Just what the doctor ordered: Scope-of-practice measures improve patient safety

The AMA affirms that all healthcare professionals play an important role in the provision of care.^[] However, the AMA is clear that the high-stakes nature of medicine necessitates that physicians act as the leaders of healthcare teams—not nurse practitioners, physician assistants, or others. This is because of physicians’ extensive education and clinical acumen.

“The health and safety of patients are threatened, however, when nonphysician health care professionals, such as nurse practitioners or physician assistants, are permitted to perform services that are beyond the boundaries of what they have been educated and clinically trained to do,” warns the AMA.

Scope of practice expansions stoked by the pandemic

In the AMA’s eyes, scope of practice refers to the activities that a healthcare professional is permitted to perform, per state laws and medical-licensing authorities. Definitions, laws, and regulations vary by state.

The AMA has targeted preserving scope of practice for more than 30 years. Calls to expand the scope of practice gained steam during the COVID-19 pandemic, according to Michaela Sternstein, JD, vice president of the AMA’s Advocacy Resource Center, in an AMA podcast.^[]

“And all of us rowing together in one direction was the recipe for success during the pandemic,” she said. “But we also knew that by allowing for unprecedented activity and scope of practice during an emergency, that it would be likely that many of these nonphysician provider groups would then take that and try to extrapolate it outside of the pandemic. And it's exactly what's happened.”

A prominent example of overreach occurred when Governor Charlie Baker of Massachusetts made permanent, by means of executive order, the independent practice of nurse practitioners and other advanced-practice nurses. This expansion of the law came without legislature input, which is a source of consternation for the AMA.

Sternstein presented some stark examples of scope-of-practice expansions. She pointed to optometrists trying to perform eye surgery, or physician assistants pushing for “collaboration” in lieu of physician supervision, thus joining nurse practitioners, who have been aiming for the same for “much longer.”

A handful of states have passed bills that transform the scope of practice of physician assistants from supervision status to collaboration. The AMA concedes defeats and victories in combating such moves.

What about increased access to care?

Advocates for scope-of-practice expansions contend that these measures are required to expand access to care in rural areas. The AMA, however, has disproved this claim by mapping the practice location of physicians and nonphysicians across the country. 

When they compared the practice locations of primary care physicians with those of nurse practitioners, they found that these healthcare professionals tend to practice in the same areas—even in areas where nurse practitioners can practice without physician supervision or collaboration.

Why the expansion of scope doesn’t work

Having this increased experience and knowledge at the head of the healthcare team is critical for the safety of the patient, claims the AMA. Moreover, according to an AMA national survey, 95% of US voters want a physician to take part in their diagnosis and treatment. 

A study published in the Journal of the Mississippi State Medical Association, and cited by the AMA, analyzed cost data for the South Mississippi system’s accountable care organization.^[][] It found that care provided by nonphysician providers assigned their own panels of primary care patients was more expensive than care provided by physicians. 

The decision by South Mississippi to let advanced-practice providers (APPs) work their own patient panels was triggered by a dearth of primary care physicians. The study was based on data from more than 33,000 Medicare patients. 

“We believe very strongly that APPS are a crucial part of the care team,” wrote the authors. However, “based on a wealth of information and experiences with them functioning in collaborative relationships with physicians, we believe very strongly that nurse practitioners and physician assistants should not function independently,” they wrote. 

The authors affirmed that, moving forward, any addition of APPs to physician-led healthcare teams will be evidence-based.

What’s being done

The AMA, the American Osteopathic Association, and state and national specialty societies have been fighting hard to keep APPs in their lane. As of July 2021, the AMA worked with 35 state medical associations to defeat legislation that expands scope of practice involving physician assistants, nurse practitioners, nurse anesthetists, nurse midwives, clinical nurse specialists, naturopaths, optometrists, pharmacists, physician assistants, podiatrists, and psychologists. Their efforts have met varying degrees of success.^[]

Sternstein explained that, along with state and national medical specialty societies, the AMA has formed the Scope of Practice Partnership with physician ambassadors (the Ambassador Program) who engage with and influence pivotal legislators and policy makers. These ambassadors are dispatched to key meetings that impact scope of practice.