Provider playbook

By Jan Bowers, contributing writer

When the COVID-19 pandemic swept across the U.S. in 2020, nurse practitioners (NPs) in several states were in the midst of a struggle to gain the right to practice independent of physician supervision. The pandemic slowed legislative activity in many states to a crawl, but it also offered nurse practitioners a new opportunity to expand their scope of practice. Faced with critical health care workforce shortages, several states have partially or fully relaxed their requirements for the supervision of non-physician health professionals (for a map of which states have suspended practice agreements see DermWorld's July 2020 feature).

Ostensibly, these waivers are temporary, but the concern among many physicians is that they will become permanent. Indeed, in its proposed 2021 Medicare physician fee schedule, CMS proposes continuing a number of scope of practice expansions beyond the public health emergency, including relaxing supervision of NPs by allowing supervision by physicians via video conference through Dec. 31, 2021, and allowing non-physician clinicians to supervise diagnostic tests.

Recently, the American Academy of Dermatology Association (AADA) joined a host of other specialty and state medical societies in signing on to a letter from the American Medical Association (AMA) to CMS Administrator Seema Verma, urging CMS to sunset the waivers involving scope of practice and licensure when the public health emergency concludes. “While these measures are temporary and limited to the duration of the PHE,” the letter states, “our organizations reaffirm our support for the physician-led, team-based approach to care and vigorously oppose efforts that undermine the physician-patient relationship during and after the pandemic.”

Sabra Sullivan, MD, PhD, former Academy Council on Government Affairs and Health Policy Chair and adjunct clinical professor of dermatology at the University of Mississippi Medical Center, concurs with the view expressed in the AMA letter. “We respect nurse practitioners,” she emphasized. “The discussion gets very polarized, and it shouldn’t. We think patients are best served by a physician-led team, because physicians have much more education and training.” Compared with the eight years of postgraduate education required of a board-certified dermatologist, NPs complete anywhere from one to four years of training. While dermatologists are required to spend 12,000 to 16,000 hours taking care of patients, the requirement for NPs is 500 to 720 patient care hours. As of 2019, more than 89% of the 290,000 NPs in the U.S. were prepared in primary care programs; 65% of those practice in family medicine. While there is no specific educational requirement for an NP who chooses to specialize in dermatology, they can take an exam to receive a certificate.

Where scope expansion stands now

Dermatology’s concern and involvement with the scope of practice issue dates back at least as far as 2006, said Lisa Albany, JD, AADA director of state policy. “That’s when the Academy joined as a member of the steering committee of the AMA’s Scope of Practice Partnership. I would say it’s been an issue in dermatology for at least 15 years.”

Today NPs are permitted to prescribe medication in all 50 states, although the degree to which they can prescribe independently varies by state. At the end of 2019, according to the American Association of Nurse Practitioners (AANP), advanced practice registered nurses, including NPs, were allowed to practice independently in 25 states. Within that group, 10 states require that NPs “transition to practice” by practicing a specified number of hours or years in collaboration with or under the supervision of a physician. The period can range from 1,040 hours (South Dakota) to five years (Virginia). The difference between supervision and collaboration isn’t always clear, Albany pointed out, but “in general, supervision laws require physician oversight of non-physicians. The treatment decisions will include the medical judgment of the physician who is the leader of the health care team. Collaboration involves a lesser degree of oversight, so you’ll have physicians who are still involved in the patient’s treatment plan, but maybe they’re just consulted. You need to look at how each bill is written, and what the language says.”

NPs’ arguments for independence

AANP’s advocacy for independent practice promotes a rebranding of NPs to emphasize their skills and training, discarding identifiers like “mid-level provider,” “physician extender,” and “non-physician provider,” in favor of terms like “primary care provider” or “advanced practice provider.” “As it would be inappropriate to call physicians ‘non-nurse providers,’ it is similarly inappropriate to call all providers by something that they are not,” states an AANP position paper on terminology. “Similarly, the usage of the term ‘allied health provider’ has no clear definition or purpose in today’s environment.”

The AANP utilizes three key arguments to support independent practice, discussed in detail on the website AANP.org:

NPs improve access to health care, particularly primary care. According to an infographic on the AANP website, 83% of NPs accept Medicare, 80% accept Medicaid, 87% accept private insurance, and 77% accept uninsured patients. More than 57% of NPs see three or more patients per hour and estimated annual patient visits exceed 1.06 billion.
NPs reduce health care costs. An AANP position paper on NP cost effectiveness cites a 1981 case analysis of NP practice by the Office of Technology Assessment (OTA) — a long defunct congressional agency — that reported that “NPs provided equivalent or improved medical care at a lower total cost than physicians.” The savings begin with the cost of NPs’ academic preparation, which is 20-25% less than that of physicians. In addition, the compensation for NPs, measured by the OTA report at one-third to one-half that of a physician, remained at the same relative level 30 years later. The position paper goes on to cite numerous studies documenting the cost-effectiveness of NPs in a variety of settings, including primary care, acute care, and long-term care.
NP care is comparable in quality to that of their physician colleagues. The AANP position paper on quality of NP practice holds that “patients under the care of NPs have higher patient satisfaction, fewer unnecessary hospital readmissions, fewer potentially preventable hospitalizations, and fewer unnecessary emergency room visits than patients under the care of physicians.” The position paper cites and summarizes more than 30 supporting articles and studies — many, but not all, published in nursing journals.

What’s the difference between physician assistants and nurse practitioners?

At 140,000, physician assistants (PAs) now number less than half of nurse practitioners (NPs) in the U.S. (290,000), but demand for PAs is projected to outstrip even that for NPs over the next 10 years. The U.S. Bureau of Labor Statistics projected in 2019 that the number of PA jobs will increase 31% by 2028, compared with 26% growth for nurse practitioners, nurse anesthetists, and nurse midwives.

NPs begin their formal nursing education at the undergraduate level, earning a bachelor’s degree in nursing before completing a master’s or doctoral degree program. They receive training in the advanced practice of nursing and must complete 500 to 720 hours of supervised clinical practice. PAs are educated at the master’s degree level through one of 250 programs available in the U.S. Incoming PA students already have an average of more than 3,000 hours of direct patient contact experience, according to the American Academy of Physician Assistants (AAPA), and complete an additional 2,000 hours of clinical rotations as required by the program. In a comparison of the two professions, the AAPA notes that PAs are trained as medical generalists, learning diagnostic and treatment skills in all areas of medicine and for all patients, while NPs are trained in a chosen health population focus area such as family, neonatal, pediatrics, or women’s health.

Both professions require licensure and certification. NPs earn a registered nurse license before beginning their graduate education, followed by a national nursing certification and state licensure and registration. After graduating from an accredited program, PAs must pass a certification exam in order to obtain a state license. To maintain their certification, PAs must also complete 100 hours of CME every two years and pass a recertification exam every 10 years. NPs must complete 100 hours of CE and 1,000 clinical hours every five years. No recertification test is required, but they may take an exam as an alternative to 1,000 hours of clinical practice every five years.

Like NPs, PAs are seeking to expand their scope of practice (see a visual breakdown in DermWorld's July 2020 issue). The official position of the AAPA is the pursuit of “Optimal Team Practice,” which promotes team care but advocates the elimination of “the legal requirement for a specific relationship between a PA, physician, or any other health care provider in order for a PA to practice to the full extent of their education, training, and experience.”

AAD response and position statement

The Academy created a position statement in response to scope expansion efforts by NPs and other providers. Last updated in 2016, the statement centers on the view that patient safety and quality care are optimized “when a board-certified dermatologist provides direct, on-site supervision to all non-dermatologist personnel.” When that supervision is conducted offsite, “the supervising dermatologist or a designated alternate dermatologist must be available in person or by electronic communication at all times when the non-physician clinician is caring for patients.” Finally, licensed allied health professionals practicing in a dermatologic setting “should only provide care after a patient receives an initial evaluation, diagnosis, and treatment plan from a dermatologist.”

In response to the AANP’s claim that NPs improve access to care, Albany points to AMA data showing that, like physicians, advanced practice registered nurses are heavily concentrated in large urban areas, even in states where they can practice independently. “You’re not seeing them move to rural areas, despite their claim that independent practice would help solve that access issue.”

Regarding cost effectiveness and quality of care, one dermatologist takes issue with the quality of the studies the AANP relies on to support their arguments. “There really isn’t good literature to back up the claims,” said Jill I. Allbritton, MD, adjunct assistant professor of dermatology at the University of Maryland School of Medicine and chair of the AADA State Policy Committee. “I think those studies are misleading because they’re not peer-reviewed. The studies I know about that are peer-reviewed and blinded show the reverse. There’s scientific literature in the dermatology field that show that nurse practitioners tend to biopsy more to find a skin cancer. They tend to see patients more frequently before they reach a diagnosis to treat the patient, and they tend to prescribe antibiotics more — frequently when it’s unnecessary — than physicians.”

Like Dr. Sullivan, Dr. Allbritton strongly supports the inclusion of NPs as part of a physician-led team. “I certainly think nurse practitioners are needed for access to dermatology,” she remarked, “and the more people who consider the patient, the more backup there is, the better the patient outcome.” However, “you just can’t compare the experience of eight years [of dermatologist training] versus two or three years.”

Share your story

The AAD’s SkinSerious^® campaign educates health care policymakers about how dermatologists work in partnership with colleagues throughout health care to improve patients’ lives. The Academy seeks stories that highlight dermatologists’ role as partners in the health care system, including during the COVID-19 pandemic response. Share yours here.

AADA advocacy results

Thanks to the efforts of its staff and physician leadership, working in partnership with the AMA and state medical and dermatologic societies, in 2019, the AADA successfully thwarted independent practice legislation in California, Florida, Mississippi, Missouri, Pennsylvania, and Texas. The AADA also helped defeat legislation in Indiana that would have allowed advanced practice registered nurses to practice independently after collaborating with another health care provider, and legislation in Kansas that would have removed the collaborative practice agreement between an APRN and a physician.

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The effort in Mississippi, spearheaded by Dr. Sullivan and the Mississippi State Medical Association, included an innovative social media campaign that targeted legislators and the public. Funded by a grant from the AMA’s Scope of Practice Partnership (SOPP), the campaign began with scientific surveys of patients’ opinion on who was in charge of their health care, Dr. Sullivan said. “No one had done a study looking at how patients felt about who led their team. We found out that overwhelmingly, patients wanted a physician involved in their medical decision-making and their medical care,” she noted. “That didn’t mean that they didn’t want to see a nurse practitioner or a physician assistant, but they wanted to know that there was a physician leading the team.” Also interviewed were physicians and NPs currently working in physician-led teams. Many in both groups preferred working in that care setting, Dr. Sullivan said, despite the fact that “we had been hearing, and our patients had been hearing, that nurse practitioners did not want to practice in a team, and everybody wanted independent practice.” Building on the survey results, Dr. Sullivan and her team created the hashtag #MedicalSchoolMatters to drive their social media activities. “We weren’t saying that nothing else matters, but rather that the education and training that physicians have means that the physician-led team provides optimal patient care.” Albany noted that “what was done in Mississippi can be replicated in many states. In fact, the Indiana State Medical Association has received a grant from the AMA Scope of Practice Partnership to fund a similar campaign to combat what they see is coming up in the near future.”

The AADA has experienced setbacks as well as successes. “Florida demonstrates the challenge and frustrations around state scope of practice legislation,” Albany said. “We were successful in preventing expansion last year, but the bill came back again this year, and in March the governor signed legislation allowing nurse practitioners in primary care specialties to practice independently after completing 3,000 clinical hours.” As enacted, the bill does not allow NPs to practice specialty care independently, a distinction Albany said probably resulted from negotiations and compromises among legislators. “However, the house of medicine works closely together, and medical specialties don’t want to see NPs practice primary care independently.”

When legislative activity resumes, scope of practice legislation will be considered in California, Louisiana, Massachusetts, Missouri, Nebraska, New Jersey, Oklahoma, and Tennessee. Albany said she anticipates that in states that enacted temporary waivers of scope of practice restrictions, non-physician providers will lobby to keep the waivers in place post-COVID. “How do we go back and argue that loosening the restrictions is no longer necessary?” she said. “Without data [that show an adverse impact on patients], it will be challenging to demonstrate to a legislator that we have to go back to the way it was pre-COVID.”

Nurse practitioners intensify efforts to expand scope of practice