Empowered by insurers and states, nonphysicians push practice limits

Organized medicine educates legislators about the patient safety issues in scope-of-practice debates.

By Myrle Croasdale — Posted Feb. 9, 2004

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Growing pressure from allied health professionals and alternative medicine practitioners to expand their scopes of practice has inspired a new level of activism within the medical profession.

As 2004 unfolds, a raft of proposed laws seeking to expand or create new scopes of practice are hitting physicians. The new laws come essentially from two groups -- the allied health professions or nonphysicians such as optometrists, psychologists, and those working in the field of complementary and alternative medicine, such as naturopaths.

The Federation of State Medical Boards' special panel on scope of practice and a working group formed under the auspices of the AMA are in the midst of creating resources for state medical groups and legislators that will address patient safety and other issues that routinely arise with each piece of scope-of-practice legislation.

Non-MD, non-DO practitioners, who have argued successfully that expanding their scope expands access to care, are emboldened by past victories. These include a congressional mandate that chiropractors become part of the Veterans Health Administration, prescribing rights for psychologists in New Mexico and independent status for certified registered nurse anesthetists in 12 states.

The road to change in CRNA status in those states was paved by a federal rule letting states opt out of Medicare requirements.

And alternative medicine practitioners have been energized by consumer demand. Studies show that an estimated 43% of Americans have used some form of complementary or alternative medicine and spend up to $40 billion on it a year.

Health insurers also are more willing to cover such care. A 2002 industry survey conducted by the American Assn. of Health Plans-Health Insurance Assn. of America reveals that 58% of plans pay for herbal medicines and 34% cover homeopathy.

Russ Newman, PhD, executive director for professional practice for the American Psychological Assn., said the public in general is unwilling to be limited in what kind of health care they can receive.

"After 10 years of market-driven managed care that really restricted access, there has been a public backlash in response to that," Dr. Newman said. That backlash also has helped fuel the drive to broaden public access to mental health care, he said.

In 2002, New Mexico became the first state to award psychologists prescribing authority.

"It came out of the blue," Dr. Newman said. "New Mexico didn't have to work as long as you usually do to get this through, because the access issue rang true there. Seventy-two percent of the population had access to only 18 psychiatrists."

Psychologists are gearing up to pursue the passage of similar bills in other states and say the access argument will be key in Tennessee. Psychologists say Tennesseans face an average wait time to see a psychiatrist of six weeks -- eight weeks in rural areas and four weeks in urban areas.

But Peter Frizzell, MD, president of the Tennessee Psychiatric Assn., called the access-to-care debate a red herring. "I don't believe that psychologists are any more dispersed in rural areas than psychiatrists, so I don't believe that's a legitimate question on their part," he said. "Our primary care physicians are much better qualified to provide some level of pharmacological therapy than psychologists, who would go through a questionable training experience that couldn't duplicate medical school and residency."

Educating legislators

As medical societies and state medical boards gear up to address such legislation, organized medicine hopes to equip them with some new resources.

"It's a hot issue that the boards have brought to the federation," said cardiologist Grant La Farge, MD, a member of FSMB's special committee on scope of practice. "There isn't a single [medical] board in the U.S. that hasn't had some form of legislation pending, some repeatedly, which makes the medical profession howl. Certain kinds of increased scopes of practice can be accepted, but rules for patient safety need to be protected."

The FSMB has found that state legislators are hungry for advice on how to approach such legislation. "They hear strong voices on both sides of the issue, and they don't know how to sort this out," Dr. La Farge said. The special committee's white paper on scope-of-practice legislation is unlikely to be finalized before 2005, but Dr. La Farge said it aims to give legislators guidelines to make informed decisions on scope-of-practice issues.

One key recommendation will be that states require an ad hoc committee for each scope-of-practice issue. Instead of putting the process entirely in the hands of politicians, who typically have no medical background, these panels would bring professionals from both sides together to examine the scientific basis for a service and weigh the need for it against its hazards. They also would help determine what level of training is required.

AMA Executive Vice President Michael Maves, MD, agreed that the need to protect the public is increasingly necessary. "There's building momentum on the scope-of-practice side. There is a lot of pressure from the allied health professions."

The AMA working group is tackling scope-of-practice pressures from a different perspective. Composed of six state medical societies, which have been actively involved in scope-of-practice issues, and six specialty organizations, which frequently face scope demands, the group aims to improve communication among physician groups and make it easier for them to share expertise.

"Our sense is there is a lot that goes on in states that the specialty societies aren't aware of, and [we want] to try to provide the states with the expertise that the specialties have abundantly to share strategies on what works," Dr. Maves said. "My sense was there has not been a lot of dialogue between national specialty societies and state societies, but scope of practice is high on all their calendars."

The working group is also speaking with allied health professional organizations. "We need contributions from physicians and from the allied health side to approach this in a rational fashion," Dr. Maves said.

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What's covered

A survey by the American Assn. of Health Plans-Health Insurance Assn. of America found that in 2002, 94% of insurers covered chiropractic care. Other coverage included:

Massage/relaxation therapy 70%
Acupuncture 67%
Acupressure 58%
Herbal medicines 58%
Biofeedback 49%
Homeopathy 34%
Hypnosis 11%


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Widening their scopes

Several health professions are expected to pursue legislation on scope-of-practice issues this year.

Advanced-practice nurses

  • Continuing efforts to gain independent practice rights in Wisconsin.


  • Asking Congress for direct access to Medicare patients.
  • Seeking authority to diagnose disorders of hearing and balance systems in children and adults, as well as to provide comprehensive treatment of these disorders in Michigan and New Jersey.
  • Asking to remove physicians from the board of examiners for audiologists, hearing aid dispensers and speech language pathologists in Maryland.


  • Pursuing the designation as primary care physicians in Missouri.


  • Seeking to expand the scope to the head, neck and beyond for dentists with oral surgery privileges in Indiana and Colorado.


  • Seeking independence from physician supervision for nurse-midwives in Massachusetts.
  • Seeking licensure and independent practice authority for lay midwives in Missouri.


  • Pursing authority to perform laser surgery in Missouri.
  • Seeking unlimited prescribing authority and the ability to treat glaucoma in Vermont.


  • Asking for authority to modify prescriptions in Wisconsin.

Physical therapists

  • Seeking authority to prescribe medication, debride wounds and perform electrotherapeutics in Massachusetts.

Physician assistants

  • Seeking permission for physicians to delegate prescriptive authority to PAs in Ohio and Louisiana.
  • Seeking permission for physicians to delegate prescriptive authority for controlled substances to PAs in New Jersey.


  • Pursuing prescribing privileges in Georgia, Hawaii, Illinois, Louisiana, Maine, New Hampshire, Oklahoma and Tennessee.

Sources: AMA Advocacy Resource Center, National Conference of State Legislatures, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Physician Assistants, American Psychological Assn. (Note: Because not all state Legislatures have convened their new sessions, this list may not be complete.)

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