Scope of practice 101

By Victoria Houghton, managing editor, June 1, 2021

DermWorld spoke to Victoria Pasko, assistant director of state policy for the American Academy of Dermatology Association (AADA), about the Academy’s advocacy efforts against scope of practice rules that threaten patient care and safety.

DermWorld: Briefly, tell us about scope of practice as it pertains to dermatology and what the AADA’s position is on the issue.

Pasko: Each state has its own scope of practice laws governing what a non-physician clinician can do and the degree of supervision required, if at all. The AADA supports appropriate safeguards to ensure patient safety and a focus on the highest-quality, appropriate care as this workforce expands. It is the AADA’s position that the optimum degree of dermatologic care is delivered when a board-certified dermatologist provides direct, on-site supervision to all non-dermatologist personnel.

DermWorld: Walk us through the process by which the AADA advocates on scope of practice issues.

Pasko: Non-physician clinicians are increasingly being incorporated into dermatology practices nationwide. One of the AADA’s top priorities is to advocate for a physician-led, team-based approach to care that ensures both the safety and best outcomes for each patient. Our advocacy goals at the federal and state levels are to ensure each member of the care team is practicing at a level consistent with their training and education. We use software to sort, track, and monitor state legislation and regulations in all of the states across all of our priorities at the state level. As of today, we are tracking well over 600 bills, about 150 of which are related to scope of practice. Each day, we get updates on the bills we are tracking, such as hearing notices, upcoming votes, and referrals.

When we see a scope bill has been introduced, we get in touch with the state medical society to see whether they support, oppose, or are remaining neutral. We also ask for bill background and insight from the field, such as what groups are behind the effort, how committed the sponsor is to moving it, how the general political environment bodes for the bill’s movement, or if they plan to engage in negotiations or compromises. Based off of this information, we reach out to the state dermatology society to gauge their level of engagement. From here, we coordinate closely with both groups to craft letters, testimony, and grassroots action alerts as needed. We rely on the state dermatology society and medical society lobbyists to advise us on when and how to engage, so we can most effectively utilize our resources.

DermWorld: What role does collaboration/coalition-building play in the work that you do in the Academy’s scope of practice advocacy activities?

Pasko: I cannot stress enough the value, if not absolute necessity, of collaborating with state medical societies, the American Medical Association (AMA), other national specialties, and of course, state dermatology societies. Legislators do not like working on scope of practice; it is no secret. But they can’t ignore it or pass it quietly if a multitude of groups are speaking up. We are stronger together!

One way we do this is through the AMA’s Scope of Practice Partnership (SOPP), of which the AADA is a steering committee member. The SOPP is a collaborative effort of the AMA, American Osteopathic Association (AOA), national medical societies, state medical associations, and state osteopathic medical associations, that focuses the resources of organized medicine to oppose scope of practice expansions by non-physician providers that threaten the health and safety of patients. Since 2007, the SOPP has awarded more than $2.3 million in grants to fund advocacy tools and campaigns for more than 105 national, state, and specialty medical and osteopathic societies. Most recently, the South Dakota State Medical Association and the Michigan State Medical Association received $30,000 and $50,000, respectively.

DermWorld: What is the value of grassroots advocacy in the process of advocating against scope of practice rules that threaten patient care and safety?

Pasko: Lawmakers at the state and federal level have an ever-increasing amount of influence over how you treat your patients, run your practice, and who can do what. But at the end of the day, they are still accountable to their constituents. The AADA’s collective voice is powerful, but to maintain our position of influence, we must be supported by the individual voices of our members. This means that each AADA member needs to commit to taking it upon themselves to express their views on the scope of practice legislation in question directly with their legislators and cultivating a relationship with their own state representative and senator. Over time, this relationship will bear fruit, and your views take on even greater importance in your legislators’ eyes.

The nurse practitioners, physician assistants, and other non-physicians seeking to expand their scope already understand the value of grassroots and are using it to their advantage.

DermWorld: What should a physician do if they are concerned about a state scope of practice policy or if they have an individual concern?

Pasko: If you see legislation in your state that looks concerning, please contact us so we can work on building a strategy and reaching out to necessary stakeholders, such as the state medical society. We can provide analysis, draft testimony, and comment letters, and can use our software to send grassroots alerts to engage the membership. We encourage members to use our tool to see what scope of practice legislation we are tracking in your state and across the country.

If you’ve seen or heard about a practice or individual in your area that you think might be violating scope of practice or truth in advertising laws, we can help by taking a look at the state law and providing our analysis. Often, we find that these practices likely aren’t breaking any laws because state medical practice rules do not restrict a physician’s area of practice or that of the non-physician clinician, in which case we will provide proactive policy strategies to the member to take back to their society as long-term solutions. You can bring these to our attention by accessing the form. AADA staff will research the state laws and provide you with resources and recommendations on how you can take action locally. Please note that the Academy is limited in its ability to take direct actions in many situations because it cannot act in a manner that might constitute restraint of trade.

Also, the AMA is collecting scope of practice stories for use in advocacy. If you treated a botched cosmetic procedure, cleaned up a misdiagnosis by a non-physician, or have any other experience that helps illustrate the dangers of non-physician scope expansion, please visit the AMA to share your story now.

DermWorld: Tell us about a recent scope of practice win. What did that success entail in terms of advocacy activities?

Pasko: The AADA worked with the South Dakota State Medical Association (SDSMA), the American Medical Association, and other national societies to defeat legislation that would have allowed physician assistants to practice independently in South Dakota after 520 supervised hours. Had the bill passed, it would have allowed physician assistants to diagnose, treat, and prescribe substances without any physician involvement.

The AADA contributed a letter of opposition, citing differences in training and education and providing data showing that dermatologists are more effective at diagnosing skin cancer than physician assistants. The AMA offered testimony in opposition, demonstrating that what South Dakota was proposing is not allowed in any other state, and is in contradiction with physician assistant educators, who agree that physician assistant training is inadequate for independent practice.

The measure was defeated narrowly by a vote of 7-6. The ceasefire is only temporary. As mentioned earlier, the SDSMA received a grant from the SOPP to prepare for defeating the bill in 2022 when it resurfaces.

DermWorld: What do you expect to see more of in the future regarding scope of practice, particularly as a result of COVID-19?

Pasko: Many state governments expanded scope for a variety of non-physicians to meet the needs of the COVID-19 pandemic. Beginning last year, we saw several states make these expansions permanent (PAs in Maine, NPs in California, and NPs in Florida who practice primary care). COVID-19 pulled back the curtain on very real access issues and non-physicians saw a golden opportunity.

One disappointing trend that we are seeing is that when legislatures pass scope expansions, much of the time, they are doing so unanimously or close to it. Moving forward, we will continue to see nurse practitioners seek independent practice as they have for years, but I think we will see an uptick in pharmacist scope expansion legislation and efforts to grant physician assistants independent practice.

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