A yearslong Department of Veterans Affairs (VA) effort called the Federal Supremacy Project threatens to override state scope of practice laws and doesn’t put veterans first.
What’s needed instead is more investment in doctors and physician-led, team-based care to ensure that veterans get the care they need and deserve, AMA President Jesse M. Ehrenfeld, MD, MPH, told lawmakers at a Capitol Hill hearing.
Dr. Ehrenfeld—a former Navy commander who receives his care through the Veterans Health Administration—testified in a hearing held by the health subcommittee of the House Veterans’ Affairs Committee about the scope of practice effort and why it is so alarming.
“This project concerns me because I believe veterans—my shipmates—will receive lower quality of care if this project is implemented,” Dr. Ehrenfeld said.
The VA in 2020 published the interim final rule “Authority of VA Professionals to Practice Health Care,” and the VA is in the process of implementing national standards of practice for 48 health care occupations through the Federal Supremacy Project. This includes optometrists, physician assistants, pharmacists and other nonphysician providers who serve more than 9 million veterans enrolled in the VA health care program.
The project preempts state scope of practice laws by invoking the Constitution’s supremacy clause.
“The Supremacy Project will make it next to impossible to match the most qualified clinicians with the needs of the veterans, potentially allowing nonphysicians to perform procedures that are beyond their scope of knowledge and state licensure,” Dr. Ehrenfeld said. “Physician-led teams are the gold standard in medicine.”
Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.
Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.
In a statement (PDF) to the subcommittee submitted before the hearing, the AMA outlined these four reasons that physicians oppose the Federal Supremacy Project.
Physicians gain 12,000 hours of clinical experience during their training. In comparison, physician assistants go through two-year programs that require 2,000 hours of clinical care and don’t require a residency.
Beyond the hours, medical school and residency provide rigor and standardization well beyond that provided in nonphysician training programs. Medical students study biological, chemical, pharmacological, physiological and behavioral aspects of the human condition.
A 2022 paper from the National Bureau of Economic Research found that nurse practitioners who were practicing independently increased health care costs by $66 per emergency department visit. They ordered more tests and formal consults than physicians and were more likely than physicians to order items such as X-rays and CT scans. They also raised 30-day preventable hospitalizations by 20% and increased the length of stay in the emergency department.
In nationwide surveys, four in five patients said they want a physician leading their health care team and 95% believe it’s important for physicians to be involved in their medical diagnoses and treatment decisions.
The Federal Supremacy Project will make it impossible for state health professions boards to oversee VA-employed physicians and other health professionals, leading to unintended consequences. Meanwhile, the VA already fails to adequately supervise and discipline nonphysician providers. Nurses and other nonphysicians have credentials reviewed before they are hired—and may never be reviewed again. Oversight will be further lowered under the project.
There are alternative solutions to meet VA health care needs, such as hiring and training more physicians, streamlining the hiring process, and increasing physician pay to recruit and retain physicians to care for our nation’s veterans.
If the Supremacy Project is fully implemented, “the quality of care provided to our veterans and potentially patients across the nation will decline,” the AMA said in a written statement. “At the very least, we urge Congress to ensure that physician-led, team-based care is maintained.” To that end, doctors should have representation on each of the VHA work groups examining practice standards—not just the Physician Work Group.