right now, most states have kicked off their legislative session, some are halfway through, some are almost done. How are these topics we're focused on today fitting into state legislators and those priority issues in most states?

Sternstein: Thank you, Dr. Underwood. And hello everyone. Such an honor to be here with such a wonderful physician like Dr. Underwood and my incredible teammates here in the Advocacy Resource Center. Well, it won't be surprising to most to hear that these three issues that we're focusing on today land right in the top priority issues for state medical associations across the country.

When the AMA identified the recovery plan and the issues included in the recovery plan after surveying physicians across the country, for the AMA, it was not surprising for us in Advocacy to see the issues that were listed. These are the issues that we primarily work on day in and day out, in collaboration and cooperation with state medical associations across the country.

So we're excited to bring you, our thinking, our expertise, our knowledge on these three issues. Of course, we in the ARC cover a whole gamut of issues that go beyond these three. We are the resource center for medicine across the country. And we're proud of the work that we do, and the wonderful relationships that we have with state medical associations, every single one in this country.

Dr. Underwood: Awesome. Awesome. And I tell you, I can verify that. They work very hard to make sure that physicians are heard, represented and stay in specialty societies, have the resources that they need. But also, we also work hand-in-hand with state medical associations, not only on legislative solutions, but also on regulatory solutions. So Kai, how do you go about impacting the work of regulators in the states?

Sternstein: So this is actually an interesting spot for us, and I think a real sweet spot for the AMA, something that we can bring to the table that many state associations on their own cannot. So we have, in the last many years, focused on national policymaking organizations that represent the regulators in the states. For example, the National Association of Attorneys General, the National Conference of Insurance Legislators, the National Association of Insurance Commissioners, the National Governors Association.

So every regulator that's in the state belongs to a national organization that represents their interests. Many of these organizations put out policy, put out model legislation, put out guidance to their constituents. We have worked very, very hard to create an environment where we and the voice of physicians and patients are respected, and heard, and desired when it comes to issues.

We've created an environment, thanks to the folks that are on this call, where we have become a trusted source to have these organizations know that they can tap into us on trends that are happening across the country. What issues should we be looking at? What do patients think? We have connections and deep relationships with patient organizations across the country, we bring them to the table. If there's something happening in the state of Texas or the state of Nebraska, we can bring medical associations to the table, we can bring physician leaders to the table to ensure that voices are heard.

This wasn't always the case. And I'm really, really proud of this work because when we influence the policymaking process with these national organizations, we touch all 50 regulators in one fell swoop. And then we can go in with the one-two punch with our state medical associations and follow up like we do. Always trying to get that win. You like that Dr. Underwood. We're always looking to get that win for medicine and for patients, for physicians, and we're relentless in that regard. And I think our work is really paying off.

Dr. Underwood: I agree. I agree. And thinking about win. When we look at our three issues that we're discussing today prior authorization, scope of practice, physician wellness. Let's hear from Daniel, Emily and Kim. So what have you seen happening on these issues in the past years or so with the states and where do things stand right now in the state legislature? I'm going to go with Daniel then I want to go to Emily and Kim.

Blaney-Koen: Thank you, Dr. Underwood. I think when we're talking about physician wellness, I think it's first to be really clear that what the AMA is talking about are multiple areas. And Kim and Emily are going to talk more about this. But it ranges from reducing administrative burdens such as prior authorization to supporting medical students and residents at every stage in their career. There are stressors and issues at every stage in a physician's career.

For the purpose of today's discussion, I think when we talk about state and national advocacy efforts, I want to focus on two areas. One is the AMA advocacy encouraging state medical boards, hospitals and health systems to remove stigmatizing and inappropriate language on their licensing and credentialing applications that mandate disclosure of past mental health or substance use disorder treatment. Such treatment that does not pose a current threat to patient safety or physicians ability to provide safe competent medical care.

And second, and this is perhaps just as important, but once boards hospitals and health systems and other credentialing organizations remove those inappropriate questions, there's a real important need to communicate those changes across the system to all physicians and other licensees to ensure that they know they are not going to be punished or they're not going to be required to disclose past treatment and have it be used against them in licensing and credentialing situations.

So let me be even more clear, Dr. Underwood. The AMA is encouraging every state medical board, every hospital and health system, professional liability carrier or insurance company, credentialing organization in the country, remove all questions on those applications about whether an applicant received care in the past or had past diagnoses or treatment of a mental illness or substance use disorder that does not represent a current impairment to safely and competently practice medicine.

And the great news, Dr. Underwood, is that we have worked closely with many organizations ranging from the Federation of State Medical Boards to the Dr. Lorna Breen Heroes Foundation to make dozens of changes across medical boards and health systems that positively affect literally hundreds of thousands of physicians across the country. A lot more work to do. A lot of success we've already had.

Dr. Underwood: Yes. Yes. And that's extremely important. I mean if you think about it. Well, I don't want to get care today because I'm going to have to explain it for the rest of my career. That really doesn't make any sense. I need help today, so let me get help today and not let that impede my ability to be a great physician tomorrow. That's excellent work. Emily?

Carroll: Right. Thanks, Dr. Underwood. I'm so happy to be here. I'm going to quickly talk about what's going on with prior authorization in the states. I think most folks on the call will understand how high a priority this is for our colleagues in the state medical associations on their advocacy agendas every year because it is a growing burden for sure on patients and physicians.

When I started doing this work probably a decade ago, on prior authorization, we were talking about standardizing the question sets and doing a single form for prior authorization. And now, we're talking about such massive reform because the process has gotten so out of control. Our colleagues over in our Administrative Simplification Initiatives department, they do a survey every year and the results are always just really alarming.

The patient impact, we find that 33% of physicians report harm to a patient, hospitalization, death, impairment because of prior authorization. And then the impact on physician practices, the resource waste and the time that physicians are having to spend on paperwork rather than caring for their patients is just a growing, growing problem.

So with that, we have really been working in the states to kind of switch the narrative on prior authorization to really start focusing on volume reduction and making the process faster, easier and only use very judiciously, and not on every pharmaceutical and service that's prescribed. So kind of where we are in the states, I think the momentum over the last couple of years has been surprising even for us who know how big a problem this is.

Last year, we saw upwards of 70 bills introduced in the states. Some of those were bills that were really broad prior authorization reform efforts. Some of them were very targeted over one issue or one service that maybe a legislator had experienced a bad outcome as a result of that prior authorization on a service. And we've had 10 bills passed at the state-level last year.

This year, even more bills. We have almost 100 bills in the state that we're tracking right now. And we've already had a couple this year past, I think we're up to three already. So it's really great progress. We're working really closely with the states and I'm cautiously optimistic that it's going to be another great year for the states in terms of prior authorization reform.

Horvath: All right. I'm up next. Hi, everyone. I'm going to talk about scope of practice. And last year, we saw a huge number of scope bills introduced across the state, really, more than any other year that we can remember. From the organized medicine perspective, I will say that last year was very successful. There were a couple losses here or there but overall, it was a successful year.

As Kai mentioned, at the outset, all of these issues are top priorities for the AMA and state medical associations and national specialty societies that we work with day in and day out. And it's no surprise that scope continues to top that list year after year. It is also no surprise to anybody on this call that scope bills continue to be introduced in state legislatures across the country, even in those states where legislators have repeatedly said no, and they've defeated scope legislation. We continue to see them come back year after year.

Similar to last year, we are seeing an increase in pharmacists test to treat bills. These are bills that would allow pharmacists to diagnose and treat a patient based simply on the results of a clear waived test and then prescribe medications to those patients. We're seeing bills that would allow pharmacists to treat for a substance use disorder or even HIV. We're also seeing bills that would allow optometrists to perform surgery, psychologists prescribing bills.

We also have seen bills that would allow naturopaths to prescribe. We've seen a number of those this year. We're also seeing bills, of course, that would allow nurse practitioners and other advanced practice registered nurses as well as physician assistants to practice without any physician involvement. And again, these bills come back year after year. And we continue to work closely with the state medical associations and have already this year.

And providing resources and making sure that they have what they need at hand to be able to educate lawmakers about the importance of physician-led teams. And push back against these inappropriate scope expansions.

Dr. Underwood: Man, oh, man. Oh, man. This interesting thing with the scope, and there's a lesson that we can learn there, is that every state they win is another state that they can win. Every state they lose is another state that they can win. They just keep coming back and back and back. Relentless. And we have to be the exact same way.

And with your team and what I'm seeing is that that's exactly what you're doing. Step by step, coming back every time. No. We're here. We're standing. And what we need are the state medical societies, the individual physicians to stand with you and with us so that we can defeat these bills, so that we can get great prior authorization legislation passed, so that we can get physician wellness policies and regulations passed. Teamwork makes the dream work. So this is awesome.

Now, we're going to go to another question here. So I was reading this and I'm like, I kind of really want to know this. How are lawmakers addressing these issues? Any trends that you want to highlight? You could get down to the deep. I'm going to go Kim first, then Emily, then Daniel.

Horvath: Thanks, Dr. Underwood. So two trends that I'll mention on the scope front. First, physician assistance. We have continued to see physician assistant bills that would replace physician supervision with a very weak definition of collaboration. And often, what we're seeing is that this collaboration would be with an employer, not necessarily with a physician. And of course, this is inappropriate for a number of reasons.

It effectively, as we view it, removes physicians from the care team. Employers don't practice medicine. They should not be the ones collaborating with the physician assistant. It also could end up resulting in employers telling physicians who and how they need to collaborate with or supervise. Physicians may not have a say then in what the physician assistants that are part of their team and they might not have a choice on what that collaboration of supervision looks like. And that's a problem.

And the other side of that is, of course, that physician assistants might not know who to go to if they have a question about a specific patient. So there needs to be strong supervision or collaboration agreements in place for both the physicians and for the physician assistants, and of course, for the patients, to make sure that they're receiving the highest quality care possible.

The second trend that we are seeing, and I kind of already alluded to this as pharmacists, seeing a lot of test and treat bills, I mentioned earlier. And they're being introduced really at the same time that pharmacists, particularly those in the community setting, are saying, I don't have enough time in the day to do what I need to do to get my regular job done, filling prescriptions, talking with and educating patients about their medications.

91% of pharmacists in chain settings rated their workload as high or excessively high and 75% said they already have so much work to do that everything cannot be done well. So we don't want to add extra burdens on pharmacists. And that's exactly what some of these bills would do. In addition to, of course, the fact that pharmacists education and training does not include performing a differential diagnosis or conducting physical examinations on patients. And of course, the clear waive test in and of itself is not enough to diagnose a patient.

And then another trend that I'll mention is truth in advertising. I have to mention this. Really, a key cornerstone of a lot of the work that we do on scope of practice, which is really—What truth in advertising is really about is making sure that all health care professionals put their license out there. They should wear name badges and include their license, include their credentials, include who they are. We want to make sure that there's truth and transparency in advertisement.

Making sure that it's clear to patients what the licensure is for the health care professionals that might be advertising, what they their education is behind that. And finally, and we've seen a couple of states pass language on this recently, and that is making sure that specialty titles like cardiologists, like anesthesiologists, like dermatologists and urologists, that those are reserved for physicians.

That is something that the AMA strongly supports. And we've got a couple states that have passed bills added on to their existing truth and advertising legislation to include those type of provisions. We have model legislation here as well, and stand ready to work with state medical associations on that issue, and really look forward to more states taking a lead on that issue.

Dr. Underwood: Man, oh, man. I mean, just think about it. We're at this place now that we really have to have on our name badges that I'm a urologist, that I'm a physician, that I'm the person they actually came there to see, that I'm the one that studied a decade. And that's just to get out and practice. But then read every day, do the CMEs, do all that so that I can be good at what I do and great at what I do.

I got to wear a badge that says, hey, by the way, that's me. Because someone else is saying that they're me. They're imposters. I mean, that's ridiculous. All right. Emily.

Carroll: I'm up. All right. Well, I'll just mention a couple trends that we're seeing in the states and the prior authorization reform legislation. The first being just sort of a reduction in the time it takes to get a response on prior authorization. The AMA's policy suggests that it should be as quick as 40 or it should be as—the longest it should be for urgent care is 24 hours and for non-urgent care, 48 hours. We're seeing some of those bills pass in the states with those quick turnaround times. So we're really glad to see that.

I'll also say there's kind of falling under that time and streamlining the process is automation. So using electronic prior authorization resources to make the process faster. But automation is a huge priority for the AMA, I will say it is not the end-all be-all of prior authorization reform. We're not just looking to get to know faster. We want to make sure, again, we're looking at volume. And think that's sort of the next trend. So really, reducing the volume of prior authorization, how often prior authorization is used.

Some of the sort of volume reducing tools we're seeing are gold-carding. So this is the idea that if you have a good or a high rate of approvals on your prior authorization requests, you're going to get a gold card. And you're not going to have to do prior authorization for that service. For a certain amount of time, a lot of states, I think are up to seven states, have been able to look at gold-carding laws and are starting to implement those programs.

We're also seeing just generally identifying services or drugs that shouldn't have prior authorization at all. We've had a couple of states say that generics should never have prior authorization and other services like that. So continue to support those efforts. We're also looking at—I'm seeing a lot of states that are looking at the qualifications of the reviewer on the payer side.

So making sure that the person who is determining medical necessity on the payer side is a qualified peer of the physician who's requesting it. So we would say that the person reviewing should be a physician licensed in the same state of the same specialty and with experience providing the care in question. So we've seen a lot of states that are able to get that similar language in law.

We're also seeing a lot of data collection efforts. And I really love these efforts because I think so many of us consider the prior authorization process sort of a black box. We don't know what's being approved, are certain specialties, or certain services or certain drugs being targeted? So we're seeing a lot of states start to require payers to report prior authorization statistics either on their websites publicly or to insurance commissioners who then issue a report detailing what the prior authorization process in that state really looks like.

So then we can sort of talk about the next steps doing more targeted prior authorization reform in those states based off of that data. We're also seeing a lot of continuity of care provisions in the state. So I think particularly, in our time of the Medicaid unwinding, we want to make sure that patients as they switch plans or come out of Medicaid and onto the private market, that they are not having to immediately get their prior authorization redone, that they can kind of continue their care during that transition time.

So ensuring at least 90 days between the start of the new plan and the requirement that undergo a new prior authorization process. And then finally, we're just seeing a lot of transparency. So what are the clinical criteria that are being used to determine medical necessity in the prior authorization process? What drugs and services actually require prior authorization?

These are things that are surprisingly opaque for a lot of payers and to a lot of physicians. So we're just trying to really kind of lift the curtain on some of these practices and get to really know what's going on from the payer side. So out there.

Dr. Underwood: I'm going to repeat something you said. I loved it. We are not working to get to know faster. It's like—yeah. No. No.

Carroll: Big reform there.

Dr. Underwood: Correct. Because some of that, as you push these reforms forward, they will find themselves in a position that they may realize that the best thing to do is to just get rid of it altogether. And that's really part of where we're headed. OK, you love it? Then let's make it better. Oh, it's a headache to make it better. Let's just get rid of it because we really don't love it. We just use it because we can make money with it, but let's fix it. All right. Cool. Awesome. Awesome. Daniel, make it happen, baby.

Membership Moves Medicine™

  • Free access to JAMA Network™ and CME
  • Save hundreds on insurance
  • Fight for physicians and patient rights
  • Limited-time half-price dues when you join!

Blaney-Koen: Thanks, Underwood. I want to pick up on something Emily said about—we don't just have to—legislators, regulators, hospitals, health systems, credentialing organizations, one of the trends that we have found is that sometimes they ask questions because they've done it for a long time, and they don't know why they're asking questions anymore.

And so what we have found is importantly, greater awareness and greater discussion among legislators, regulators and others, and leaders in hospitals and health systems, that there is a lot that can be done at every level to better support physician wellness.

And again I'm going to focus a little bit on the questions here because once we've had those discussions about removing stigmatizing questions on licensing and credentialing applications or in legislatures the last two or three sessions, we've helped establish physician wellness programs. The regulators and legislators are almost always supportive. We have had near unanimous passage of laws in Virginia, South Dakota, Arizona, Kentucky, Indiana, Delaware. These are red, blue and purple states. So this is not a partisan issue.

We've worked with large national health systems such as HCA Healthcare and Envision to revise their credentialing questions throughout their system affecting hundreds of thousands of physicians. We've also worked with regional systems in Virginia, the entire Commonwealth of Massachusetts. Our hats are off to the Massachusetts Hospital Association and the Massachusetts Medical Society and Blue Cross Blue Shield of Massachusetts, who with the AMA and others, we all came together to make those commitments for the hospitals and health systems in Massachusetts.

To make that commitment to revise their applications to remove all of the stigmatizing language that we've discussed positively affecting more than 30,000 physicians. But we've also done it in Johnsbury, Vermont. Small, little hospital in Johnsbury, Vermont, that helped everything there. And there's an important bill in the Minnesota legislature up for hearing on Thursday, where thanks to the Minnesota Medical Association, hopefully these questions will be removed through all credentialing bodies in the state of Minnesota.

So but at the same time, there are some medical boards and health systems, Dr. Underwood, that continue to hold on to the harmful belief that they just want to know if somebody has ever been in treatment. And when we dig down and we say, well, why do you want to know? And they say, well, we just want to know. And we point out the data that show you know 40 to 50% of medical students and physicians say, we do not seek care because we are afraid of disclosing that to a medical licensing board or an employer.

And the medical boards and employers will say, well, we want to know if somebody is in treatment so we can help them. And we say, well, this is a problem here. We're at cross purposes. People are not going to seek care if you tell them that you're going to be watching over them. So we have to find that balance. And we have to work through that fear that can cause situations to worsen potentially debilitating illness.

There are about 50% of medical students say that they either personally know or know of another medical student who has considered death by suicide. So we want to avoid these tragedies. And thankfully, almost everybody we talk to understands this. And those that don't, we continue to have conversations to work through this. Because these aren't necessarily the easiest conversations to have, but we do this on a regular basis. Again, in partnership with many organizations. And we're going to continue to do it because the stakes are high.

Sternstein: Dr. Underwood, can I jump here really quickly? Because I know you know this. But we've just done a round-robin with these three folks on our team, and I just cannot emphasize enough to physicians in this country how incredible this work is. So when you talk about trends for example in prior authorization, first of all, many of those trends and the movement in those trends planted by Emily Carroll, six, seven, eight years ago.

This is a relentless year in, year out effort when it comes to prior authorization, bringing the physician voice forward, the patient voices forward to regulators at that National Association of Insurance Commissioners that was talking about before. That's just one example. Daniel, nobody told him he needed to go to the systems. Nobody told him that he needed to go work with the medical boards, he did that. He took that upon himself. The energy, the passion behind the work.

With Kim in scope of practice, the most funded, well-oiled machine campaign that we have. Every trend that pops up, we are ready because people like Kim have devoted time and effort monitoring trends across the country, developing resources, model bills, workforce mappers, seeking out studies to counter the narratives that are put out by our non-physician provider colleagues at the national level. Debunking myths. This is what we do day in day out across the country.

And I just think this is the story that's not told very often. We are a small group in the AMA, but think we are a mighty group. And I cannot emphasize enough that it's only because of our collaboration with state medical associations. And if physicians are frustrated, upset—join your medical association. Join the AMA. We need your voice. You're the best salesman on this Dr. Underwood, but we cannot do this work without you all. We are incredibly passionate. And we will fight relentlessly for patients and physicians.

Dr. Underwood: Thank you. Because yes, having seen them do this work and having watched it move forward, sometime you forget. You forget to say, hey, by the way, you know what, yesterday, this didn't exist. Yesterday, we were thinking maybe we can make this happen. The idea that even something that people would say, wait a minute, it should be very easy to get these questions removed, but it's not because as Daniel said, people are holding on to them like it's their family life—financial legacy.

I'm holding on to it forever. And why do you want to hold to it? I want to help those people. Well, no, you're not helping them. You're preventing them from getting the services that they need. Doctors who you see in every day, they may be going through something. But they know that if they receive help, that you're going to use that to punish them two years later or so when they're credentialing comes up or when they decide to move to another facility and they won't be able to get licensed in that state or get credentialed in that hospital.

Fear, real or imagined, that's the impact. Yes. I'm going to tell you, thank you, Kai, because your team has worked its tail off to make these things a reality for us. Are we winning every single battle? No, because that's not reality of life. But however, we will win more if more of us puts up, get in the game, get in the fight, bring our money to the table, our bodies to the table, our resources to the table that we show up day in and day out, and we're relentless. Yes. We can have more victories.

Now, thinking about victories, let's stick on that for a second. And let's talk about the few of the victories in each of these areas that we've had over the past years and how significant they are. And have you found these wins shifting conversations in the state? And this time, we're going to go with Emily first, then Daniel, then Kim.

Carroll: Thanks, Dr. Underwood. There have been a significant number of victories in the states over the last year. And I just feel so lucky to get to work with the leaders of the state medical associations and in the national medical specialty societies who are key to obviously getting these bills across the finish line in the states.

And as I mentioned, these are—and as you mentioned as well, this are many years of laying the groundwork for prior authorization reform. It's usually not like a state introduces a bill one year and it's passed a couple of weeks later. It's a lot of work by the medical associations in the states to educate legislators on the problem, to bring patient groups together, to address the issue as a coalition. So it's just many years and enormous amount of time to get these bills across the finish line.

Last year, we saw three major bills passed and several others that were more targeted. But after many years, our colleagues in the District of Columbia were able to pass a fabulous reform bill that incorporated a lot of the components of our model bill and principles, and worked with a great coalition of patient groups and other physician and provider groups in the state. New Jersey, same thing. Many, many years of work by the medical society resulted in a bill being enacted last year.

In Tennessee as well. Tennessee did a great job getting their bill across. But then there were many others that I'm not mentioning that were hard fought and fantastic victories last year as well. And I think we're going to see that kind of same momentum happening this year. Mississippi just passed a bill, a prior authorization bill just a couple of days ago, and we have more coming. So I think as these bills pass, other states look at those successes and build off of this.

I think the most commonly asked resource that I'm asked for is our state law chart. So that one state who's working on prior authorization is able to see what their neighbors recently passed or how they approached a certain problem related to prior authorization. And so every time a state is able to enact something, know that you're helping another state move their prior authorization progress forward.

Dr. Underwood: Kim? Thank you, Emily.

Horvath: All right. Thanks, Dr. Underwood. So there is an amazing amount of work at the state level by state medical associations and national specialty societies, we can't say that enough on all of these issues. And I'll just let you know, we had a number of tremendous victories last year on scope of practice.

Together working, again, close collaboration with the states medical associations, there were over 100 victories on scope of practice. But that was also because there were a significant number of bills. So we also saw more bills than any other year. But in terms of some states that had I will say, significant wins, South Dakota, defeated a physician assistant scope bill for the third year in a row and by wider margins than previous years.

California defeated an optometry surgery bill last year, they defeated it again this year. The APRN Compact which is something that we saw introduced in a number of states, that was defeated in every single state last year. Mississippi, the scope bill did not even make it out of committee that year—last year and they had a number of them.

Texas defeated every single scope bill in their legislature. They had over 100. Over 100 just in Texas last year. Texas is not in session this year, thankfully. But each of these victories, and again, to Emily's point, I'm not mentioning all of them. This is just a handful. But each of these victories should not be taken for granted. The state medical associations and the national specialty societies put in so much effort to achieve all of these victories, to make them happen.

It's a years-long process. Again, educating lawmakers on the difference in the education and training of non-physicians compared to physicians, what the patient safety implications are for the scope bills, what the cost differences are, how expanding scope of practice has been shown to actually increase the cost of care, refuting those myths that we hear from non-physicians about them going into rural areas.

If you would expand their scope of practice, they'll practice in rural areas. We know that's not the case by our resources like our Geomaps. We can show that is not the case. And the fight does get harder year after year. I mean, states are incredibly relentless and they will work on these, but it does get harder. And for the most part, and you alluded to this before, non-physicians go in and fight these bills year in and year out.

They have one issue. One issue. This is it. Physicians, groups, AMA, the state medical associations, they have a number of issues that they are working on, fighting on behalf of patients. Prior EHR, physician wellness, we're talking about those today, but also the overdose epidemic, telehealth, AI, reproductive health, the list goes on. But, that's what leaders do, so we will continue to lead on all of these issues including making sure that lawmakers know the importance of physician-led care.

In each of the states where we do have victories, other states learn from those states that were successful. Whether it's sharing communication materials that they created, repurposing some of our tools to brand for their state medical associations, all of it. Coming together, sharing resources and making sure that everybody has the best information that they can again support physician-led care.

Dr. Underwood: Daniel.

Blaney-Koen: Yeah. One of the things that Kim and Emily are both sort of bringing up is that all of these affect individual physicians. I'm going to highlight individual physicians again for a couple of reasons. One, I think it's important to be really clear that every victory that we have on these issues directly affects individual physicians, with respect to physician wellness. Some of the significant wins.

At the federal level, the AMA has supported and is continuing to support the Dr. Lorna Breen Health Care Professionals Protection Act. It's going to have a particular focus in the next round of appropriations on reducing administrative burdens. So we've identified that. On the legislative front, we've really followed the leadership from the Medical Society of Virginia. And they were one of the first states to enact laws to protect the confidentiality of individuals seeking care in a wellness program.

And what we've done from the AMA, is take that law and encourage other states to adopt something that works for those states. And we're somewhere between 5 and 10 additional states have built on what Virginia has done. And we're continuing to build on that. On the regulatory front, again, with medical boards, I'll give you one example, Kai is very generous, but our partners at the Medical Association of Georgia made introductions to us to the Composite Medical Board of Georgia. And we had discussions with their executive director.

And in the course of literally a few weeks, the Medical Board of Georgia changed its questions based on those discussions. And it wasn't because of anything magical we said, we brought awareness to the issue. And they hadn't looked at it in a long time. And they got it. They understood it. They took that leadership challenge to make that immediate change.

That's what physicians do on a daily basis. You don't tell your patients, "Well, wait a couple of months and then do the course of treatment that I'm recommending for you today." So that doesn't happen. Some of the things that people might not have heard about, a lot of times in the beginning of our campaign, a couple of years ago, we kept on hearing things like, well, The Joint Commission requires us to ask these inappropriate questions, and we thought that was strange.

And it took us a couple of weeks. But we called The Joint Commission, we found the right person to talk to, and we said, hey, we heard that The Joint Commission requires hospitals and medical boards to ask these inappropriate stigmatizing questions. And The Joint Commission virtually scratched their head, and they said, no, we don't do that.

And then The Joint Commission took a big leadership step and issued a public statement saying they supported the AMA, the FSMB and others that they don't require those questions. So we break down these myths. And we keep doing that every time we hear it. And so what is it—one of the other places that an individual physician can be a leader?

Every physician on this call or that you talk to your friends and colleagues, you can send the AMA your credentialing applications. Let us analyze it to see if they have inappropriate questions, and then we will be happy to work with your hospital and health system or your state medical board to revise those questions. We're happy to reach out. I don't mind if people tell me no. I don't mind providing that direct analysis.

My colleagues, who I work with here, we do that literally on a daily basis. So the most significant, people are getting it. There's a lot more people that need to get it, and that wasn't the case six months ago, let alone a few years ago. So one at a time, Dr. Underwood. We're taking care of this one at a time.

Dr. Underwood: Awesome. Awesome. I tell you what a thrill you were speaking. I was listening attentively and however, through my mind, I was hearing the theme song of Rocky. And we have to be congratulated for that. Our teammates across the country who are in the states coming together to fight these things to stand up need to be applauded for that.

But at the same time I need you to turn to your colleagues who are complaining about what's not being done and say to them, put up, stand up, shut up. We prefer you to put up and stand up because without them, we can't continue to win, and with them, we can solve most of these problems.

We can create the collaborations we need. We would have the resources to be successful in these battles. Having said that, talking about resources, what are some of the resources that you have to offer to those working in these state advocacy issues? And I'm going to go with Daniel, Emily and Kim.

Blaney-Koen: Thanks, Dr. Underwood. I think the resources that I have, and I'll be pretty brief here, I have a lot of examples of states that have done the work. So we have great model state legislation. So other state legislators, you don't have to guess about what works. My greatest skill as a lawyer is copying and pasting. So I can give you that information that other states have already enacted. And again, they've enacted unanimously in the red, blue and purple states.

On the regulatory front, any medical board that is interested in what language that more than 20—I think we're up to almost 30 states now that have adopted language consistent with the AMA recommendations and the recommendations of the FSMB. If you're wondering what those recommendations are, let us know and we will provide you that exact language that your colleagues in other states are using, national best practices.

The same for hospitals and health systems. One of the most important credentialing advisors is the National Association of Medical Staff Services. It's a really arcane sort of a really unique name, but everyone in hospital and health system credentialing world knows who NAMSS is. And NAMSS recommends language consistent with the AMA recommendations. So the resources that we have use the resources that other leading institutions, legislatures and medical boards already are using.

We don't have to reinvent the wheel, Dr. Underwood. There are great examples. And we can get you that direct language that your colleagues are implementing as national best practices.

Dr. Underwood: All right. Thank you. Emily.

Carroll: All right. Well, I'll just be quick as well. In terms of state legislation and prior authorization, we have a model bill that is constantly sort of evolving our counsel and legislation. We discuss additions or subtractions from the bill probably once a year based on best practices we're seeing in the states in terms of legislation, but we offer that and it serves as a basis for a lot of the reform proposals we see every year.

We also have, as I mentioned, our state law chart where you can see what other states are doing. Again, copy and paste is a great thing. And kind of look and see where other states have had success and where you might have that in your state as well. We offer issue briefs, constant bill analysis, always feel free to reach out to me to get thoughts on a bill. We have draft testimony.

We regularly write letters in support of legislation in the states, if helpful. But I would argue probably my greatest resource is Heather McComas in our Administrative Simplification Initiatives department. They put there the awesome team that puts together that prior authorization survey every year. So looking at the impact of prior authorization on patients and physicians, and more recently employers, which I think is an important group that we need to start having those prior authorization conversations with.

We work really closely with that team collecting data and other research about the negative impact of prior authorization. And we just generally work really closely with that department to make sure states have all the resources they need to keep having these important prior authorization conversations.

Dr. Underwood: Kim.

Horvath: Thanks, Dr. Underwood. So Kai mentioned, at the outset, we have an expansive library of tools and resources on scope of practice that we provide to the state medical associations and national specialty societies. We've got model legislation on physician-led team-based care, on truth and advertising that I already mentioned earlier. We have a series of issue briefs that provide a short and sweet overview of some of the key topic areas, including studies and some data.

We've got a legislator handouts series. We have a number of state laws charts comparing scope of practice laws on physician assistants, nurse practitioners, naturopaths, pharmacists. You name it, we've got it. We, of course, have our Geomap series, which is over 4,500 static maps now. 50 states across three points in time now comparing the practice locations of physicians to various non-physicians in each and every state.

We have our Health Workforce Mapper, which is available to anyone on the AMA website, and that is a mapping tool as well that the Geomaps are actually built off of the similar platform that can show you not just the practice locations, but a number of other population health indicators and others as well. We've got patient surveys. We've got handouts for patients giving them some information on how they can find out who is providing their care, just some simple questions that they can ask.

We've got a media toolkit. We, of course, have our data series modules which dives really deep into the difference in education and training. And that is the backbone of a lot of our resources like our legislator handout series and our issue briefs. And we use that information in all of our letters to lawmakers when we talk to them about the different scope bills that they might be considering. Making sure again, that they know what the difference is and why it matters when we're talking about providing care to patients.

And this is just—we also review bills for state medical associations to point out some of the concerns that we have and how it might look compared to other states as well. And then, of course, we draft letters. We have physicians who testify in state legislatures often on a scope of practice. Dr. Ferguson has testified a number of times this year already, and you have in the past as well, Dr. Underwood, so thank you for that.

And we'll continue to use these resources and make sure that they're available to our colleagues at the state level.

Dr. Underwood: Yes. Yes. All right. So now is the time that you, our virtual audience, will have a chance to have your questions answered. If you have any questions for our panelists, if you haven't already done so, please add the questions in the chat. And we'll get started now. Now, some of you have already submitted questions, so I'm going to start with them first and then I'm going to go and see where we are on in the chat.

So Kai, how does the ARC team work with the states and specialties around the country? So if I'm a physician, and I want to see your material to advance legislation or regulation, how do I go about that? How do I make that a reality?

Sternstein: Great question. Great question. So first of all, we're available. And we're probably I would say one of the most responsive units in the AMA. And you'll get information about how to contact us directly here at the AMA. I strongly encourage you to be an AMA member, though, before you connect, but we will never turn anyone down.

Hopefully, your interaction with us, if you're not a member, will cause you to become a member once you've met us and experienced the amazing work that this team does. And frankly, all of advocacy, we are part of a broader advocacy business unit that is just lights out.

Also another way, through your medical association because if you come to us for a model bill for example, we will always let our medical association colleagues know we need the collaborative set up that exists within the Federation of Medicine to get model bills kind of across the finish line. So we don't want to have physicians going off on their own without the benefit of the knowledge and expertise of our knowledge and expertise, but also that of the state medical associations and the specialty societies as well.

So boots on the ground on the state medical associations. They live in the state capitals, they know what's going on. Oftentimes, we read about things and the process is already light years ahead of what's listed in the New York Times for example, or whatever. So we have to rely on one another. We are stronger together in this. So whether it's through the state medical associations or your specialty societies, or directly to us, our materials are available.

We are available to talk to you about issues as they come up and how to best strategize on how to accomplish a win for medicine at the state level.

Dr. Underwood: All right. So patient safety often comes up as we discuss this. And it's interesting, when I look at scope of practice, I think when we talk about physician-led teams for some people, we haven't defined who's playing what position. No team would allow a center to say, I decided I'll be the quarterback today or the guard to say, hey, by the way, I'm going to be the receiver today because it doesn't make sense. You don't win games that way.

So when people—and those of you who don't know, I'm talking about football. So people who we're talking about patient safety and patient care delivery, when people say, "Hey, although I haven't received the training to be an eye surgeon, I'm an optometrist but I haven't received the ophthalmology training of an eye surgeon, ophthalmologist, but I want to do what they do," that's like the center saying I want to be the quarterback today.

So first of all, Kim, how do we make patient safety key when we're addressing these inappropriate scope expansions?

Horvath: It's a great question. Thank you for that, Dr. Underwood. I would say that patient safety is paramount when we are talking about an appropriate scope expansion. It's really the center of our conversation on these issues. And to build off with what you were saying about optometrists, we make sure that legislators know that optometrists have not attended medical school.

And when they go into these states, they are putting language in these bills that would allow them to perform surgery after completing a weekend course in a hotel ballroom probably performing simulated surgery. And they want legislators to believe that is adequate to be able to allow them to turn around and perform surgery on patients. They are trained. They're great members of the health care team, but they're trained in primary eye care, not in surgical techniques. And we need to make sure that lawmakers know that.

We also use patient safety in our discussions on nurse practitioners and physician assistance. We know, for example, that nurse practitioners practicing outside of physician-led care use more resources, which increases the cost of care and yet there are studies that show that they actually achieve worse outcomes than physicians. And it confirms what we have been saying that removing physicians from the care team is associated with lower quality care.

And that same study also shows that nurse practitioners actually cost more to employ because of all the extra studies and tests that they want to run on patients. So in the end, physician-led care is the most important—is the answer. And certainly, the patient safety aspect is really key in our work in this space.

Dr. Underwood: Awesome. Awesome. Kai, do we have any questions in the chat?

Sternstein: I think we do have a couple. Let me just really quickly—Kim, you touched upon this briefly, but there's a question about the lack regulation of nurse practitioner education or I should say lack thereof. Do you want to touch on that a little bit and how we let legislators know? And also, the question around kind of frustration like legislators are exhausted, they're bombarded by scope issues, how do we get past sound bite type of messaging that they're so willing to accept just to solve the problem and move on?

Horvath: Yeah. No. Really good question. So on the sound bite thing, I think that what we always do is we go back to data. And we make sure that lawmakers have data at hand and provide them with the citations behind that, and why it is important and why it matters for patient care. On the nurse practitioner and what we see in terms of their training, we see it. We know. And again, we try to make sure that lawmakers know there is a lack of standardization in nurse practitioner education and training.

They only complete two years of graduate-level education and 500 to 750 hours of clinical training. But of that, 60% of nurse practitioner programs are partially or completely online, and nurse practitioners often have to find their own preceptor. So there is no standardization in the clinical training piece. And what that means is when you go back and then look at that is that not all nurse practitioners are trained the same way.

And studies done by nurse practitioner organizations actually show and confirm that there is wide variation in terms of clinical experiences in basic things like prescribing medications, performing comprehensive physical examinations, really basic, basic elements that every nurse practitioner should be able to do, we're finding that there are some nurse practitioners that may only perform that one or two times during their entirety of their training.

That is a problem. And so again, we point this out to lawmakers and make sure that they understand this, but definitely a problem.

Dr. Underwood: So we had a lot of great questions. And unfortunately, we won't be to get to them. I just looked at my watch and I realized that we're out of time. Man, so I want to thank you for our amazing panelists. I want to thank all of you for this great discussion and all of you for listening, and for asking such great questions and for thinking about what we're talking about, and hopefully, utilizing the information that we have in the future, if you haven't already done so.

Our AMA Advocacy Resource Center on our website is the place to find the resources, the data points, the model legislation, the white paper, and a host of other materials to support you in our advocacy efforts at home. Notice I said our, not your advocacy efforts because we are in this together. So we're asking that you take advantage of our amazing resources and you work with us and allow us to work with you because teamwork makes the dream work.

So please join us in our future AMA Advocacy Insights webinar, where we will take you inside the most important policy issues affecting physicians, patients and our health care system. Until then, be well. Thank you very much. This was awesome. Thank you, guys. And I enjoyed it. See you soon. God bless.

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

Get the latest advocacy news

Stay up-to-date on how the AMA is fighting for physicians in the courts and legislature with your personalized news feed on the AMA Connect app.