The scope widens

Scope of practice expansion efforts: What you need to know

“Access to care to the detriment of quality care is not true access,” says Nick Schilligo, AOA vice president of public policy.

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.

Physician assistants

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.

8 comments

  1. Those who’ve not had the gumption, fortitude, or time to really put in the work to justify the privilege of practicing medicine rationalize and politicize their way to doing so. The Scope of Practice Scam continues…

    1. Hi Steve. Scope of practice is not a scam. Pretending that all PA’s possess skill and judgment is part of the “scam” being foisted on an unsuspecting public. Allowing PA’s to practice independently is the real “scam”. Osteopathic Medical education along with a good residency sets a very “high bar”. PA’s cannot hit that mark. The general public will be put at risk.

  2. Just for the record, the AOA believes that a newly graduated NP is more qualified to provide patient care than a newly graduated physician who becomes an Assistant Physician. When one objectively compares the education of the NP to the AP, it is clear that the AP is far more qualified to practice under a collaborative practice agreement. Perhaps that is why the Utah Legislature this year passed a version of Missouri’s first in the nation AP bill unanimously in both the House and Senate in spite of the AOA’s strident opposition. With the number of residency slots failing to keep pace with increased medical school enrollment, the problem is getting worse as shown here, http://www.kevinmd.com/blog/2017/09/stop-exploiting-medical-students-residents.html Read my comment on that article to learn more about the real potential of the Assistant Physician concept. Over a thousand US medical school graduates don’t match and if you include international graduates the number that go unmatched is over 8,000. Deep in debt and without a residency what would you suggest these highly trained doctors do, if not work under the guidance of a physician, just like a NP does. Why not let them make a living, provide badly needed care in shortage areas and advance their skills. I note with interest that this article does not address the fact that 21 states now allow NP’s to practice independent of any physician. Why is the AOA is railing against a physician-physician team providing care in shortage areas under a collaborative agreement, and not about NP’s practicing independent of any physician? If the AOA membership had a true understanding of the Assistant Physician and the potential of this concept going forward to step into the gap of severe future physician shortage, I believe they would have an entirely different view than is being publicly put forward on their behalf by leadership at the moment. The CEO of the National Rural Health Association agrees with me on this: http://www.governing.com/topics/health-human-services/gov-doctor-shortage-residency-faith-rural.html For anyone interested in continuing this discussion, feel free to contact me: (573)201-8914 (cell)

  3. There was a reason I left the PA ranks to attend Medical School and then pursue 3 specialty programs – advanced knowledge! Although I have great respect for PAs and APNs, they are limited in their training, advanced medical knowledge, scientific research, and broad picture understanding of advanced medicine in general. They are not physicians and adding a “Dr” to their title is disengenuous when interacting with patients … these practitioners know they are not physicians … but do the patients they work with understand the difference? PS. There is a red line called Medical School with subsequent years of training that qualifies practitioners to declare themselves true physicians …

  4. Every other country Medical graduate can practice basic medicine at a medical officer or house officer level.He or she may not be a consultant.But still able to practice medicine.Nurse practitioner and PA has less clinical hours than a medical student.How come they are allowed to practice without any restrictions?I am not against NP or PA.I just feel AP are more qualified and under estimated!
    Beena Joseph MD

  5. I am a PA (the first licensed in Colorado) trained by the military during the Vietnam era physician shortage; later, under the GI bill I went on to earn a PhD. I have always believed and advised students that “If you want to practice medicine, go to medical school.” I have seen the standards of care eroded by NP’s who hang out their shingle and are unsupervised as well as responsible only to the board of nursing in their particular state. There is a place for ‘mid-level’ practitioners; but their (and my) place is to ‘assist a fully trained and credentialed physician. The independent practice requests being made by ‘assistants’ will lead to a degradation of the practice of medicine, a loss of public confidence in the professional standards of medicine and an increase in liability. I applaud the AOA in its stance against independent practice by not fully qualified practitioners. The result would be tantamount to flying on a plane flown by a pilot who has one hour of flying time.

  6. The professional certifying bodies must get their heads around this and GET REAL. Decide what it takes to provide a standard of care for EVERY patient, EVERY time. The quality of patient care varies widely between 2-year trained PA’s, nurses practitioners and residency trained board certified physicians. The truth is, the billing codes submitted by each is the SAME, so why pay a doctor when a lesser trained provider to whom a lower salary is paid can generate the same revenue. There is variable and inconsistent supervision of PA’s and NP’s by physicians… snap out of it! Not to mention the replacement of RN’s with MA’s… Quality of patient care has fallen to the wayside making way for volume and profit. There is a call for transparency in health care… well… take a long hard look at the truth. There is no excuse for the deliberate compromise of quality of care for any patient… for any reason.

  7. I am a board-certified physician in a non-primary care specialty. I am an adjunct professor at 2 medical schools and have a master’s degree in medical education. I have trained and supervised physician residents, medical students, PA students, and NP students over the past 5 years and continue to do so. I also mentor 1st and 2nd year medical students. There is an enormous difference in the knowledge and experience between these groups. Non-physician providers should not be completely independent and always work with a collaborating physician. They are very effective and versatile doing what they do, but the challenge is when the guidelines and protocols are ineffective. A medical school graduate has better knowledge and a much different experience in rotations than the others, but remains inexperienced in clinical decision making. Honestly, remember the first 3 months of internship? We all realized how little we knew! For the “doctor” to practice without that 1 year of graduate medical education at least is absurd and dangerous. There is a reason states require passing Step III in order to have an UNrestricted license.They all started out with names that described their position (Physician Asst, physician extender, mid-levels, etc) because that is what they are. This is more about money and greed than it is about increasing quality care.

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