2023 was a big year for scope of practice, and the AMA’s fierce advocacy alongside state medical associations and national medical specialty societies contributed to the defeat of more than 100 state-level scope of practice bills.
State legislatures across the nation considered an unprecedented number of bills seeking to preempt physician-led team-based care and inappropriately expand the scope of practice of non-physicians. The AMA played a role in defeating bills that impacted a broad range of non-physician health care providers from nurse practitioners, nurse anesthetists (CRNAs), and physician assistants to psychologists, optometrists, naturopaths, and even pharmacists. All of the proposed scope bills had two things in common: they threatened patient safety by proposing to allow non-physicians to engage in patient care activities that constitute the practice of medicine and for which they are not trained to provide, and they were pitched aggressively to legislators by impassioned stakeholders looking to erode physician-led care. Always fighting to preserve safe, high-quality care, and determined to keep physicians at the head of the health care team, the AMA met the 2023 scope challenges head-on, securing more than 100 scope of practice wins for physicians and patients.
Every year the AMA fights legislation to expand the scope of practice of advanced practice registered nurses (APRNs), and in 2023, AMA’s advocacy resulted in entirely positive outcomes for physician-led care. For example, alongside the Missouri State Medical Association the AMA successfully engaged with the Missouri state legislature to oppose multiple bills that aimed to remove collaborative practice requirements for nurse practitioners, authorize nurse practitioners to prescribe medications, and allow CRNAs to provide anesthesia care without any physician involvement. All the Missouri APRN bills died. And Missouri is not a unique case—all told, AMA helped to defeat at least 24 bills that would have expanded the scope of practice of nurse practitioners to include making a diagnosis, treating patients, or prescribing medications independently, and helped to defeat at least a dozen bills that would have weakened or eliminated physician supervision requirements for CRNAs.
With AMA’s engagement and the hard work of state medical associations and national medical specialty societies, all major scope of practice expansion bills impacting nurse practitioners were soundly defeated this year, and no CRNA scope of practice expansions passed.
Adding to scope fights on the nursing front, non-physicians outside the nursing field proposed bold scope of practice expansions. Pharmacy groups, for example, came out in full force with bills proposed across the country that would have allowed pharmacists to diagnose and treat patients over the pharmacy counter. The AMA fought alongside Mississippi State Medical Association to defeat a bill that would have allowed pharmacists to independently diagnose patients and prescribe medications for a wide range of potentially serious health conditions, even though pharmacists lack medical training and receive no education in making a diagnosis or performing a physical examination. The AMA played a role in defeating pharmacy bills like this one in about a dozen states. Fighting against other propositions, the AMA also helped to defeat bills in at least six states that would have allowed optometrists to perform eye surgeries or administer injections, despite the fact that optometrists have minimal to no training in such practices.
When it comes to physician assistants, the AMA helped to defeat more than a dozen bills that aimed to weaken physician involvement in physician assistant practice or allow use of the title “physician associate.” Some physician assistant scope expansion bills did make it through state legislatures this year; however, no physician assistant title change bills were successful. One bill, enacted in Montana, allows for full independent practice by physician assistants, but only after completing 8,000 hours of postgraduate clinical experience. Other physician assistant bills enacted this year may loosen the relationship between physician assistants and physicians, but they tend also to include protective provisions, like requirements that a physician assistant must achieve 6,000 or more practice hours after graduation before the physician assistant may enjoy weakened physician supervision or collaboration requirements. The AMA played a role in securing favorable or neutralizing amendments to a handful of these bills.
In the face of a surprising wave of psychologist prescribing bills, the AMA helped to protect patients in six states. A bill in New York that is similar to many of the psychologist prescribing bills that were introduced would have authorized psychologists—whose education includes no medical training or hard sciences requirements—to prescribe powerful psychotropic medications and controlled substances to all patients regardless of age or health status, without physician involvement, merely upon completion of an ill-defined crash course in prescribing. AMA and the Medical Society of the State of New York advocated strongly against this bill, and AMA’s workforce maps, which demonstrate how physicians and non-physicians tend to practice in the same areas of a state, debunked the notion that expanded prescriptive authority for psychologists would improve access to care and helped to defeat this and similar bills.
Finally, and of note, the AMA contributed to the defeat of naturopath licensing bills in at least 7 states.
2023 proved to be a successful year for physicians on the scope front, as the AMA protected physician-led care in all 50 states and, working together with our physician partners, defeated more than 100 bills across the country, despite facing a precedent-defying volume of bills. As scope of practice expansions threatening patient safety emerge across the country in 2024 and beyond, the AMA will rise to the task.
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