Profession

Physician task force confronts scope-of-practice legislation

A new coalition within organized medicine cites patient safety as the reason for coming together.

By Myrle Croasdale — Posted Feb. 13, 2006

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With 31 states and the District of Columbia expected to face legislation that asks to alter or expand the scope of more than 20 allied health professions this year, organized medicine says it's time to join forces to oppose any changes that jeopardize the health and safety of the public.

With the American Medical Association's support, a steering committee of six state medical societies and six national medical specialty groups has been looking for solutions over the past year. In January they released their answer -- the Scope of Practice Partnership, a coalition of physician organizations that will bring their collective experience and resources to the fray to replace what often has been a fragmented approach to scope-of-practice battles. The effort is particularly important, committee members say, because all of medicine suffers, not just a single state or medical specialty, when the practice of medicine is put into hands without the training to practice it.

"The driving need for such a group is to ensure quality care for patients," said AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, a participant in the steering committee that gave rise to the Scope of Practice Partnership. "While nonphysician providers have been, and will continue to be, important elements in the provision of health care, it is important that our patients know and receive the care that only physicians are uniquely qualified to provide."

Once the steering committee formalizes its membership, it intends to move on its agenda.

"Our goals for the upcoming year are to serve as a forum for discussion of scope-of-practice issues, to conduct research of value to state and specialty societies facing scope battles and to share lessons learned across geographic and specialty societies," Dr. Maves said.

In 2006, partnership members plan to conduct research comparing allied health practitioners' training and qualifications to that of physicians' education and licensing. They also will map the distribution patterns of allied health practitioners to determine if those practitioners are practicing in physician shortage areas. In recent years, allied health professionals have been successful in expanding their scope in rural states by saying this will help improve access to care in underserved areas.

The persistent stream of scope-of-practice legislation also has spurred a committee at the Federation of State Medical Boards to create a guide for medical boards and legislatures that outlines key patient safety and quality-of-care issues to be addressed when considering scope alterations.

"Bottom line, our whole position is public protection. Any decision must be in the best interest of patients," said Lisa Robin, FSMB vice president of leadership and legislative services.

Pressures on the health care system

Momentum behind the legislative efforts comes from a variety of sources. For example, technological advances and managed care pressures to limit hospital stays have prompted the number of office-based surgeries to rise sharply in recent years. In turn, this has created more demand for anesthesia professionals.

Such changes often have outpaced the legislative process, according to Mitch Tobin, senior director of professional practice affairs for the American Assn. of Nurse Anesthetists, which is why groups such as the AANA want legislative change. "Many laws are out of date and don't reflect current practice," he said.

From the perspective of certified registered nurse anesthetists, that means independent practice, a stance the American Society of Anesthesiologists does not share.

"Our position that patient care is improved when an anesthesiologist is involved has been reinforced by various studies," said Orin F. Guidry, MD, president of the American Society of Anesthesiologists. One study found that with every 10,000 Medicare patients who had general or orthopedic surgery, there were 25 more deaths when an anesthesiologist did not direct the anesthesia care.

Some physicians are concerned that once a group expands its scope, further expansions may follow.

Psychologists now may prescribe in New Mexico and Louisiana. In New Mexico, they must be supervised by a physician for two years and may then become more independent and prescribe after consulting with the patient's primary physician. In Louisiana, there is no supervisory training period, but psychologists must get the approval of the patient's primary care doctor before prescribing.

But during the Hurricane Katrina crisis, David Edward Post, MD, past president of the Louisiana Psychiatric Medical Assn., said two medical psychologists arrived to volunteer while he was working at an emergency medical center in an abandoned New Orleans store.

He was stunned when they told him they had been writing prescriptions at another site without physician input.

"The way I understood the law, they needed to be in collaboration with a doctor," Dr. Post said. The incident left him wary that groups might request scope expansions that would take effect during emergencies.

Diana Ewert, senior manager of state government relations for the American Academy of Family Physicians, said new pressures to expand some health care professionals' scope of practice are emerging as state budgets tighten and those professionals sell themselves to lawmakers as less-expensive alternatives to physicians. Combine this with family physicians dropping risky procedures to stay financially solvent amid rising medical liability rates and falling reimbursements, and the environment is ripe for scope expansions as allied health care practitioners seek to fill the gap, she said.

"There's a need for medicine to be collectively vigilant as more strain is put on states' health care dollars," Ewert said. "Physicians have the education, training and experience to bring together and use a team appropriately, but there needs to be physician oversight."

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ADDITIONAL INFORMATION

2006 legislation

Lawmakers in 31 states and the District of Columbia are expected to face scope-of-practice legislation involving more than 20 allied health professions, according to the American Medical Association. Below is a partial list of bills gaining attention and the changes being sought.

Advanced-practice nurses

  • Authority to prescribe controlled substances: Florida, Missouri
  • Authority to prescribe schedule II drugs, same Medicaid reimbursement as physicians: Illinois
  • Independent hospital admitting privileges: Ohio

Naturopaths

  • Licensure: Delaware, Florida, Illinois, Massachusetts, Minnesota, Missouri, North Carolina, New York, Tennessee
  • General scope expansion: Georgia
  • Inclusion in health insurance plan reimbursement: Vermont

Nurse anesthetists

  • Restricted use of anesthetic agents by nurses other than certified registered nurse anesthetists: Tennessee
  • General scope expansion: Virginia

Nurse and lay midwives

  • Licensure and independent practice: Illinois
  • General scope expansion: Massachusetts, Missouri
  • Limited prescriptive authority: Virginia

Optometrists

  • Prescriptive authority: Alaska, Florida, Illinois, Massachusetts, New York
  • Authority to perform some surgical procedures: Alaska, Florida, Georgia, Tennessee
  • General scope expansion: Colorado
  • Authority to perform laser surgery: Missouri
  • Expansion of drug formulary: Ohio
  • Physicians seek to roll back optometric surgical scope regulations: Oklahoma

Physical therapists

  • Patient direct access to therapists: Illinois, Michigan, Missouri, Nebraska, New York, Tennessee, Washington, D.C.

Podiatrists

  • Expand surgical scope to below the knee: Illinois
  • Diagnosis and treatment of the foot and ankle: Massachusetts
  • Foot amputation: Missouri
  • Treatment of the ankle and soft tissues below the knee: New York
  • Treatment of the ankle and soft tissues to the level of the myotendinous junction: South Carolina

Sources: American Medical Association, NETSCAN's Health Policy Tracking Service

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Questioning scope expansion

  • Is there a verifiable need for the requested change?
  • What effect will it have on public health and safety?
  • What formal education and training support this change, and is there a formal process of accreditation for these teaching institutions?
  • Is independent practice advisable, or should collaboration or supervision be required?
  • If a bill seeks to bypass licensing or regulatory requirements to allow the requested change, what's the rationale for this, and what effect will it have on patient safety?
  • How will regulatory boards interact to evaluate the scope request?
  • What is the financial impact and incentives related to this change?

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External links

Federation of State Medical Boards for the Special Committee on Scope of Practice informational guide (link)

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