Why the latest congressional effort at scope creep is a no-go

Kevin B. O'Reilly , News Editor

AMA News Wire

Why the latest congressional effort at scope creep is a no-go

Sep 21, 2023

What’s the news: A sweeping piece of legislation newly introduced in this session of Congress—the “I CAN Act”—would let nonphysician practitioners perform tasks and services outside their education and training, and that could mean higher costs and lower-quality care.

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.

To avert harm to patients enrolled in Medicare and Medicaid, the AMA and nearly 100 other physician organizations are responding to the “I CAN Act” by telling Congress it’s a no-go, just as they did when a similar bill was put forth last year.

“Our organizations remain steadfast in our commitment to patients who have said repeatedly that they want and expect physicians to lead their health care team and participate in their health care determinations,” says the letter (PDF) from the AMA and a broad coalition of state medical and national specialty societies.

“In a recent survey of U.S. voters, 95% said it is important for a physician to be involved in their diagnosis and treatment decisions. Patients expect the most qualified person—physician experts with unmatched training, education, and experience—to be diagnosing and treating injured or sick individuals and making often complex clinical determinations.”

But the newly introduced “I CAN Act,” like its predecessor, “runs counter to this preference by effectively removing physicians from important medical treatment decisions regarding a patient’s care.”

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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What doctors wish patients knew about scope of practice

Why it’s important: All health professionals, including nonphysician practitioners, play an essential role in delivering patient care. But nonphysician practitioners’ skills and training are “not interchangeable with those of fully educated and trained physicians,” says the physician organizations’ letter. “This is fundamentally evident based on the difference in education and training between the distinct professions.”

Physicians complete four years of medical school, plus three to seven years of residency, including 10,000-16,000 hours of clinical training. Nurse practitioners, by contrast, complete only two to three years of graduate level education, have no residency requirement, and complete just 500–720 hours of clinical training. 

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Physician assistants, meanwhile, complete two to two and half years of graduate level education with only 2,000 hours of clinical care and no residency requirement.

“It is more than the difference in hours and years of training—the depth and breadth of physicians’ education is far beyond that of nonphysician practitioners,” notes the letter from the AMA and others.

“Equipped to handle any clinical scenario as the most highly trained health care professional, physicians are the appropriate leaders of the health care team. The reality is that nonphysician practitioners do not have the education and training needed to be the head of the care team and our nation’s Medicare and Medicaid patients deserve physician-led care.”

When nonphysician practitioners are allowed to practice independently, the letter cites the results: “lower-quality, higher-cost care.” Nonphysician practitioners “tend to prescribe more opioids than physicians, order more diagnostic imaging than physicians, and overprescribe antibiotics—all of which increase health care costs and threaten patient safety.”

Among the most recent evidence of how the differences in training play out in patient care is a working paper published by the National Bureau of Economic Research. That study concluded that nurse practitioners delivering emergency care without physician supervision or collaboration increase lengths of stay by 11% and raise 30-day preventable hospitalizations by 20% compared with emergency physicians.

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3-year study of NPs in the ED: Worse outcomes, higher costs

The “I CAN Act” also would undermine the Medicare anesthesia supervision rule, which “sets a minimum physician supervision standard, while giving flexibility to states to utilize higher levels of clinical oversight or to ‘opt out’ of the rule. There is no literature to support the safety of eliminating physician clinical oversight of anesthesia. To the contrary, independent literature points to the risk to patients of anesthesia without appropriate physician clinical oversight.”

Learn more: Find out in detail why education matters to medical scope of practice, with information on:

  • Nurse practitioners compared with physicians.
  • Physician assistants compared with physicians.
  • Nurse anesthetists compared with anesthesiologists.
  • Psychologists compared with psychiatrists.
  • Naturopaths compared with physicians.

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.