Scope of Practice

Battlefield widens with hundreds of scope-creep bills introduced

Andis Robeznieks , Senior News Writer

Just when it seemed as though efforts to inappropriately expand scope of practice for nonphysician health professionals could not get more aggressive, it appears that the scope of practice legislative battlefield has widened. 

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“We've seen a ton of activity so far at the state level this year,” said Kimberly Horvath, a senior attorney with the AMA Advocacy Resource Center who works closely to connect state medical and national specialty associations with the AMA’s scope-of-practice research, tools and resources. She noted that, in Mississippi alone, 11 scope-of-practice bills were defeated.

“We've seen hundreds of bills,” she added.

These include bills to allow nurse practitioners, physician assistants and certified registered nurse anesthetists (CRNAs) to practice without a supervising physician. Similarly, legislation has been introduced in several states to replace requirements for physician supervision with requiring “collaboration” with a hospital or an “employer”—which of course “not the same as with a physician,” Horvath noted.

This flood of activity was no surprise, however, as the AMA surveyed state medical associations and national specialty societies to gage their interest in scope-of-practice bills prior to the start of 2023’s state legislative sessions and about 86% identified scope of practice as a top legislative priority.

Horvath spoke during an episode of the “AMA Advocacy Insights” webinar series, which focused on protecting patients from harmful scope-of-practice expansions.

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. 

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AMA Board Chair Sandra Adamson Fryhofer, MD, noted the work done of the AMA Scope of Practice Partnership, a coalition of 109 state medical associations, national medical specialty societies and osteopathic organizations.

The partnership has awarded more than $3.5 million in grants to its members to fund advocacy tools and campaigns and “has been instrumental in defeating these types of scope-expansion bills, and so many more,” said Dr. Fryhofer, an Atlanta internal medicine physician. The AMA has boosted its support of the AMA Scope of Practice Partnership to $300,000 a year. 

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“Patients are at risk when nonphysicians are allowed to practice outside their level of training and expertise,” Dr. Fryhofer said. “The magnitude of this [AMA] investment underscores the urgency of this issue.”

Legislation was introduced in about 20 states this year to allow pharmacists to test, treat and prescribe medications for conditions such as strep throat or a urinary tract infection.

Meanwhile, bills to allow psychologists to prescribe medications were introduced in about a dozen states, as were bills giving optometrists the authority to either prescribe medications or perform surgery and injections, Horvath said.

Sean Graham, government affairs director for the Washington State Medical Association, mentioned how scope battles in these states have expanded beyond the traditional fights that Horvath mentioned.

“There was another host of bills that we might have had some concerns with that we were able to work through around medical assistants, athletic trainers [and] music therapists—yes, music therapists,” Graham said.

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A bill was also introduced in Washington to expand the authority of behavioral health specialists who only had undergraduate degrees, he added. 

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Most of these scope-of-practice expansion bills were defeated. One exception was the approval of a bill giving optometrists’ prescribing authority and allowing them to perform injections and surgical procedures. The original bill would have also allowed them to perform laser procedures, but that provision was removed.

Similar battles took place in Georgia.

“It was a high-energy session this year, with a ton of activity in the health care space on the scope front,” said Derek Norton, the Medical Association of Georgia’s interim director of government relations.

The fight to oppose independent practice for certified registered nurse anesthetists (CRNAs) was “first and foremost,” he said.

There were also bills introduced in Georgia on regulating practice of community midwives and allowing physical therapists to order diagnostic imaging tests and use ultrasound.

“One of the keys to success on [the CRNA] issue, and others was keeping the focus on patients and patient safety—that really resonated with legislators, and particularly on this issue,” Norton said.

This was a point made by Dr. Fryhofer also.

Bolstered by the evidence, the AMA “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,” she said. “Physician-led teams are best for our patients.”

Visit AMA Advocacy in Action to find out what’s at stake in fighting scope creep and other advocacy priorities the AMA works on.