Scope of practice regulations, which govern health care professionals’ responsibilities and independence, are currently a topic of national debate. The AOA, in support of its belief in physician-led teams, continues to fight unnecessary scope-of-practice expansion efforts by other types of clinicians that might interfere with a physician’s ability to provide the best care possible for their patients.
It’s important for physicians to keep abreast of the latest developments regarding scope-of-practice expansion efforts. Here’s a breakdown:
Assistant/associate physicians (APs)
A 2014 Missouri law allows medical school graduates who did not match into a residency program to practice medicine in rural and underserved areas of the state after a 30-day period of direct supervision by a licensed physician. As of January 2017, the state is accepting applications for AP licensure and allowing these individuals to practice with limited supervision. They are also able to prescribe Schedule III, IV and V drugs.
Despite AOA opposition, Utah adopted a similar law this year, which allows APs to practice without collaboration with a fully licensed physician for six months, but does limit the number of years that an AP can practice as such.
Kansas and Arkansas previously adopted AP-style laws, but these states only authorize APs to practice under the continuous, direct supervision of a fully trained and licensed physician, and they also limit APs’ prescribing ability as well as the number of years they can practice as an AP. The AOA was successful in helping to strike down similar AP bills in Virginia and Nevada.
The AOA opposes independent, or practice under limited supervision, by APs on the grounds that patient safety could be compromised and a two-tier health care system could be created.
“Access to care to the detriment of quality of care is not true access,” said Nick Schilligo, AOA vice president of public policy. “When you eliminate the requirement that a fully licensed physician be involved in care decisions, it jeopardizes patient safety.”
In lieu of APs, the AOA advocates for better solutions to the health care shortage in rural and underserved areas. These include loan deferment and forbearance programs for physicians who commit to practicing in these areas, increased payments for primary care physicians and the creation of new residency programs that focus on primary care in these areas.
In response to nurse practitioners achieving independent practice authority in 21 states and the District of Columbia, as well as increased competition from other health care providers, PAs have begun moving towards increased independence.
The American Academy of PAs has removed the word “physician” from the PA title, and in May 2017 adopted a new “Optimal Team Practice” model. This model professes to adhere to the physician-led, team-based care model; however, it calls for the elimination of any legal requirements that PAs maintain a specific relationship with a physician in order to practice, advocates for independent state licensing and disciplinary boards for PAs and requests authorization for PAs to be paid directly by insurers.
In Illinois, Gov. Bruce Rauner recently signed a bill into law that reflects some of these changes in rhetoric surrounding PA practice by: 1) changing the language describing the relationship between PA and physician from “supervisory” to “collaborative,” 2) allowing PAs to be listed as health care providers under Medicaid, and 3) increasing the number of PAs with whom a physician is allowed to collaborate to five full-time-equivalent PAs, except in certain settings.
The AOA has not taken a formal position on “supervisory” versus “collaborative” language as both maintain physician involvement; however, the organization will be closely monitoring and weighing in on scope-of-practice legislation in support of its policy of advocating for a physician-led, team-based model of care.
Proponents of changes to PA laws say they will help address physician shortage issues in rural and underserved areas by increasing the number and scope of providers available to care for patients. However, as with APs, access to care provided by an individual who has not completed the level of education, training, examination and competency demonstration requirements of a physician is not true access.
“The physician is the highest-trained individual in the schematic,” says AOA Trustee Joseph Yasso, DO. “It makes no sense to put someone who has lesser training in the lead role.”
Doctor of Medical Science degree
Last year, Lincoln Memorial University (LMU) launched the first-ever Doctor of Medical Science (DMS) degree program. The two-year program is designed for PAs who have already completed a master’s degree to obtain advanced clinical and scholarly training in order to help address health care provider shortages.
A second DMS program was recently announced at Lynchburg College in Virginia, with master’s-level PAs completing advanced clinical practice, leadership development and scholarship training over nine-to-12 months.
“The AOA is concerned that the DMS degree will lead to increased licensure and practice and an inappropriate scope of expansion that may hurt patient care,” says Schilligo. “The AOA plans to actively oppose any DMS licensure bills.”
Four states have introduced legislation to recognize future DMS degree-holders, but no state has passed legislation so far.
“Currently, no state has approved any legislation regarding the practice of a Doctor of Medical Science,” an LMU statement notes. “While the university is optimistic, it cannot guarantee the success of any legislative efforts.”
What DOs can do today
DOs can join in advocacy efforts by contacting their lawmakers to educate them on the issues.
“DOs provide a really unique perspective,” says Raine Richards, JD, AOA legislative associate. “Their stories impact legislators and the public in ways that people who are more removed cannot, especially when they illustrate how these policies impact their practice and their ability to treat patients.”
DOs should also be aware of the power they can wield in greater numbers, Dr. Yasso notes. “We need to be ever vigilant. There will always be some piece of legislation that looks to increase rights for PAs or NPs, so we need to support our state associations and the AOA.”
DOs can also advocate by participating in DO Day on The Hill, where they can speak directly with legislators about the dangers of scope of practice expansions.