Moving Medicine
Protecting patients from inappropriate scope of practice expansions, Part I
Jul 7, 2023
Featured topic and speakers
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 episode, guests discuss the importance of these issues to organized medicine from the perspectives of the AMA, the Medical Association of Georgia and Washington State Medical Association.
Moderator
- Sandra Adamson Fryhofer, MD, immediate past chair, AMA Board of Trustees
Speakers
- 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
Host
- Todd Unger, chief experience officer, American Medical Association
Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Unger: Welcome to Moving Medicine—a podcast by the American Medical Association. Here at the AMA, we believe patients deserve care led by physicians, the most highly educated, trained and skilled health care professionals. That’s why the AMA defends the practice of medicine against scope of practice expansions that threaten patient safety. Today’s episode, hosted by Doctor Sandra Fryhofer, immediate past chair of the AMA Board of Trustees, will address just that. Dr. Fryhofer is 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. They'll discuss the unique challenges states encounter when facing multiple scope bills, how to overcome these issues and ways that physician advocates can get involved. Here’s Dr. Fryhofer.
Dr. Fryhofer: Hello everyone and welcome. I'm Dr. Sandra Fryhofer, AMA board chair and I'll be your host for today's session designed to help keep physicians informed and engaged on issues impacting physicians, our patients and our entire health care system. Today's topic focuses on inappropriate and unsafe scope expansion by nonphysicians. We'll talk about the ever more aggressive efforts by nonphysicians to expand their scope of practice and how this puts our patients at risk. Every year, in nearly every part of the country, bills are being introduced that try to inappropriately expand scope of practice for nonphysicians, including physician assistants, nurse practitioners, pharmacists, optometrists, psychologists and other nonphysician health professionals.
In fact, legislation has been introduced in about two dozen states already this year that would change practice requirements for PAs, including amendments to provisions or totally removing requirements for physician supervision or collaboration. In my home state of Georgia, and thanks to a grant from AMA Scope of Practice Partnership, the Medical Association of Georgia was able to boost its advocacy work and successfully defeated two state bills that would've allowed CRNAs―that’s certified registered nurse anesthetists―to practice without any physician supervision.
Our state medical society was also able to get a bill passed that strengthens Georgia's truth in advertising laws and increases health care transparency in our state. The Washington State Medical Association also received a grant from SOPP for their 2023 legislative session. They used this funding to strengthen on-the-ground lobbying efforts during a very busy legislative session. Multiple scope bills from a variety of nonphysician groups were introduced. We're seeing increasing threats from unsafe scope expansions by nonphysicians in nearly every state.
Patients are at risk when nonphysicians are allowed to practice outside their level of training and expertise. This is why AMA has increased its financial support of SOPP this year, raising our annual contribution from $50,000 now to $300,000 a year. The magnitude of this investment underscores the urgency of this issue. At the state level, during a busy 2022 legislative session, AMA advocacy, along with our federation partners, achieved more than 35 victories opposing inappropriate and unsafe scope expansions by nonphysician health care providers. Numerous bills have already been defeated in 2023 and we'll talk about some of those today.
On the federal level, scope expansion is expected to be a primary advocacy focus of nonphysician groups and this congress this year. AMA has already organized a sign-on letter to the House Ways and Means Committee and to the Energy and Commerce Committee, expressing strong opposition to H.R. 2713, the Improving Care and Access to Nurses Act, also referred to as the ICAN Act.
This legislation, which seeks to expand scope of practice for nonphysician health care providers, would endanger the quality of care received by patients covered by Medicare and Medicaid. AMA, as well as multiple evidence-based studies, 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.
Physician-led teams are best for our patients. Our recent study out of Stanford shows nurse practitioners practicing independently achieve worse health outcomes and use more health care resources than physicians. NPs also exhibit lower productivity than do physicians. Their patients have longer length of stays and higher costs. They achieve less favorable results. The Stanford study also found use of current staffing allocation of nurse practitioners and emergency departments results in a net additional cost of $74 million per year, compared to staffing the emergency department with only physicians.
In Hattiesburg, Mississippi, a study found care provided by nonphysicians working on their own patient panels led to higher costs, more referrals, higher emergency department use and lower patient satisfaction as compared to care provided by physicians.
Study after study supports the truth we know. Physician-led care teams lead to better and safer care for our patients. NPs are not a replacement for physicians. PAs are not a replacement for physicians. An AMA survey confirms an overwhelming number of Americans want a physician involved in their care. In fact, 95% of U.S. voters say having a physician involved in their diagnosis and treatment is important to them.
AMA is responding and leading. AMA will always defend patients, physicians and the practice of medicine from inappropriate and unsafe scope expansions. The panel of experts we have with us today will tell us more about where these battles are unfolding and where we've had success.
Let's first welcome Kim Horvath, senior attorney at the AMA. Kim is instrumental in leading our scope advocacy efforts and has nearly two decades of advocacy experience in the health care space. She's a sought after expert on a range of legislative issues. So Kim, welcome and thank you.
Our next panelist is Derek Norton, CEO of Topspin Strategies. Derek is the interim director of government affairs for my own state medical association, MAG, the Medical Association of Georgia. Derek's also the mayor of the city of Smyrna. I mentioned those recent wins in Georgia, defeating scope expansion bills. Well, Derek and his team were instrumental in those victories and he'll tell us more about that today. So Derek, welcome.
Also with us today is Sean Graham, director of government affairs for the Washington State Medical Association. Sean joined WSMA in 2013 and has helped physicians in Washington State successfully advocate on a number of health care issues that impact patient care, including scope. Sean previously worked in a number of capacities in the Washington State Senate. So welcome Sean.
Kim, I'm going to start with you. Can you give us a broad overview of the type of scope of practice legislation we've been seeing so far this year?
Horvath: Yeah. Thanks so much Dr. Fryhofer, and thanks so much for the kind introduction as well. We've seen a ton of activities so far at the state level this year and really no surprise. Before we started 2023, we did a survey of the state medical associations and national specialty societies to gauge their interest in scope of practice and what they saw coming for the upcoming legislative session. And just like previous years, about 86% of state and specialty societies identified scope of practice as a top legislative priority. And I think that was a precursor to what has happened so far this legislative session, which is lots and lots of bills.
So in terms of trends of what we're seeing, we're continuing to see of course nurse practitioner scope expansions, but I think we're seeing a really increase in number of, for example, physician assistant bills. You mentioned about two dozen states in which we've seen bills that would expand the scope of practice of physician assistance, either redefining collaboration or essentially removing physician supervision or collaboration of physician assistants, sometimes replacing it with collaboration with an employer or a hospital which is, of course, not the same as with a physician.
We've also seen about 20 states that would have had bills that would allow pharmacists to test, treat and prescribe for medications for things in which a clear waive test can be determined to be used to determine whether somebody has something like strep throat or a urinary tract infection but then allowing the pharmacist not just to test for that but then to prescribe medication for it.
We've also seen about a dozen states that have had bills that would allow psychologists to prescribe, and a number of states that would allow optometrists to either perform surgery or prescribe medications. Again, no shortage in number of bills, we've seen hundreds of bills this year.
On the proactive side though, I will say we have seen an uptick in truth in advertising laws, including states like Georgia, which have expanded their existing truth in advertising laws to uncover things like titles, specialty titles. We've seen an uptick in those bills.
And we've also seen some bills in states where they've been a little more proactive in trying to preserve physician-led team care. And the AMA actually has model AMA legislation, again supporting physician-led teams. Some states are using that as a basis to proactively push physician-led team legislation.
So far, in terms of where we are with the legislative session, about 20 states have adjourned for the year, so that still leaves quite a few states.
But there are many states that will continue to meet in their state legislatures for the remainder of the year, and there are a number of states that even if they aren't in legislative session, they will be having meetings, either working groups with legislators during the summer into the fall. So this work on this issue doesn't end even if the legislative sessions have adjourned for the year. And we continue to work hand-in-hand with the state medical associations during that time, continuing to build out our resources to help them and just there as needed in this fight.
Dr. Fryhofer: Well, the work of SOPP is so important and you just described challenges in every corner. Every time you turn around there's some sort of new issue that's coming across our desk. So Derek and Sean, your legislative sessions are now finished for the year. Can you give us an overview of the types of scope of practice bills you faced in your respective states and how you're addressing them? Derek, let's hear from you first.
Norton: Sure. Thank you, Dr. Fryhofer. I'm so glad to be with you all today. And you're right, thankfully, we finished our legislative session at the end of March. It was a high energy session this year with a ton of activity in the health care space.
On the scope front we dealt with several issues, first and foremost, was the CRNA independent practice fight, which was a huge battle this year in Georgia. We were up against the newly appointed, very powerful and motivated rules committee in the Senate, whose wife is not only a CRNA, but she was the current president of the CRNA State Association. So you can imagine what we were facing there. We spent a lot of time educating legislators on correcting misinformation, and I'll tell you that the $50,000 grant that we received with the Medical Association of Georgia from the Scope of Practice Partnership went a long way towards advocating and educating in that space.
We're so appreciative of the part that the SOPP played in this fight, and I'm pleased to report that we were successful this year in ultimately defeating this proposal. We won the battle in the Senate Health Committee by two votes, a committee on which the rules chairman sits, and we won the House Committee vote by a wider margin of 13 to 6. And I think one of the keys to success on this issue and others was keeping the focus on patients and patient safety. That really resonated with legislators and particularly on this issue.
We also faced a proposal to increase prescriptive authority for APRNs, PAs and NPs to be able to order schedule II drugs. And we were successful through the process, narrowing the legislation to what they could prescribe and how many days they could prescribe it and the age of those they could prescribe to. But ultimately, after being able to scale back the original bill, we were also able to prevent it from being called up, and so it ultimately died this session.
Some additional scope issues among others that we dealt with this session were Senate Bill 164, which would've created a license for APRNs. Another proposal that would've provided for the licensure and regulation of community midwives and a bill that would've allowed physical therapists to order diagnostic imaging and use ultrasound. And I'm happy to report that all of those proposals were defeated.
We also were proactive with the "Healthcare Practitioner Truth and Transparency" bill that addressed title misappropriation and I think we're going to discuss that a little bit later. That gives you a snapshot of some of the things we were dealing with in Georgia this year.
Dr. Fryhofer: Well, Derek, you just had an onslaught of issues and it was a fight with a capital F for sure, and thank you so much for your hard work. I know you probably had many sleepless nights just wondering what was going to happen the next day. But thank you for working so hard for the patients of Georgia and the physicians who care for them.
So Sean, what's been happening in Washington State?
Graham: Yeah. Thanks for the opportunity to be here and the ability to commiserate with everybody about our work on scope of practice. And I know that we're all in this together. I don't pretend that WSMA has all the answers when it comes to scope. If anything, the opposite might be true.
There's a lot of bills that are annually proposed in Washington State, because a lot of bills have passed here in the past. And for many of you, we might be a little upstream from where you're at, so you can think about this as a preview of your future life. But as is usually the case, we had a long list of scope of practice bills in the 2023 legislative session.
We also had a new wrinkle, after 20 years of having a chair of the House Healthcare Committee who was a former nurse and who had become over her tenure in that chair position, really weary of scope of practice, she retired and so we had a new dynamic in the legislature and a lot of nonphysician practitioners perceived that there was an opportunity to press their scope of practice issues that might have been sidelined for a number of years.
And like a lot of other states, we have legitimate workforce and access to care issues in Washington State. We know that most of those scope of practice proposals that are considered won't positively impact those workforce and access, but legislators don't always understand that math.
So in terms of the bills that we opposed this year, the primary bills, ARNPs, which are licensed and have pretty broad autonomy in Washington State, are proposing to be reimbursed at parody with physicians for the services that they provide. Physician assistants, as mentioned, want to move away from supervision and towards collaborative practice with a physician or an employer or a hospital.
Naturopaths, which are licensed in Washington State, had a proposal to increase their scope of practice to include prescriptive authority for all drugs, schedules II through V. Psychologists here proposed a new ability for prescriptive authority and as mentioned, we also saw a bill from the pharmacists that would allow independent ability to diagnose and treat certain conditions. Those bills were all fortunately defeated.
The one bill that we opposed, which ended up passing into law, unfortunately, was around optometric scope of practice. Optometrists here had proposed an increase in their prescriptive authority, the ability to perform injections, broad surgical procedures, as well as lasers. What ultimately passed into law was a narrower version of that bill that did allow for prescriptive authority injections and some limited surgery, but no laser procedures.
We also had a scope of practice bill that we supported here in Washington State working with the anesthesiologist to propose to license anesthesiologist assistants. That bill got some consideration and will be reintroduced again next year. And then there's another host of bills that we might have had some concerns with that we were able to work through around medical assistants, athletic trainers, music therapists―yes, music therapists―behavioral health specialists like undergrad degree support specialists and certified peers, and then international medical graduates, in addition to the scope bills in our state that we don't tend to engage on as directly, examples around dry needling and dental therapy.
Also want to say thank you to the AMA Scope Of Practice Partnership. As noted, we were able to have some additional on-the-ground support on these scope of practice issues this year, and I know that we would've had very different outcomes without the grant, without the support from the AMA.
Dr. Fryhofer: Well, Sean, you have really had your hands full. It sounds like they've been coming after physicians in Washington State with both barrels, so thank you for all your hard work. And it sounds like you had some good wins, I'm sorry about that optometrist bill. Has the governor signed that bill yet?
Graham: Unfortunately, it was signed into law last week. And we had, working with the AMA and physicians in Washington State and beyond, had mounted a strong campaign, hundreds and likely into the thousands of messages into the governor requesting a veto, but unfortunately it was signed into law.
Dr. Fryhofer: That really is unfortunate for the safety of our patients. So I'm going to stick with you for another moment, Sean. You mentioned a lot of bills on a lot of different areas of scope of practice, so how did this volume of bills impact your advocacy and what advice do you have for states facing a similar volume and variety of legislation from various nonphysician groups?
Graham: Yeah. It's tough. Our legislative sessions start annually in January. And if you talk to us, or if you ever heard one of our staff meetings in November, we always have grand plans of how we're going to be focused on scope of practice. We're going to limit engagement. We're going to ignore the noise. And then the second week of session we're neck deep in scope. We're sweating out a committee vote on a bill about psychiatric pharmacists or whatever.
The reality―I think what we've come to terms with, is that we can't skimp on scope. If we don't do it, no one will. No one else is going to defend the profession. And there's probably no one who's going to look out for patient safety in the way that we will.
So a couple of things that we've done. I mean the first is to accept it, bake it into the agenda, know that you're going to have to allocate a significant portion of your resources on scope of practice, and make sure your physician leadership knows the calories that you're going to be burning on scope and how it impacts other parts of the agenda.
We also want, to Derek's point, we want to make sure that legislators know that our opposition to scope of practice bills is based in patient safety concerns and not turf wars. I think there tends to be an impression of legislators, that this is all just about bottom line and making sure that physicians can make money. The physicians that I hear from over the years and who engage on these issues are purely interested in ensuring that patients are receiving high quality safe care.
The other thing that we've done in Washington State is collaborate really closely with physician specialties. A lot of physician specialties in physician organizations in Washington State have their own contract lobbyists. And so as things have evolved, I think about scope of practice in two buckets. One is those issues that are more specialty specific as opposed to others that might be more general, so the optometry bill that was proposed here this year, we're going to work closely with the ophthalmologist. We're going to follow their lead and support them in opposing those bills as opposed to legislation around naturopaths or ARNPs, that might impact the house of medicine more generally, where we're going to be the lead on that in helping to organize physician organizations in opposition.
The other things that we've done here just briefly, hired a contract lobbyist to focus just on scope of practice. Thanks again to the AMA for the grant funding there. And proactively work out the scope issues that you can during interim. I'd often feel like that's easier said than done.
We don't want to be negotiating on a bad bill until and unless we have to. But the last thing that I'd say is, making sure that legislators are aware of the breadth of practice issues that you're fighting. A lot of times we might have a tendency to focus on these kind of on a one-off basis and not take a step back, realize the totality of the bills that are being considered.
I think it creates an opportunity to talk with legislators and leadership of the caucuses and to point out all the different bills that we're fighting and to impress on them that you got to pick and choose. You can't make us fight all of these and overextend our resources. So I, again, don't pretend that we have the answers necessarily, but that's some of the tactics that we've utilized.
Dr. Fryhofer: Well, you have certainly been working very hard and it sounds like also education is a big part of that. Losing that legislature that had been there for such a long time sounds like that was a big loss for you, so educating the people there on the difference between physician training and these nonphysicians is important, as well as focusing on the patient safety issues. So thank you so much for that.
Derek, I know MAG's been working hard and proactively on the truth in advertising bill, while simultaneously and fervently opposing several scope expansion bills. Tell us about this dynamic. I know it was challenging by having both things going. Did it seem to be helpful? Tell us what you went through.
Norton: No. It wasn't helpful. It was difficult, to be honest really, because as I mentioned before, we were fighting directly with the powerful Senate Rules Committee chairman on the CRNA issue. And we didn't want that fight to bleed over into our effort to get the truth and transparency legislation across the finish line. So it was a delicate dance.
I can't stress enough how important our strategic partnerships became, particularly with the Georgia Society of Anesthesiologists and the Georgia Alliance for Patient Protection―their acronym is GAPP―as the session progressed. Just as a little bit of background, GAPP was formed as a local version of the national group that many of you all might be familiar with, the Physicians for Patient Protection or PPP group. They've been active in Indiana and other states. But they have a mission to ensure physician-led care for all Georgians and promote truth and transparency regarding health care credentials.
As we partnered with them, they became the outward-facing advocate for Senate Bill 197, even though MAG and GSA were calling all the shots, and pulling all the levers behind the scenes, so that way we were largely able to keep Senate Bill 197 off of the rules chairman's radar as far as it being a MAG priority issue, which was helpful and avoid any collateral damage from other scope battles, including CRNA independent practice.
And it kept the focus on patients which was essential, as I said before, to the bill's success. Ultimately, I'm pleased to announce that we passed Senate Bill 197 and the governor signed it into law. I was there, I got the pen in my coat pocket, and so we're very pleased with this result.
Dr. Fryhofer: That is great news. And I would think that the truth of advertising, talking about the differences between training, was probably helpful in getting the legislators to focus on the different education and training that physicians have as compared to nonphysicians.
All of our experts today have been so incredibly knowledgeable and committed to making sure that we're advocating individually and collectively to support and defend physician-led teams to protect our patients and to protect the quality of care our patients receive. And we're extremely grateful for all of your time today.
Unger: Don’t miss part two of this conversation. Subscribe to the Moving Medicine podcast anywhere you listen to your podcasts or visit ama-assn.org/podcasts. Thank you for listening.
