An AMA-led coalition of 108 national, state and specialty medical societies, has been active in dozens of states this year, working to block legislation that would provide inappropriate expansion of the medical services and procedures nonphysician health professionals are allowed to perform.
That coalition, the AMA Scope of Practice Partnership, helps educate lawmakers about the pitfalls of scope-of-practice expansion legislation, which may involve allowing optometrists to perform eye surgery or permitting nurse practitioners (NPs) to independently diagnose and treat patients.
There have been more than 70 bills introduced in state legislatures this year related to expanding scope of practice for nonphysician health professionals in pharmacy, primary care, optometry, oral health and behavioral health, according to the National Conference of State Legislatures.
“We've been working on this issue for 30 years, but—absolutely—it is becoming more and more important each and every day,” said Kimberly Horvath, a senior attorney with the AMA Advocacy Resource Center.
Fighting scope creep is a core element of the AMA Recovery Plan for America’s Physicians. You took care of the nation. It’s time for the nation to take care of you. It’s time to rebuild. And the AMA is ready.
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.
“Patients are really concerned that allowing nonphysicians to provide physician-level care is a step in the wrong direction,” Horvath said this spring during an episode of "AMA Moving Medicine."
Patients demand physician-led care
Patients demand physician-led care
Ninety-five percent of patients said it was important for physicians to be involved in their health care diagnosis and treatment decisions, according to survey data Horvath cited during the interview.
“Patients want physicians leading their health care team—they don't just want it, they expect it,” she said.
The differences in education and training among health professionals is a major reason for this preference and it often is the deciding factor when a legislator votes against scope expansion. And that’s no surprise, given that physicians have years more training—including thousands of hours more clinical training—compared with nonphysicians such as NPs, physician assistants (PAs) and certified registered nurse anesthetists (CRNAs). Learn more with the AMA’s “Protect access to physician-led care” issue brief (PDF).
Battleground states
Battleground states
So far in 2022, the AMA has worked with 30 state medical associations on scope of practice to achieve “some key victories,” Horvath said. “All the work that we do in this area is hand in hand with the state medical associations across the country. We just rely on them so much for their political acumen in this space.”
As an example, the Scope of Practice Partnership amplified the Wisconsin Medical Society’s call to action which led to Wisconsin Gov. Tony Evers' veto of a bill that would have allowed advanced practice registered nurses (APRNs) to practice independently without a supervising/collaborating physician. This victory was significant as the legislation, Senate Bill (SB) 394, would have endangered patients and hurt Wisconsin’s reputation as one of the best states in the U.S. for high quality and efficient health care.
Here are other notable victories in the AMA and state medical associations’ efforts to fight scope creep.
Alabama
Multiple bills have been defeated, including:
- SB 120, which would have allowed optometrists to perform eye surgery.
- SB 307/House Bill (HB) 402, which would have expanded pharmacists’ scope of practice.
- SB 101, which would have expanded podiatrists’ scope of practice.
Colorado
HB 1095, a bill that would have removed physician-supervision requirements for PAs, was defeated.
Hawaii
Senate Concurrent Resolution 156, which would have directed the Department of Commerce and Consumer Affairs to convene a task force to develop legislation that would grant qualified psychologists’ prescriptive authority, was defeated.
Indiana
SB 239, a truth-in-advertising bill, was signed by Gov. Eric Holcomb. It requires health professionals’ advertisements and websites to make clear what type of license the person holds. The bill also limits the use of medical specialty designations to physician specialists, including anesthesiologist, cardiologist, dermatologist, family physician, ophthalmologist, orthopedist, psychiatrist, surgeon and others.
Kentucky
HB 354, a bill that would have removed the physician-collaboration requirement for APRNs for prescribing, was defeated. AMA Immediate Past President Susan R. Bailey, MD, participated in a legislative study committee meeting on APRN scope.
Louisiana
Multiple bills were defeated in Louisiana this year, including:
- SB 175, which would have removed the physician collaboration requirement for APRNs who have 1,000 hours of previous experience.
- HB 543, which would have removed the physician collaboration requirement for APRNs who completed 2,080 hours in collaborative practice and would have granted APRNs broad signature authority.
- SB 158, which would have removed the physician supervision requirement for physician assistants and replaced it with a weakened form of collaboration.
- SB 296, which would have amended the definitions for federally qualified health centers (“FQHCs”) and “rural health clinics” to include pharmacists in the list of those who could provide primary care services.
- SB 329, which would have allowed pharmacists to order diagnostic tests, interpret results, write prescriptions and fill medications for certain prescriptions.
Maryland
Multiple bills were defeated, including:
- HB 276/SB 513, which would have allowed clinical nurse specialists to prescribe medications and to order, perform, and interpret diagnostic tests.
- SB 154 would have entered Maryland into the APRN compact, which governs NPs, nurse midwives, CRNAs and others. The compact would have overridden existing Maryland law that states that NPs are required to “consult and collaborate with, or refer an individual to, an appropriate licensed physician or any other health care provider as needed.”
- HB 790/SB 311 would have allowed podiatrists to use the term “podiatric physicians.”
- SB 808/HB 961 would have removed the physician supervision requirement for PAs.
Missouri
Several bills were defeated, including bills that would have expanded the scope of practice of nurse practitioners and nurse anesthetists.
Mississippi
SB 2178, legislation that would have expanded APRN scope of practice, was defeated.
Learn more about Mississippi’s Hattiesburg Clinic, whose value-based care journey illustrates the power of data analysis—and the vital importance of physician-led team-based care.
South Dakota
SB 134 was defeated. The bill would have eliminated physician-supervision of PAs and only required physician assistants with fewer than 6,240 hours of clinical practice to have a signed collaborative practice agreement with a physician. AMA President Gerald E. Harmon, MD, testified in opposition to the bill before the South Dakota Senate Health and Human Services Committee.
Tennessee
HB 184/SB 176, which would have removed a requirement for physician collaboration for NPs’ prescriptive authority and allowed NPs to practice without any physician involvement, was defeated.
Washington
Multiple bills were defeated, including:
- SB 5542, which would have allowed optometrists to prescribe medications and perform surgeries.
- SB 5088, which would have given prescriptive authority and other scope expansions to naturopaths.
- SB 1863, which would have established prescriptive authority for psychologists.
- SB 5704/SB 5222, which would have required insurers to reimburse NPs at the same rate as physicians.
Scope creep a constant concern
Scope creep a constant concern
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Despite the efforts of the AMA, the Scope of Practice Partnership, and state and specialty societies, lawmakers in Kansas and New York enacted legislation expanding the scope of practice of NPs, while Virginia and Colorado enacted legislation to allow optometrists to perform surgery.
And much state legislation is still in play.
“There are a lot of bills that we're still really interested in and working with the states on—and actually gearing up for 2023 already in a lot of states,” Horvath said.
The AMA creates resources that set the record straight for policymakers on scope of practice, one of the only national organizations that has created hundreds of advocacy tools for medicine to use when fighting scope creep.
That includes model bills and training modules that inform legislators, regulatory bodies and other policymakers about the education and training of certain health professionals compared to the qualifications that physicians must attain to accept the responsibility for full, unrestricted licensure to practice medicine.
One continuing argument is that expanding scope of practice will make health care more accessible as APRNs fill gaps in physician shortage areas.
But Horvath said research using the GEOMAP series and AMA Health Workforce Mapper has shown this doesn’t happen and APRNs tend to practice in the same areas as physicians.
The evidence shows that allowing nonphysicians to practice without physician involvement will not expand access to care in rural and underserved areas.
“Laws that expanded the scope of practice for nonphysicians have not correlated to increased number of nonphysicians moving into those rural areas,” Horvath said. “So these maps have been instrumental in pushing back against that notion.
“We also provide survey data, talking points, write letters and have board members that testify in states,” she added.
Horvath recommended that physicians get to know their state legislators before asking them to support or oppose a bill. She also suggested that they provide them with data that supports their position and real-life examples of how issues affect their patients and the lawmaker’s constituents.
“They should know who you are,” Horvath said. “Don't wait for a bill to be filed or for a key vote. Start this now. Build those relationships, because it takes time. Even if you haven't done it before, let today be day one to reach out to your lawmaker.”
