Organized medicine is banding together once again to oppose federal legislation that would expand the scope of practice for nonphysician practitioners (NPPs), such as nurses and physician assistants, at the expense of Medicare and Medicaid patients’ safety.
The Texas Medical Association, the American Medical Association, and scores of other national specialty and state medical associations raised concerns about the Improving Care and Access to Nurses, or “I CAN,” Act (House Resolution 2713) by Rep. David Joyce (R-Ohio) in a June 1 letter to U.S. House leaders.
“[W]e are deeply concerned that this broad, sweeping bill endangers the care of Medicare and Medicaid patients by expanding the types of services [NPPs] can perform and removing physician involvement in patient care,” they wrote, reiterating a November 2022 letter sent in response to an earlier version of the bill. “This legislation would allow [NPPs] to perform tasks and services outside of their education and training and could result in increased utilization of services, increased costs, and lower quality of care for patients.”
Medicine advocates on behalf of patients, who, they wrote, “want and expect physicians to lead their health care team and participate in their health care determinations.” For instance, a 2021 AMA survey of U.S. voters found 95% of respondents said it’s important for a physician to be involved in their diagnosis and treatment decisions.
Medicine also counters claims that expanding the scope of practice for NPPs would increase patient access to care in rural or underserved areas.
“In reviewing the actual practice locations of primary care physicians compared to [NPPs], it is clear that physicians and nonphysicians tend to practice in the same areas of the state,” the signatories wrote.
Although NPPs are important members of the health care workforce, they cannot replace physicians, according to the letter, which highlights the stark discrepancies in education, training, and experience across different licenses.
A physician completes four years of medical school plus three to seven years of residency, including up to 16,000 hours of clinical training, according to AMA. In contrast, a nurse practitioner completes only two to three years of graduate-level education and as few as 500 hours of clinical training.
“The reality is that [NPPs] do not have the education and training needed to be the head of the care team, and our nation’s Medicare and Medicaid patients deserve physician-led care,” they wrote.
In addition, medicine cites studies showing NPPs are more likely than physicians to overuse diagnostic imaging and other services, overprescribe opioids, and over-engage specialists. This behavior, in turn, “increases health care costs, threatens patient safety, and leads to poor health care outcomes,” according to the letter.
For example, the signatories reference the recent experience of Hattiesburg Clinic in Mississippi to bolster their case that health care teams should be led by physicians. After 15 years of growing its care teams by adding NPPs because of a shortage of primary care physicians, the clinic found it had “failed to meet [its] goals in the primary care setting of providing patients with an equivalent value-based experience,” as clinic physicians wrote in the January 2022 issue of the Journal of the Mississippi State Medical Association.
Amid these general concerns, the letter also addresses two specific provisions of the I CAN Act. As proposed, the legislation would remove supervision requirements for certified registered nurse anesthetists, which medicine argues are critical for patient safety.
“The current rule represents a well-established and functional compromise approach to physician clinical supervision,” according to the letter. “The unique structure of the rule sets a minimum physician supervision standard, while giving flexibility to stats to utilize higher levels of clinical oversight or to ‘opt out’ of the rule.”
The bill also includes a section the signatories say lacks clarity and could lead to unintended consequences, such as preventing Medicare administrative contractors from limiting the types of NPPs that can provide certain covered services within their jurisdiction.
The bill, which was filed April 19, has been referred to the House committees on Energy and Commerce and on Ways and Means. An identical bill introduced last session by Rep. Lucille Roybal-Allard (D-California) failed to make it out of committee.
For more information, check out TMA’s Federal Advocacy webpage.