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Scope of Practice Legislative Landscape
This document summarizes scope of practice trends for various healthcare providers. It discusses how 26 states and DC have granted independent practice to nurse practitioners. It also outlines proposals for physician assistants to establish independent regulatory boards and directly bill insurers. The document reviews passed legislation in 4 states creating a new provider category called assistant/associate physicians who have completed medical licensing exams but not a residency. It summarizes scope expansions under consideration for pharmacists, psychologists, and naturopathic providers.
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Scope of Practice Legislative Landscape
- 1. Scope of PracticeLegislative Landscape Shelby King Manager, Center for State Policy
- 2. Agenda • Scope ofPractice Trends • Nurse Practitioners • Physician Assistants • Assistant Physicians • Pharmacists • Naturopathic Providers • Psychologists • Others • Scope of Practice Resources
- 3. Nurse Practitioners • 26states and DC have independent practice for nurse practitioners • Transition to Practice • APRN Multistate Licensure Compact • Joint Boards
- 4. Physician Assistants • AAPA“optimal team practice” • Remove the concept that PA scope is determined by physician delegation • Establish Independent Physician Assistant regulatory boards • Directly bill insurers and be reimbursed at physician rates • Prohibit insurers from imposing requirements more restrictive than state law • Continue movement towards “PA” • Doctor of Medical Science • Proposed new provider category for physician assistants who completed a DMS degree and have three years of clinical experience • Practice primary care with limited physician supervision
- 5. Assistant/Associate Physicians • Passedin AR, KS, MO, UT • New provider category • Successfully completed Step 1 and Step 2 of the United State Medical Licensing Examination • Has not completed an approved postgraduate residency • Congress of Delegates
- 6. Pharmacists • Vaccination Administration • Prescribing Medications •Medical Providers *Fact sheet taken from the National Association of State Pharmacy Associations
- 7. Psychologists • 5 stateshave passed legislation (IA, ID, IL, LA, and NM) • AAFP’s policy on prescribing drugs • APA: • Parity/Network Adequacy • Integrated/Collaborative Care • Telemedicine
- 8. Naturopathic Providers • Licensure •Prescriptive Authority • Surgical Authority • “Physician”
- 9. Others • Chiropractors • Midwives •Optometrists • Podiatrists
- 10. Resources Available • AMAScope of Practice Partnership • HealthLandscape • Center for State Policy Resources • State Advocacy • EACH OTHER
- 11.
Editor's Notes
- #3 State legislatures in 2018 considered over 800 bills seeking to eliminate team-based care models of health care delivery and/or expand the scope of practice of non-physician health care professionals.
- #4 AAFP policy is that the nurse practitioner should not function as an independent health practitioner. The AAFP position is that the nurse practitioners should only function in an integrated practice agreement under the direction and responsible supervision of a practicing, licensed physician. 26 states and DC have independent practice for nurse practitioners. Transition to Practice Over 200 bills were filed to expand the scope of practice of advanced practice registered nurses. Many of these bills chip around the edges of state laws, notably laws regarding certification of a disability or cause of death, authorization of involuntary commitment, and so on. Good news - medicine was largely successful this year at preventing APRN independent practice laws from passing. You’ll hear from Dr. Riley on South Carolina’s advocacy efforts later. However, legislation establishing “transition to independence” for nurse practitioners continues to resonate with legislators. Of the states that introduced legislation which would allow NPs to practice independent of physician collaboration, supervision or oversight a majority would have allowed independent practice only after the NP completed an identified number of hours or years of clinical practice in collaboration with a physician (and in some cases, a Nurse Practitioner with a certain amount of experience). The amount of time ranges from 18 months to 5 years and the number of hours ranges from 1,800 to 2,080 Virginia passed this type of legislation this year. The legislation eliminated the requirement for a practice agreement with a patient care team only if the nurse practitioner completed the equivalent of at least five years of full-time clinical experience. Additionally they had to file an attestation to the Board of Medicine and Board of Nursing. The requirement that the APRN complete five years of full-time clinical practice on a physician-led team before gaining the authority to practice independently is the most substantial of any state “transition to practice” requirement. APRN Multistate Licensure Compact The National Conference of State Boards of Nursing recently launched a revised APRN Multistate Licensure Compact. The APRN Compact differs from the Federation of State Medical Boards Compact (FSMB Compact) in two key ways: The APRN Compact grants a multistate license – a licensed APRN will have to apply for a single multistate license that will allow the APRN to practice in any APRN Compact state. In comparison, the FSMB Compact creates a pathway by which physicians can obtain multiple single-state licenses. The APRN Compact authorizes any APRN practicing in an APRN Compact state under an APRN Compact license to practice independently. As such, the APRN Compact undermines state law in a way that the FSMB Compact does not. APRNs practicing in APRN Compact states with a regular license (not a multistate license) will still be required to follow state law on collaborative practice. In addition, all APRNs, whether practicing under a regular or multistate licenses, will have to follow the applicable stat’s rules for collaboration/supervision while prescribing controlled substances Dangerous because legislators don’t understand what’s in the bill. So far only three states – ID, ND, and WY – have joined the APRN compact. Ten states have to enact the APRN Compact for it to be launched. In May, the AAFP joined the AMA and sent a letter joined by over 80 medical associations to NCSBN, urging the removal of the problematic language from the APRN Compact. Joint Boards If the writing is on the wall and independent practice is going to move forward you might consider advocating the nurse practitioners be regulated under a joint Board. In some states, Nebraska/Virginia/Kansas, Nurse practitioners are regulated by the Board of Nursing and the Board of Medicine under a Committee of the Joint Boards. This allows both Boards to promulgate regulations governing the licensure of APRNs, governing prescriptive authority, and establish grounds for disciplinary action Model legislation is available.
- #5 AAFP’s position on physician assistants is that they should practice in integrated practice arrangements with practicing, licensed physicians. Optimal Team Practice The American Academy of PAs (AAPA) continued developing its new policy in support of independent practice in 2018, releasing model legislation and regulation that eliminates provisions in laws or regulations that require a physician assistant to have a supervisory or collaborative relationship with a physician in order to practice. The legislative and regulatory measures would also: Remove the concept that Physician Assistant scope of practice is determined by physician delegation, instead allowing Physician Assistants to provide “any legal medical service for which they have been prepared by their education, training and experience and are competent to perform;” Support the establishment of independent Physician Assistant regulatory boards to license, regulate, and discipline Physician Assistants; Support Physician Assistants being able to directly bill insurers and be reimbursed for care at physician rates; Prohibit insurers from imposing practice, education, or collaboration requirements that more restrictive than state law; and Continue the movement towards changing the title of “physician assistants” to just “PA” No state has seen legislation attempting to implement the “optimal team practice.” Nonetheless, AAFP chapters should be prepared for “optimal team practice” proposals in the future legislative sessions Doctor of Medical Science This was legislation proposed in Tennessee and pushed by the Lincoln Memorial University. The legislation would create an essential access practitioner for those who complete their Doctor of Medical Science. This license would be open to physician assistants with a master’s degree and three years of clinical experience after they completed a DMS program, which would be administrated through a medical school and consist of 50 credit hours. After which they could practice with limited physician supervision in undeserved areas. The Tennessee AFP and Tennessee Osteopathic Association advocated against the bill in opposition to their medical society which remained neutral. The AOA and AAFP also sent letters opposing this legislation The AAPA is also against this legislation because they do not feel that PAs need to complete this program to be qualified to have independent practice. Ultimately, LMU withdrew the proposed legislation, although their DMS degree program will move forward. They said that the program will move forward with a “focus on the educational value of DMS training for practicing physician assistants.” This legislation has also been introduced in Virginia
- #6 Assistant and Associate Physicians This concept was first introduced in Missouri in 2014. The law will allow certain medical school graduates who have passed Step 1 and Step 2 of the licensing exam, but have not completed residency training to practice medicine under a restricted license. The license would allow the assistant physician to enter into a collaborative practice arrangement with a physician for the purpose of practicing primary care and prescribing in rural and under-served areas. This has passed in Arkansas, Kansas, Missouri, and Utah with varying degrees of scope of practice and limitations. Missouri legislation is the most aggressive The AAFP does not have policy on this issue. However, the AMA does. Their policy states that they oppose special licensing pathways for physicians who are not currently enrolled in an ACGME or AOA training program, or have not completed at least one year of accredited post-graduate US medical education. There was a Congress of Delegates resolution related to assistant physicians that passed this year. Therefore there will be more education and resources to come surrounding this issue.
- #7 Vaccination Administration All 50 states and DC allow pharmacists to administer vaccinations; however, states have limitations based on age, type of immunization, consent of a parent or guardian, and/or required authorization. All 50 states and DC allow pharmacists to administer the influenza vaccine. 19 states allow pharmacists to prescribe and administer these vaccines independently 31 states and the District of Columbia allow pharmacists to administer flu shots through collaborative practice agreements, standing orders, prescriptions from providers, or other protocols. 5 states expand pharmacist vaccine administration authority in the case of a public health state of emergency. Prescribing Medications Pharmacists prescribing legislation has been circulating in recent legislative sessions. All 46 states have collaborative drug therapy management legislation or regulation and the AAFP supports arrangements where the pharmacist is part of an integrated, team-based approach to care. However, the AAFP does not support independent prescription authority for pharmacists. We have policy that encourages state chapters to oppose state legislation allowing pharmacists to dispense medication beyond the expiration of the original prescription for other than emergency purposes. All 50 states allow pharmacists to dispense naloxone Six states have active regulation that allows pharmacists to prescribe and dispense oral contraceptives Six states allow pharmacists to prescribe and dispense smoking cessation aids In Idaho a few years back they passed legislation which allows their Board to promulgate rules related to pharmacist prescribing of drugs, drug categories, and devices provided they meet one of the four statutorily authorized conditions. Controlled substances, compounded medications, and biological drugs are specifically excluded by the statute. In July, as a result of this legislation, Idaho implemented the most wide sweeping prescribing rights for pharmacists in the country. The new rule allows pharmacists to prescribe medications for cold sores, seasonal influenza, strep throat, and urinary tract infections, as well as statins for patients with diabetes. In 2016, pharmacists in Idaho also gained prescriptive authority for epinephrine auto-injectors and are also able to dispense dietary fluoride supplements, vaccines, and opioid antagonists. The new provision requires that pharmacists use an assessment form based on current clinical guidelines or evidence-based research to determine whether or not a medication is medically appropriate. Additionally, pharmacists will plan follow-up care and notify a patients primary care physician of any prescribed therapies. Medical Providers We have recently see legislation introduced that would allow pharmacists to provide health and wellness assessments. This is particularly concerning and something that chapters should prepare for.
- #8 28 states have considered legislation which would allow for psychologists to prescribe medication Laws very – some legislation defines drugs/prescription/ and medicines as listed under the Controlled Substances Act, Pharmacy Practice Act Other laws are just for psychotropic medications Most bills that are introduced would require psychologists to complete just 10 weeks of online training before they begin writing prescriptions. Additionally, all oversight and certification would lie within the American Psychological Association Records show that in the states that do allow psychologist prescribing, psychologists are prescribing their patients heart medications, muscle relaxants and cholesterol drugs. AAFP’s policy on prescribing drugs reiterates that the AAFP believes that only licensed doctors of medicine, osteopathy, dentistry, and podiatry should have statutory authority to prescribe drugs for human consumption The American Psychiatry Association is a great person to collaborate with as psychologists scope of practice bills move forward. APA counters that instead states should encourage telemedicine, enforce mental health parity laws and integrate mental health across health care setting.
- #9 AAFP Policy is clear: We oppose licensure of naturopaths In states that permit licensure of naturopaths, the AAFP opposes any expansion of naturopaths’ scope of practice that is not supported by naturopathic education and training. Specifically stating that naturopaths are not prepared to safely or effectively prescribe medications, or perform surgical procedures Cannot be called a physician Public and private payers should not pay for naturopathic services Additionally, the training programs should be monitored constantly. Legislation continues to be introduced in states around licensure, prescriptive authority, and surgical authority. Licensure 20 states and DC have laws that license naturopathic providers. South Carolina and Tennessee explicitly prohibit the practice of naturopathy. Prescriptive Authority Most states that license naturopathic providers have prescribing authority, they are not allowed to prescribe controlled substances aside from New Hampshire and Washington, which both allow limited exceptions for certain drugs. The majority of states allow a naturopath to prescribe and administer nonprescription natural therapeutic substances, drugs and therapies. Surgical Authority 12 states and DC allow naturopaths to provide minor surgeries. Definitions of minor surgeries vary, they typically refer to the repair, care and suturing of superficial lacerations and abrasions and the removal of foreign bodies located in superficial tissue. 11 states allow for naturopathic tests Physician Finally, seven states allow naturopathic providers to use the term physician, however this is prohibited in seven states and DC.
- #10 Who else? We continue to see various scope of practice introduced regarding chiropractors, midwives, optometrists, and podiatrists. Chiropractors “Return to Play” – a majority of the states do not authorize chiropractors to evaluate students with concussions and certify them to “return to play”, laws for a handful of states are not clear on whether chiropractors in fact are authorized to certify return to play. All states require that a “licensed health care provider or professional” must clear a student, however about a third do not define exactly what that encompasses. For example, Iowa includes chiropractors as a licensed health care provider. Unclear statutory language has led to debate on who within their scope of practice recognizes, treats, or manages concussions. A position statement of the American Chiropractic Board of Sports Physicians, for example, states that “Doctors of Chiropractic may evaluate, diagnoses, and manage concussed individuals.” In fact, we have seen legislation introduced in states to allow for chiropractors to evaluate students for return to play. Midwives The AAFP position is that certified nurse midwives should only function in an integrated practice arrangement under the direction and responsible supervision of a practicing, licensed physician qualified in maternity care. However, states continue to introduce legislation which would allow for independent practice for midwives. 25 states and DC have independent practice. 7 states allow independent midwifery practice, but without prescriptive authority Optometrists States have introduced legislation allowing optometrists injectable or surgical authority. We have seen states try to sneak this through the regulatory process. For example in 2017, the Illinois Department of Financial and Professional Regulation proposed a rule that would have added seven surgical procedures and three different types of injections to the optometry scope of practice without commensurate legislation authorization. A great partner for this legislation is the American Academy of Opthalmology Podiatrists Legislative, and other changes, have been (or are being) considered to expand podiatrists' scope to include lower legs, knees, and even the leg up to the hip. In a small number of states, podiatrists are allowed to treat hands. There is also a push to expand the ability of podiatrists to amputate beyond the toes, up to the whole foot or even the ankle, and to expand podiatrists ability to use anesthesia and give prescriptions. A great partner for podiatry scope of practice bills is the American Academy of Orthopaedic Surgery
- #11 AMA Scope of Practice Partnership The AAFP is an integral member of the Scope of Practice Partnership, which is a collaborative effort of the AMA, AOA, national medical societies, and state medical associations that focuses resources of organized medicine to oppose scope of practice expansions by non-physician providers that threaten the health and safety of patients. As a result from the partnership we have access to tons of resources dedicated to scope of practice. If you are facing a legislative battle please reach out as we are happy to share any and all resources that we have access too. We have more available than what is posted on the website. For example, we have access to model legislation regarding joint boards and legislative charts which break down the prescribing laws, independent practice statutes, etc related to certain mid-level providers. Additionally, the AAFP also sits on the Steering Committee which selectively funds advocacy campaigns addressing scope of practice concerns in states that have committed their own resources but are still in need of financial or in-kind assistance. If you are facing a scope of practice battle, please consider reaching out to your medical society to work on an application for a grant. We recently approved a grant in Pennsylvania that was endorsed by the Pennsylvania Academy of Family Physicians and will help as they work to defeat scope of practice legislation regarding nurse practitioners. HealthLandscape Additionally, HealthLandscape is a key resource as you work on scope of practice. HealthLandscape has created the Health Workforce Mapper which can map where mid-level providers practice compared to family physicians. Each of you have an example in your folder If a chapter reaches out about scope of practice resources I always include HealthLandscape and my go to is to point to states that have already allowed for independent practice and have not seen a great migration of nurse practitioners to rural areas. For example in Montana, there are 11 counties that did not have family physicians; however, in those same 11 counties, 6 of them also didn’t have nurse practitioners. Additionally, 4 other counties did not have nurse practitioners where there were family physicians. In addition to illustrating the geographic locations of the health care work force in each state the Workforce Mapper has been updated to include population health data by geographic location. The Population Health Explorer feature offers data on a variety of population health factors, including health care access and quality, health behaviors such as smoking and alcohol use, demographics, and social environment factors. With this new feature, you can not only see where the physicians of the country practice, but overlay where the patients are, and what factors influence their health and access to care. You can also identify health professional shortage areas, hospital locations, and other workforce trends Center for State Policy Resources The Center for State Policy also has backgrounders on the Center for State Policy issuing the AAFP’s recommendations and a brief overview of the scope of practice variances across the state. Chapters also have access to all of our grassroots capabilities – SpeakOut, etc. If you need help during your advocacy efforts surrounding not just scope, but anything, the Center is happy to provide technical assistance and help you create a document, find relevant research, etc. State Advocacy Additionally, the AAFP will weigh in on state legislation at the request of a chapter. We have been doing this most recently with Medicaid waivers, but last year also submitted letters to the Tennessee legislature about Doctor of Medical Science and the Pennsylvania legislature with regards to independent practice for nurse practitioners. Collaboration Among AAFP Chapters FINALLY and most importantly, we can all learn best from each other. Chapters have been pursuing innovative ways to defeat scope of practice legislation for years – Michigan was a Leadership in State Governmental Advocacy Winner last year and South Carolina was a winner this year. These are just two examples of AAFP chapter work on scope of practice. The Center for State Policy tries to provide avenues for collaboration. We have recently launched the Chapter Advocacy Staff Community for staff members to discuss legislation introduced, share resources developed, etc. Additionally, each year we create the State Legislative Summary which shares what each chapter worked on – we have a section dedicated to scope of practice and we hope this resource allows chapter staff to connect with chapter colleagues who have faced similar state legislative issues.