Scope of Practice

They’re back: Wide array of scope creep bills proposed in 2024

Tanya Albert Henry , Contributing News Writer

AMA News Wire

They’re back: Wide array of scope creep bills proposed in 2024

Mar 18, 2024

After state legislatures saw a record number of scope of practice expansion bills in 2023, nonphysician providers’ efforts weaken physician-led, team-based care is not slowing down in this year.

Some areas that nonphysicians again are looking to gain ground this year:

  • Pharmacists are pursuing bills that would allow them to test for and prescribe medications for several conditions, as well as bills that would allow them to treat substance-use disorder, or even HIV outside a physician-led team.
  • Optometrists are seeking bills that would allow them to perform surgery.
  • Psychologists and naturopaths are pursuing bills that would let them prescribe medications.
  • Nurse practitioners, other advanced practice registered nurses, and physician assistants are backing bills that would allow them to practice without any physician involvement.

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“Bills continue to be introduced in state legislatures across the country. Even in those states where legislators have repeatedly said ‘No’ and they’ve defeated scope legislation, we continue to see them come back year after year,” Kimberly Horvath, a senior attorney in the AMA Advocacy Resource Center said during an AMA webinar on three key health care issues playing out at the state level in 2024.

Urologist Willie Underwood, MD, chairs the AMA Board of Trustees and moderated the webinar.

Of efforts to inappropriately expand scope of practice, he said, “They just keep coming back and back and back, relentless. We have to be the exact same way.”

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.

Two notable scope of practice trends that AMA is helping to push back against are bills that would:

  • Replace physician supervision with a weak definition of collaboration.
  • Allow pharmacists to diagnose a patient based on the results of a test the pharmacist administers and then prescribe medication to treat those patients, known as “test to treat.”

Bills that would weaken physician supervision or collaboration of nonphysician providers often remove this language altogether or replace it with a weakened form of collaboration or consultation. For example, some physician assistant bills call for collaboration to be with an employer, not necessarily with a physician.

“It effectively—as we view it—removes physicians from the care team,” Horvath said. “Employers don’t practice medicine. They should not be the ones collaborating with the physician assistant.”

Such changes “also could end up resulting in employers telling physicians who and how they need to collaborate with or supervise. Physicians may not have a say in the physician assistants who are part of their team, and they might not have a choice on what that collaboration or supervision looks like and that’s a problem,” she added.

Instead, there needs to be strong supervision or collaboration agreements in place to ensure that patients get the highest quality of care possible, she said.

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Meanwhile, allowing pharmacists to do “test to treat” is incompatible with the hectic realities of contemporary health care, Horvath said. Among pharmacists surveyed in chain settings, 91% rated their workload as high or excessively high and 75% said they already have so much work to do that everything cannot be done well.

“We don’t want to add extra burdens onto pharmacists, and that’s exactly what some of these bills would do,” Horvath said. That concern comes “in addition to, of course, the fact that pharmacists’ education and training does not include performing a differential diagnosis or conducting physical examinations on patients.”

Recent AMA survey data shows that scope of practice tops the list of 2024 legislative priorities for medical association professional surveyed, with 86% ranking it at the top of their legislative priority list.

After playing a role in helping defeat 100 inappropriate scope creep bills last year, Horvath said the AMA continues to work closely with state medical associations this year to defeat bills, providing resources and ensuring that they have what they need to educate lawmakers about the importance of physician-led teams. The AMA also has a truth-in-advertising model bill designed to help ensure patients clearly know the credentials of the professionals treating them.

Learn more with the AMA about the important differences between physicians and nonphysicians

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Dr. Underwood also emphasized AMA advocacy in working with state medical boards, hospitals and health systems to remove stigmatizing language on licensing and credentialing applications.

AMA’s direct engagement to remove questions that mandate physicians to disclose past mental health or substance use disorder diagnosis or treatment has included recent successes ranging from national to regional systems.

The AMA also continues to support the Dr. Lorna Breen Health Care Provider Protection Act, which supports health care workers’ mental health. Individual physicians, hospitals or health systems who are curious whether their licensing or credentialing applications are consistent with national best practices that support physicians’ health and wellness can send those applications directly to the AMA for analysis.

Dr. Underwood said that the AMA is working hard to remove stigma because physicians who need help today shouldn’t be putting it off because they don’t want to be explaining it for the rest of their careers. Such an approach “doesn’t make any sense,” he said, which is why removing the stigmatizing questions is something that needs to be done as soon as possible by all boards, systems and hospitals.

Along with reducing physician burnout, another pillar of the AMA Recovery Plan for America’s Physicians and a focus on the AMA’s state advocacy agenda is fixing prior authorization.

Nine states passed bills to help right size prior authorization last year, and dozens more are considering similar legislation in 2024 that could build on a landmark $15 billion win for doctors at the federal level.

“It’s really great progress,” AMA senior attorney Emily Caroll said. “We are working really closely with the states, and I am cautiously optimistic that it’s going to be another great year for the states in terms of prior authorization reform.”

The AMA is tracking almost 100 bills dealing with prior authorization at the state level this year, with a few states already passing laws. Trends among the bills include reducing the time it takes to get a response on prior authorization and continuity-of-care previsions that ensure patients switching plans don’t have to immediately go through prior authorization.

Dr. Underwood encouraged physicians to “take advantage of” the AMA’s “amazing resources and work with us ... and allow us to work with you because teamwork makes the dream work.”

Fight scope creep