Defending scope of practice
Academy defeats many scope of practice expansion bills in 2023 with more to follow in 2024.
By Ruth Carol, Contributing Writer, December 1, 2023
If wins are for celebrating, the American Academy of Dermatology Association (AADA) will be doing a lot of that in 2023 as it has defeated several scope of practice expansion bills in partnership with state dermatology and medical societies. If losses are for learning, the Academy will be using the recent shifts in the scope of practice landscape to defeat bills that will be introduced in 2024.
“Overall, it was a successful year, especially given the number of bills that were introduced,” noted Lisa Albany, JD, the AADA’s director of state policy. In 2023, 22 states introduced bills to expand scope of practice for physician assistants; only four states passed them.
Considered a top advocacy priority, the Academy will continue to battle state legislation that weakens the quality and safety of specialty care. “All we can do is continue to fight scope of practice bills as they are introduced,” stated Alex Gross, MD, FAAD, chair of the AADA State Policy Committee. “We must be ready to take on all the folks who are trying to broaden their scope of practice,” he added.
In Alabama, the state legislature rejected legislation that would have lowered the standards of surgical eye care by authorizing optometrists to perform surgical procedures, including removing lesions on the face and performing laser procedures. The AADA joined with the Alabama Dermatology Society, Medical Association of the State of Alabama, Alabama Academy of Eye Surgeons and Physicians, and the Alabama Society of Plastic and Reconstructive Surgeons to defeat the bill.
Although this legislation was not technically a dermatology issue, the former president of the Alabama Dermatology Society brought it to the attention of the Academy, said Aliya Courtney Hines, MD, PhD, FAAD, deputy chair of the AADA State Policy Committee. He even testified at the hearing. “It was a great example of collaboration and a grassroots approach across specialties,” she said.
In Georgia, health care transparency legislation that limits the use of medical specialty titles in advertisements and clinical settings to physicians was enacted. This is another “ologist” bill, the first of which was passed in Indiana in 2022, that prohibits non-physician clinicians from using medical specialty titles or designations, such as “dermatologist,” “cardiologist,” or “anesthesiologist,” Albany explained. The Georgia bill, however, requires physician assistants (PAs) and nurse practitioners (NPs), who hold a doctorate degree and use the title “doctor,” to clearly state in a clinical setting that they are not a medical doctor, she said.
“This law prevents non-physician clinicians from using titles and language that might confuse patients into thinking that they’re seeing a doctor,” said Dr. Gross, who is also the chair of the Legislative Committee for the Georgia Society of Dermatology and Dermatologic Surgery. The AADA assisted the state dermatology association with a grassroots effort by having dermatologists send letters supporting the legislation and showing up to testify at senate hearings. “All that adds extra weight to your efforts,” he said.
“This law prevents non-physician clinicians from using titles and language that might confuse patients into thinking that they’re seeing a doctor.”
In Mississippi, legislation was defeated that would have authorized pharmacists to treat skin conditions. The Academy supported the Mississippi Medical Association and Mississippi Dermatology Association in their efforts. The house of medicine came together to defeat the Mississippi bill, with physicians from several specialties sending letters of opposition and testifying against the legislation, Albany said.
In New Hampshire, legislation would have allowed naturopaths to serve as medical directors at medical spas. The sponsor, however, withdrew the legislation and asked that the issue be studied. The AADA worked with the New Hampshire Medical Society to prevent the legislation from going forward. “We don’t know whether we’ll see it back next year,” Albany said.
In South Dakota, the Academy partnered with the South Dakota State Medical Association to defeat a bill that would have authorized PAs to practice independently. The state medical association was also awarded an American Medical Association Scope of Practice Partnership (AMA SOPP) grant used to energize a very successful grassroots campaign, Dr. Hines said, adding, “Grants of this nature help amplify our message.” Many specialties teamed up to oppose the bill, which has now failed for the third time. The AADA also successfully opposed legislation in the state that would have lowered the standards of surgical eye care by adding laser and scalpel surgery to an optometrist’s scope of practice.
Losses highlight changing landscape
Where the Academy was unsuccessful this year in stopping unsafe scope of practice expansion reveals growing challenges in the landscape. For starters, legislators are fatigued by scope of practice battles. “They want physicians and non-physician clinicians to come to a compromise,” Albany said.
In some states that passed scope of practice expansion, compromises were negotiated between non-physician clinicians and state medical societies, she said. The bill that passed in Colorado was more broadly written than in the past when it was repeatedly defeated. While PAs no longer have to practice under physician supervision, they will be required to have a collaborative agreement with an employer, physician, or physician group. However, for PAs with fewer than 5,000 hours of practice and those switching to a new specialty with fewer than 3,000 practice hours, the collaborative agreement is a supervisory agreement.
In another growing trend, PAs are targeting states in which NPs have gained independent practice. “The PAs argue that if NPs are allowed to practice independently, they should be able to as well,” Dr. Hines said. “It has become an uphill battle in those states.” Currently, 29 states allow unsupervised practice for NPs, Dr. Gross noted. Three states allow PAs to practice with limited or no oversight.
The types of non-physician clinicians who want to expand their scope of practice also continue to grow. They include pharmacists, naturopaths, optometrists, dentists, and aestheticians.
“With large health systems, including academic institutions, and private equity getting involved in running health care entities, physicians may be pressured to provide patient care how they are told, rather than doing what is in the best interest of the patient.”
They are increasingly targeting the use of injectables, botulinum toxins, and fillers. In Washington state, for example, naturopaths have been pushing for authority to use these products since 2018, Albany said. Despite the AADA arguing to have fillers removed, the bill that was eventually passed allows naturopaths to use botulinum toxin. “When physicians’ NPs and PAs administer botulinum toxins under physician supervision, it’s hard to convince legislators that someone with more training, such as a dentist, shouldn’t be allowed to use them,” Albany said. “But fillers can do a lot of damage, including lead to blindness, if injected incorrectly. I don’t think there’s an understanding among other specialists that using these products is a threat to patient safety. We must do a better job educating other specialties about the dangers of cosmetic procedures,” she added.
More recently, some unlikely allies are coming out in support of scope of practice expansion for non-physician clinicians. In Colorado, there were more physicians than in the past supporting the legislation, Albany said. There were also more health care systems supporting this issue in Colorado and other states, which is concerning because it’s a group with a lot of lobbying power, she noted. Also, some of them employ Academy members. “Physicians, including dermatologists, are really upset about this but some are hesitant to voice their opinion because it would mean going against their employer,” Albany said.
“With large health systems, including academic institutions, and private equity getting involved in running health care entities, physicians may be pressured to provide patient care how they are told, rather than doing what is in the best interest of the patient,” stated Sabra Sullivan, MD, PhD, FAAD, who serves as the president of the Mississippi Dermatology Association. “Mid-level providers working independently may not have the training to resist such pressure,” added Dr. Sullivan, who was also a member of the AADA Scope of Practice Workgroup.
Stepping into an advocacy role
Many dermatologists find themselves becoming an advocate regarding one issue and then they are hooked.
As chief of dermatology at the University of Mississippi, Dr. Sullivan became extremely concerned when a local Medicare policy indicated that actinic keratoses shouldn’t be treated if they are not cancer. “I thought if I explained why this was wrong, they would fix it,” she said. When that didn’t happen, Dr. Sullivan managed to get a meeting with her senator to explain why this policy was not medically sound. “That is when I learned that voters matter,” Dr. Sullivan said. “When I told him that people in Louisiana and Alabama can get their actinic keratosis treated, but not his constituents in Mississippi, he understood the impact of the issue,” she recalled.
Growing up in rural Ohio, Dr. Hines saw firsthand what lack of access meant to patients in underserved communities. When she first started doing telemedicine to increase access to care, there was very little payment for it. Working at the Veterans Administration, Dr. Hines became involved in efforts to get the government and insurers to pay for telemedicine. “I couldn’t understand why they wouldn’t pay for this when it increased access,” she said.
Dr. Gross joined the Georgia State Medical Association when he was trying to amend a laser law that passed. A lobbyist suggested having someone join the state medical board. “I’ve been on it for 16 years now,” he said, adding, “I would encourage anyone interested in serving on a medical board to do it.”
There are currently 19 physicians serving in the 118th Congress (four senators and 15 representatives). Learn more about the Academy’s resources to combat scope of practice creep.
Band with other specialties
It’s important to keep in mind that this is a marathon not a sprint. “We have an important message to get out there. We want to make sure that the public and legislators know that the best care is provided when the physician is head of the care team,” Dr. Hines said. While the Academy supports physician-led team-based care, it recognizes that non-physician clinicians play a valuable role in the delivery of health care, she added.
To combat legislator fatigue, the Academy will continue to strengthen its united front with the house of medicine to minimize the perception that scope of practice is simply a turf war between dermatologists and non-physician clinicians. To that end, the AADA serves on the AMA SOPP, as well as works with state and local dermatology and medical societies on these efforts. “We have the most impact when we collaborate with other specialties,” Dr. Sullivan said. She also believes that the Dermatology Section Council at the AMA has helped shed light on these issues throughout the house of medicine.
Albany believes that the more aligned the AADA and other medical specialties are with messaging, the less likely that scope of practice will be seen as a turf battle. Plus, working together allows the specialties to present a broader picture of the negative implications of expanding scope of practice for all patients. Relaying patient stories across the specialties has a better chance of resonating with more legislators, she added. It also enhances grassroots efforts, grows physician presence at state houses, and combines resources.
Highlight access, cost, patient needs
“Unfortunately, the significant differences in education and training between dermatologists and PAs and NPs do not resonate with legislators as we had hoped,” Albany said. “They are really focused on access.” As more states allow NPs and PAs to practice independently, the data demonstrating that they are not increasing access to care in rural and underserved areas continue to grow, Dr. Hines said. The AMA’s tracking tool shows that PAs and NPs who can provide care independently are clustered in the same urban areas as physicians. “The key is getting the data out there and allowing people to see that the argument being used to support independent practice for advanced practice nurses is not being achieved,” she added.
Other mounting data demonstrate that care provided by non-physician clinicians is not cost effective. Studies have shown that care provided by NPs and PAs may increase costs due to inappropriate prescribing, unnecessary referrals to specialists, and unneeded diagnostic imaging studies across specialties. A recent study conducted by the Hattiesburg Clinic, a multispecialty clinic and accountable care organization, found that care provided by non-physician clinicians working on their own patient panels led to higher costs, more referrals, higher emergency department use, and lower patient satisfaction than care provided by physicians. The authors concluded that although NPs and PAs play a crucial part of the care team, they should not function independently. “We need more studies like this one,” Albany said.
Within dermatology, studies have shown that advanced practice professionals require many more biopsies than dermatologists to diagnose skin cancer and PAs are less accurate than dermatologists at diagnosing melanoma. “In addition to patient stories, we have to highlight data demonstrating that patients don’t get the same quality of care when they are being treated by a care team that is not led by a physician,” Dr. Hines said.
Other evidence suggests that patients want to be seen by a physician. When legislation was introduced in Mississippi to grant independent practice for NPs, Dr. Sullivan was involved in conducting a survey looking at what patients want. It turns out that nine out of 10 Mississippians (18 and older) prefer to have a physician involved in their care, she said. “Every year after that, the NPs have come back, and now they are being joined by PAs and pharmacists who want to practice independently,” Dr. Sullivan said. “That is why we update the survey annually and support it with a campaign using social media, billboards, and talk radio, as well as encouraging people to write letters and speak to their legislators. Having heard what patients think has been helpful in defeating these bills,” Dr. Sullivan said. This survey has been emulated in many other states, she added.
The other side of the coin of defeating scope of practice expansion is promoting truth in advertising. “We should take the offensive by helping pass truth in advertising bills, so that patients know who is taking care of them,” Dr. Gross said. Patients are being told through the media that being seen by an NP or PA independently is equivalent to being seen by a physician, Dr. Sullivan added. As NPs and PAs gain independent practice, the Academy is tracking the ologist legislation to make sure that patients know who they are seeing and have an opportunity to make an informed decision about who they want to see, Dr. Hines said. The Academy is preparing for more opposition to truth in advertising bills, Albany said. It was surprising to see such strong opposition, especially from nurses and optometrists, in states like Florida, she added.
Make a difference
Dermatologists may represent fewer than 1% of all physicians in the country, but that doesn’t mean they can’t make their voices heard. One way to accomplish that is to get involved in Academy advocacy efforts. “Join an AADA committee or task force,” Dr. Gross said. “Each year, there’s an open call to serve on them.”
Join a state dermatology society, a state medical association, or both. “That way, when something hits, we can have a rapid response,” Dr. Sullivan said. Dr. Gross, who has been a longstanding member of the Medical Association of Georgia, finds it rewarding, albeit time consuming. “We don’t win every battle, but we win more than we lose,” he said.
Dr. Hines would like to see more physicians run for office because they offer a unique perspective and are very effective legislators. But she understands that it is a huge commitment. “We’re very lucky in Georgia that we have four physician legislators,” Dr. Gross said. “That gives us a little bit of an edge when we’re trying to pass health care legislation.”
An alternative to becoming a physician legislator is building a relationship with state legislators. The Academy offers a program to help host an office visit with a legislator. “Position yourself as a trusted physician advisor, so when these issues cross their desk, they can reach out to get a medical perspective,” Dr. Hines said. Conversely, this will open the door to contact state representatives and senators when issues arise, Dr. Gross added. It’s also good to build trusted relationships with the staff who advise the legislators on these issues, Dr. Sullivan said.
“If we keep the grassroots efforts strong, fewer legislators would be willing to take up these bills,” Albany said. To help build a grassroots effort, the Academy recently launched a playbook for federal policymakers, but it can also apply to state policymakers.
The Academy offers numerous resources from helping draft comment letters that state dermatology societies can sign onto and providing software to dermatologists to contact their legislator by email and/or telephone to offering templates used to provide testimony. Since COVID-19, testifying at a hearing has never been easier because it can be done virtually in every state, Albany said. In many states, it’s no longer necessary to take off work and drive to the state house. The AADA even offers an advocacy grant that provides financial assistance to state dermatology societies to host a lobby day, hire a lobbyist, or conduct outreach events to build grassroots interest in pending legislation. The scope of practice toolkit contains model letters, position papers, and studies about the quality and cost of care delivered by non-physician clinicians. The toolkit is available to all Academy members and state dermatology societies. At the Advanced Leadership Forum and Legislative Conference, dermatologists can learn how to advocate for pro-dermatology policies, Dr. Sullivan said.
“Our voices really do make a difference but there are other strong voices out there. Our voices need to be stronger,” Dr. Hines said. “The more individual members are involved, the more likely we will be successful in winning these fights.”
Even after winning, the Academy can’t rest on its laurels. “Just because we defeat a bill one year doesn’t mean it won’t come back in another form,” Dr. Sullivan added. “We must be constantly vigilant.”