Protecting patients from inappropriate scope of practice expansions, Part II


Moving Medicine

Protecting patients from inappropriate scope of practice expansions, Part II

Jul 28, 2023

Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety. In this second half, guests pick up their discussion on issues regarding scope of practice expansion and its impact on medicine from the perspectives of the AMA, the Medical Association of Georgia and Washington State Medical Association.


  • Sandra Adamson Fryhofer, MD, immediate past chair, AMA Board of Trustees


  • Kim Horvath, JD, senior attorney, AMA Advocacy Resource Center
  • Derek Norton, interim director, Government Relations, Medical Association of Georgia;
  • Sean Graham, director, Government Affairs, Washington State Medical Association.


  • Todd Unger, chief experience officer, American Medical Association

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

Unger: Welcome to Moving Medicine—a podcast by the American Medical Association.  

Today's episode jumps back into our conversation about protecting patients against inappropriate practice expansions, including the latest on AMA advocacy efforts. The conversation is led by Doctor Sandra Fryhofer, immediate past chair of the AMA Board of Trustees. She's joined by Kim Horvath, JD, senior attorney at the AMA Advocacy Resource Center; Derek Norton, interim director of government relations at the Medical Association of Georgia; and Sean Graham, director of government affairs at the Washington State Medical Association. If you missed part one, I encourage you to go back and give it a listen. And now, Dr. Fryhofer. 

Dr. Fryhofer: Many thanks to each of our panelists for being here. I want to talk about balancing priorities and certainly the Washington State Medical Association and the Medical Association of Georgia, each had a number of legislative priorities this year. In Washington State, WSMA has led efforts to reform prior authorization, ensuring access to reproductive health care services and addressing gun violence. So, Sean, can you tell us more about those issues and how did your advocacy fit within your overall legislative agenda?

Graham: Yeah. It's a good question. I would estimate that our work on scope comprised about a third of the resources that we were expending through the legislative session. And on balance, it was a really successful session for the Washington State Medical Association. As you noted, we saw a bill passed here around prior authorization reform to standardize and modernize prior authorization, expedite turnaround times for determinations, as well as build on the federal rules through CMS that folks are probably aware of that requires integrated electronic processes for prior auth. We're very pleased to see that move through this year. And then also worked on a package of bills around abortion and reproductive care access, seeking to make sure that there are liability protections in place for patients and physicians. We want to protect physician licenses—we want to ensure access to abortion medication.

And then the last kind of big bucket in terms of our priority issues, what we were helping to proactively bring forward this year, was around addressing gun violence—requiring background checks and waiting periods for firearm purchases, affecting an assault weapons ban and imposing some liability for gun manufacturers. And then there's a host of other issues that we worked on this legislative session, telemedicine, consolidation, the ability of physician groups to enter into partnerships is a big issue in our state. We have a health care cost transparency board that I know some other states do too that folks are looking to beef up and build out an enforcement component of. And then, any number of insurance mandates and regulations that were considered this year.

Dr. Fryhofer: Well, as you know, AMA now has a Gun Violence Task Force and many of the items that you just mentioned are part of our AMA Recovery Plan for America's Physicians. We're all just kind of working together to try to work on these state-by-state battles. But, Sean, again, thank you for sharing that with us. Derek, in Georgia, and thanks to continued advocacy, MAG has led the way for surprise billing revisions, network adequacy and candor, so please share more details about these victories in Georgia, and what is candor?

Norton: Sure. Glad to. Scope was certainly front and center and at the top of our legislative priorities list. Sean, you said, a third of your time was spent on it, I would say 50% or higher in Georgia. We just had so much coming at us and we expended tremendous resources on those issues. But the three other issues that were front and center in our legislative priorities list, like you mentioned, surprise billing revisions, network adequacy and candor. H.B. 295 by Representative Lee Hawkins, who is a dentist, chairman of the Health and Human Services Committee in the House and one of our best relationships at the Capitol. He brought this bill forward, and we worked with him. Bethany, my predecessor in this role, worked with him a lot on it, revises Georgia's current surprise billing laws by clarifying what constitutes an unfair claim settlement practice by an insurer.

It expands the timeline for filing request for independent dispute resolution and for the IDR entity to come to a decision from 30 days to 60 days and grants additional flexibilities to the Department of Insurance to administer the program, including fines for non-compliance. And we're pleased to have been able to get this bill across the finish line this session. Senate Bill 20 dealt with network adequacy—this was brought by one of our physician legislators, Kay Kirkpatrick, and it authorizes the Department of Insurance to set and enforce network adequacy standards. It really just gives the insurance commissioner in Georgia the tools he needs to increase network adequacy in our state. And also pleased to say, that this bill passed and was signed into law actually on the same day as the Truth and Transparency Legislation.

And then Sharon Cooper, who is a longtime ally in the House, formerly the Health and Human Services chair, and comes to all the MAG events, and her husband was a physician. She brought H.B. 470, which was the candor legislation. It's a dispute resolution bill that would've provided an additional and alternate process for patients, physicians and facilities to resolve unanticipated outcomes. We got this through the House, I think it was unanimous, but for whatever reason, it didn't fall high enough on the Senate's priority list. And so it was not pulled up for a vote, but it still remains—we're a two-year biennial here in Georgia, and so it'll be eligible for consideration, having already passed the House this year and the Senate next year.

Dr. Fryhofer: Well, I know all of those key contacts you mentioned, and we've worked hard over the years within the state of Georgia to develop relationships with those key contacts. Thank you for that hard work. Derek and Sean, how did each of your state organizations encourage physician engagement on the scope bills? And do you have any tips for physicians who want to be active advocates on these issues? Derek let's start with you on that one.

Norton: Sure. I've been doing this for about 20 years or more, and I've worked with other groups and associations along the way, and I've seen many organizations attempt to have an impact on legislative activity from the grassroots level. But I have never seen anything like how physicians in Georgia engaged to move the needle on important bills. They stepped up in a huge way again this year, and it reminded me a lot of the grassroots effort, gosh, I don't know, maybe five or six years ago now, I can't believe it's been that long, when we were in the middle of the surprise billing fight in Georgia. MAG was at odds at that time with the powerful insurance committee chairman in the House, who's now the rules chair, but we couldn't keep his bill, which we opposed in that instance from reaching the House floor for a vote.

But when it did reach the floor, the emails and texts and phone calls to all legislators by our Georgia physicians and these were not form letters—these were individual, well-thought-out responses and communications made a huge difference, and we were able to defeat his bill during that battle on the House floor. And just like that battle, this year, the same type of effort and outreach from the same physicians, specialty societies and county medical societies this year helped us defeat the CRNA Independent Practice Legislation. And as far as tips for physicians who want to be engaged on these issues and advocate successfully, it comes down to just simply getting to know your legislators—not when they're in session and have 10,000 issues coming at them rapid fire, but in the off-season, either right after the session is over with or in the months preceding the next legislative session. I encourage all physicians to go meet with your legislator at their local coffee shop, get to know them, tell them that you're interested in what they're doing and that you want to share what's important to you.

Let me tell you, a physician constituent coming to speak with one of these citizen legislators who don't necessarily know anything about the health care space, these are part-time legislators in Georgia who are bankers and farmers, and you name it, whatever else, your perspective on health care issues is very meaningful to them. And if you can develop that relationship and have their cell phone, and they have yours, and then when legislation is moving at the Capitol, they use you as a resource. There's nothing more valuable than that to you as an individual physician, your society and the House of Medicine in general. That's my advice—just take the time out of everybody's busy schedules and reach out. They're very approachable and you'll be well served by doing that.

Dr. Fryhofer: Well, certainly the patients of Georgia and the physicians who care for them are very fortunate to have a very strong medical association looking after us. And Derek, thank you for your hard work. I remember when I went through the Georgia Physicians Leadership Academy, getting to know your congressperson, your legislator, and having their cell phone was so important. I think this particular session just proves how important that is. Sean, how have you gotten more physicians involved in these efforts in Washington State?

Graham: Yeah. I think it's a similar dynamic, and Derek said most of it better than I can. A lot of the tools that WSMA would utilize I think are pretty common in terms of promoting these issues in our messaging, utilizing calls to action through emails. In any given session, we have hundreds, again, if not thousands, of messages that are generated that way that go into legislators, in addition to independent messaging that physicians may do or that may come through their physician specialty organizations. We organize an annual legislative summit, an opportunity for folks to come to the Capitol and have meetings with their legislators, talk about WSMA's priorities.

But to Derek's point, I think that what is most important is building those relationships over the interim. I imagine the dynamic in Washington is typical of elsewhere. You're going to get fifteen minutes, best case scenario, with a legislator during session, and there might be a lot to fit into the conversation by contrast over the interim, you can regularly meet with them in the community for an hour, invite them to your practice even, have them come see where you work and have a sense of what your work environment looks like—build those relationships in the interim. I think it can be hugely helpful to have physicians reaching out to their legislators during session, even if they don't have an existing relationship. But what's really going to get the attention of a legislator is when they can remember, "Oh yeah, I've met that person. We've connected on multiple occasions. I have trust in them, I have confidence in the information that they're providing me during legislative session."

And I know folks are busy, physicians are busy, you know who else is busy? Non-physicians. And dentists make time and optometrists make time, chiropractors make time. It's imperative that the physician community does as well. And the only thing that I would note, this just came to me—run for office, y’all. I've been at WSMA for 10 years, and I was actually just coming on, unfortunately, as the last physician legislator that we had in our state was unelected. And there have been a number who have ran unsuccessfully since. We've tried to support them where we can. We're fortunate to have a physician in Congress in Washington State, I should mention that a pediatrician, Dr. Kim Schrier. But at the state legislature, we haven't had a physician in ten years.

And more broadly, there's been a lot of attrition of health care providers in our state legislature. If you went back a couple of years, there was quite a few different types of health care providers. And at current, I don't believe we have a practicing health care provider in our Washington State legislature. Out of 147 legislators, we've got a non-practicing dentist and two non-practicing pharmacists. And that's really it. To Derek's point, legislators come from all walks of life, they're not versed in health care. They are really looking to physicians in their community to provide them information on these issues, ideally through the legislative interim and to be building those relationships year-round.

Norton: Let me add something to what Sean just said, Dr. Fryhofer, if you don't mind.

Dr. Fryhofer: Sure.

Norton: The value of having physician legislators behind the ropes, it is—I just can't stress that enough. And in Georgia, we've been blessed—prior to this session, we had five physician legislators. And up until last year, the chair of the Senate Health and Human Services Committee and the chair of the Senate Insurance Committee were both physicians. And I don't know that that's been the case anywhere else in the country. We have four now, we have two in the House and two in the Senate. But the program that Dr. Fryhofer mentioned before, our Physician Leadership Academy in Georgia, we encourage physicians to run for office.

And I don't know about other states out there, but Georgia experiences incredible turnover for legislators every year. Here I think 50 something out of our 236 members of the legislature were new, right? So, identifying those seats and being able to have a crystal ball and look out a couple of years or four years and understand that some of these more seasoned legislators are going to be retiring. Identifying physicians in those districts and trying to encourage them early to run. They've got all kinds of support from medical society and their peer groups. So, if they can make the time, it's just an incredible asset to have them in the legislature.

Dr. Fryhofer: And we've also had a few physicians' spouses that are in the legislature. If the physicians are too busy to run, get your spouse to run. How's that? Sean, did you want to say something in addition?

Graham: No. It's just that I'm jealous of y’all in Georgia. We are fortunate to have a couple physician spouses here. But I would give a lot to have some physicians in elected office here too in the legislature.

Dr. Fryhofer: How do we advocate for physician rights as compared to non-physician providers on the hospital level?

Graham: We've had some experience with this in Washington State. And I'll say, where this has come up, I can think of some different examples, a lot of these have taken non-legislative routes. Direct advocacy, it's been the case that physicians might have an issue with a health system's policy rather than with state policy, so not something that necessarily required legislation, but something that we were able to work with the particular health system and make sure that there's an awareness. The one that comes to mind for me, there's an awareness of the titles that practitioners may be using in the hospitals and making it clear physicians as opposed to non-physicians who are working in the hospitals.

Dr. Fryhofer: Okay. Kim, again, thank you so much for your work with SOPP. How can physicians learn more about AMA's work on scope of practice?

Horvath: Thanks, Dr. Fryhofer. Hopefully, you don't have to look far. I think there are a couple ways. First off, if you don't already subscribe to Advocacy Update, that's a great way. We try to share some of the state level activity in that resource and including updates on the most current legislative activity. There are often AMA news articles talking about the work on scope of practice, either at the state level or just more generally about the issue, so that's another place and a place where you can often learn. The AMA website also has some resources if you just want to learn more about the issue.

And then another place that I would encourage, and again, speaking about physicians who maybe want to run for office or want to be physician advocates. The State Advocacy Summit is another place where you can learn not just about scope of practice, but all the issues that physicians across the country care about. It is a health policy conference that the unit that I work in, the Advocacy Resource Center, puts on every year. It occurs in January, and it's a time when we bring in national experts to talk about a variety of legislative issues. That's another way we can dive in much more deep and learn about the issues and get to know people like Derek and Sean, who are usually in attendance and other physician leaders in your state. So that's another opportunity as well.

Dr. Fryhofer: I think this upcoming SAS (State Advocacy Summit) will be in January in Amelia Island, which is a really nice venue. It's a little more casual, it's really a great way to learn and get to know other people within the AMA. So thanks so much for that, Kim, and thank you for your leadership in this space. SOPP, AMA Scope Of Practice Partnership is such a great resource for these advocacy efforts. This discussion has been so informative, but unfortunately, we're out of time for today's session. Thank you for being engaged on issues that most directly impact America's physicians and our patients. And remember, AMA is your ally and your partner as we work to create a health care system that's better for patients and the physicians who care for them. Thank you and have a great rest of your day.

Unger: Don’t miss an episode. Be sure to subscribe to Moving Medicine wherever you get your podcasts. Thank you for listening.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.