Don’t override state scope of practice laws in the VA

Tanya Albert Henry , Contributing News Writer

AMA News Wire

Don’t override state scope of practice laws in the VA

Mar 21, 2024

Physicians are concerned that veterans could face a different and lower standard of care than other patients thanks to dissimilarities in scope of practice laws that the states have already established and National Standards of Practice (NSPs) that the Department of Veterans Affairs (VA) is considering through its Federal Supremacy Project.

Fighting scope creep

Patients deserve care led by physicians, the most highly trained health care professionals. The AMA fights for physician-led care nationwide at the state and federal levels.

In a letter to VA Secretary Denis McDonough (PDF), the AMA and 29 national physician specialty organizations told the secretary that they are particularly concerned about reports that the VA is considering:

  • Different standards for some nonphysician occupations that will vary on a facility-by-facility basis.
  • Allowing some nonphysicians who hold licenses from states with certain scope laws to practice under that license at any VA facility, no matter what state the facility is in, and what the scope laws may be in that state.

“The inconsistency in standards mentioned by the VA calls into question the need for NSPs, which have been promoted as necessary to standardize health care practices systemwide in the VA regardless of state licensure and scope of practice laws,” says the letter from AMA and others. “We therefore call on the VA to explain how the development of multiple NSPs for one occupation and the ability of scope to be determined on a facility-by-facility basis would be meaningfully different that the current variability among state scope of practice laws.”

The American Academy of Family Physicians, American College of Emergency Physicians, American College of Physicians and American Psychiatric Association are among the 29 organizations that joined the AMA in sending the letter.

The letter also questions the VA’s claims that the new EHR system being developed with the Department of Defense (DOD) cannot handle different privileging and care across the Veterans Health Administration (VHA). The VHA is the largest integrated health care system in the nation, delivering care to more than 9 million veterans at nearly 1,300 health care facilities and 170 VA medical centers.

“If the joint VA/DOD EHR system can handle different NSPs, it should also be able to handle different state scope of practice laws, thereby calling into question the need for this entire project,” the letter says. “Instead, the VA should focus on strengthening team-based care, improving oversight of its nonphysician workforce, including documenting disciplinary actions, and consistently reporting to the National Practitioner Data Bank.”

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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Calls for physician involvement

The VA is in the process of implementing national standards of practice for 51 health care occupations— including optometrists, physician assistants, pharmacists and other nonphysician providers—through the Federal Supremacy Project. The project comes after the VA published the interim final rule, “Authority of VA Professionals to Practice Health Care” in 2020.

The AMA has sent previous letters highlighting concerns that are still “front and center” to the organization’s opposition to the Federal Supremacy Project, including higher costs and lower quality of care, ignoring what patients want, and undermining state regulation

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In acknowledgment of the AMA’s ongoing concerns, the VA agreed to stagger publication of all draft National Standards of Practice in the Federal Register with a 60-day comment period. The VA also held listening sessions last year to solicit feedback on the National Standards of Practice that have yet to be published the Federal Register. The AMA participated in all the listening sessions and submitted detailed written comments afterward.

AMA President Jesse M. Ehrenfeld, MD, MPH, a former Navy commander who receives his health care through the VHA, testified before Congress last year to express the AMA’s concerns about why the project is so alarming.

The most recent letter urges the VA to increase transparency around the Federal Supremacy Project if it is going to continue to develop national standards of practice, including “disclosing the names of NSP Workgroup participants to ensure that these Workgroups are fair, well rounded, knowledgeable, supportive of team-based care, and not just working to achieve a predetermined outcome favored by a particular stakeholder.”

The letter also calls on the VA to include physician representatives on all the workgroups and ensure that they are not physicians in VA leadership positions or physicians who could be unduly influenced by connections with the VA.

“Our organizations believe that it is critical that the VA has unbiased physician representatives who are willing to follow the evidence on all NSP Workgroups and we stand ready to assist the VA in identifying physicians willing to serve in this capacity,” the letter tells the VA.