How 3 specialties are facing down scope-creep challenges

Andis Robeznieks , Senior News Writer

Every year, bills to expand the scope of practice for nonphysicians flood state legislatures and threaten to put patient safety at risk by authorizing these health professionals to perform services and procedures they have not received adequate training and education to perform.

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.

Recently, these scope battles have also erupted on the federal level in certain Medicare programs and the Department of Veterans Affairs’ Federal Supremacy Project, which is developing national standards that will supersede state laws regulating practice for 50 health care occupations, including physicians, certified registered nurse anesthetists, optometrists, and others. 

The AMA has been pushing back against these initiatives. On the state level, the fight has been led by the AMA Scope of Practice Partnership, whose members include every state medical association, 39 state osteopathic associations, 18 national specialty societies and the American Osteopathic Association.

The partnership advocates and supports physician-led care and opposes inappropriate scope expansions and provides grants to its members to help them strengthen their advocacy. The AMA Board of Trustees recently boosted its support for the Scope of Practice Partnership by $300,000.

Sandra Adamson Fryhofer, MD

“Removing physicians as the leaders of health care teams puts our patients at risk,” according to AMA Board Chair Sandra Adamson Fryhofer, MD. “There's also a growing body of evidence that doing so not only causes worse patient outcomes, but actually increases cost of care.”

A member of the Scope of Practice Partnership steering committee, Dr. Fryhofer was joined on a panel at the 2023 AMA National Advocacy Conference by representatives from the American Society of Anesthesiologists, American Academy of Ophthalmology, American Psychiatric Association and Kimberly Horvath, a senior attorney with the AMA Advocacy Resource Center.

“Unfortunately, scope battles are no longer confined to states, and we're now seeing nonphysician groups pushing legislative and regulatory efforts through Congress and to the administration, creating new urgency on this issue,” said Dr. Fryhofer, an Atlanta internist.

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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Inappropriate scope expansions that the AMA and other physician organizations are fighting include efforts to let optometrists perform eye surgeries, psychologists prescribe medications, and nurse anesthetists provide aesthesia without physician supervision.

“It goes on and on,” Horvath said.

Kimberly Horvath

Manuel Bonilla, chief advocacy and practice officer for the American Society of Anesthesiologists, said “the support of the AMA has been critical to the success” that anesthesiologists have had in battling scope creep at the federal and state levels.

Another panelist was Craig Obey, the American Psychiatric Association’s chief of government affairs staff, who lauded the AMA’s support in fighting a proposal to define psychologists as “physicians” under Medicare.

“This was a bill that had been knocking around for multiple Congresses, but had not seen the light of day, really, until during the pandemic,” Obey said. “We had to fight aggressively to get on that panel to testify just to speak to why this was a bad idea.”

Medicare defines physicians as those who medically diagnose, prescribe and manage medications, and supervise medical staff. Psychologists are required by Medicare to report to an attending primary care physicians in these circumstances. But there was a movement to change the definition to remove this requirement. 

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“The AMA was invaluable in its help, rallying the entire Federation of Medicine around this, producing a letter [PDF] that went to the Hill,” he said. It “really made a difference in pushing back and letting people know you're going to have a fight on your hands if you try and move this, and we kept it from being brought up, and it hasn't come back since then.”

Rebecca Hyder, the American Academy of Ophthalmology’s vice president of government affairs, also was on the panel. She noted that the California legislature approved a bill to allow optometrists to perform eye surgery, but it was vetoed by Gov. Gavin Newsom.

“His rationale for vetoing it was that he did not think optometrists had the training and education to be able to do the procedures,” Hyder said.

Learn with the AMA about why education matters in scope of practice.

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Illustrative of how these measures get resurrected every year, a bill nearly identical to the one Newsom vetoed has already been introduced—and the Scope of Practice Partnership is supporting the California Medical Association’s fight to stop it.

The battle on this scope-of-practice issue goes on in other states. The AMA sent a letter (PDF) to the Idaho House and Senate health committee chairs in strong opposition to a bill similar to California’s vetoed optometry scope measure.

“The thought of nonphysicians injecting eyes and doing laser surgery is just ... it's preposterous,” Dr. Fryhofer said.

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