Team captains
As pandemic-related flexibilities expire, dermatologists are working to codify team-based care
Feature
By Allison Evans, Assistant Managing Editor, August 1, 2022
It’s safe to say that while many things came to a grinding halt during the beginning of the pandemic, the push to expand non-physician scope of practice took off and is still very much in flux throughout the country. With some hard-won victories and challenging battles, the American Academy of Dermatology Association (AADA) — working in concert with local dermatologists and medical organizations — continues to stay vigilant and engaged to protect patients and the specialty.
The pandemic made it much more difficult for physicians to have direct access to their legislators. “The problem during COVID was that you couldn’t get in to talk to the legislators, so everything was about perception,” said Sacramento dermatologist Ann F. Haas, MD, FAAD, who has been advocating for the specialty for more than 30 years. “There is a real difference when you’re talking to someone face to face versus trying to talk to somebody on a video call.”
Lemons into lemonade
During the pandemic, Dr. Haas and CalDerm (the state dermatology society in California) worked tirelessly with colleagues and physician organizations to prevent the passage of Assembly Bill (AB) 890 in California — a bill that allowed for independent practice of nurse practitioners (NPs). “COVID highlighted access issues, particularly in rural areas, so all of a sudden, this bill passed and it became a done deal — and we couldn’t even get in the door,” said Dr. Haas, chair of the Legislative and Regulatory Committee for CalDerm.
As Dr. Haas experienced, putting in the effort doesn’t always result in victory, but there are still opportunities to educate and guide policymakers along the way. After the California bill passed, Dr. Haas and her colleagues geared up to influence the regulatory phase.
“We knew we needed to give input to the California Medical Association’s task force on AB890 which was to advise the California Board of Nursing, as the California Board of Nursing would be ultimately responsible for dealing with the licensure of NPs and determining how it would all work,” she explained. “We nominated Sacramento dermatologist Margaret Parsons, MD, FAAD, to join the CMA’s advisory task force (she was actually the chair) so that there would be dermatology input as things moved forward.”
“If you nip it in the bud, that’s golden,” Dr. Haas said, “But if you’re stuck, then you need to get in and figure out where you could start to slow it down and where you can try to control it, which is the position we found ourselves in.”
AADA truth in advertising victory
In March, Indiana became the first state to protect medical specialty designations with the passage of Senate Bill 239, signed into law by Gov. Eric J. Holcomb. The patient safety measure, which took effect July 1, specifically prohibits the misappropriation of medical specialty titles such as dermatologist, anesthesiologist, cardiologist, and others by professionals who have not graduated from medical school and completed the necessary training to adopt the physician title. It also prohibits health care professionals from using deceptive or misleading advertising that misrepresents or falsely describes their profession, education, or skills.
“Health care professionals at every level should be proud of their profession and want to help patients make an informed choice when seeking out options for treatment,” said Indiana dermatologist Carrie Davis, MD, FAAD, who provided testimony in support of this bill, including presenting survey data specific to Indiana. “Our patients have the right to know the credentials and the level of training of that person making the important medical diagnosis, pushing medications into an intravenous line, using a scalpel, or pointing a laser at their face, torso, arms, or legs.” In 2020, an independent survey of Indiana consumers found that one in four was not confident they knew which medical professional they had seen in the past few years.
A recent survey conducted by the American Medical Association confirms increasing patient confusion regarding the many types of health care providers, including physicians, nurses, physician assistants, technicians, and other providers. The survey revealed:
47% of patients incorrectly believe an optometrist is a medical doctor.
39% of patients believe a nurse with a “doctor of nursing practice” degree is a medical doctor.
88% of patients believe only medical doctors should be permitted to use the title “physician.”
79% of patients support state legislation to require all health care advertising materials to clearly designate the level of education, skills, and training of all health care professionals promoting their services.
Indiana health care professionals will have until January 2023 to comply with the advertising and marketing provisions.
Win: Colorado dermatologists defeat physician assistant independent practice legislation
Early in 2022, the Colorado House rejected legislation that would have allowed physician assistants (PAs) to practice independently. The Colorado Dermatologic Society (CDS) and the Colorado Medical Society, with the support of the AADA, American Medical Association, the American Society for Dermatologic Surgery Association, and other members of the house of medicine, urged legislators to retain existing high standards of care for Colorado patients. Academy member Geoffrey Lim, MD, FAAD, legislative trustee for the Colorado Dermatologic Society Executive Board, testified in opposition to the bill.
“Introduced under the title ‘PA Collaboration Requirements,’ HB22-1095 intended to weaken the relationship between a PA and a physician or podiatrist in two primary ways,” Dr. Lim explained in the June issue of DermWorld (staging.aad.org/dw/monthly/2022/june/ask-the-expert-battling-scope-expansions-colorado). “First, it proposed to change the term used to describe the relationship between a physician and a PA from ‘supervision’ to ‘collaboration.’ Second, it proposed to remove the requirement that a PA be supervised by a physician or podiatrist.”
Collaboration would only be required for PAs with fewer than 3,000 hours of practice experience or those beginning practice in a new specialty, said Lisa Albany, JD, director of state policy at the AADA. “The collaboration requirement would be eliminated for PAs with 3,000 or more practice hours, or for PAs practicing a new specialty who have completed 2,000 practice hours in the new specialty and at least 3,000 total practice hours. Instead, PAs would be required to consult with and refer to other members of the PA’s health care team based on a patient’s condition.”
The best and most effective care occurs when a team of health care professionals with complementary — not interchangeable — skills work together, she affirmed.
This is the second consecutive year that the CDS has faced a bill that threatened the critical link between physicians and PAs, Dr. Lim said. Having testified the year before as well, Dr. Lim came to understand that legislators placed value on two pieces of the argument: access to quality care and decreasing costs of health care. He spent countless hours preparing peer-reviewed, evidence-based studies that supported physician-led, team-based care, and also gathered real-life examples of patients adversely affected by extraneous testing, misdiagnosis, and lack of adequate treatment where physicians were not involved in their care.
“The idea was not to pass blame or point the finger, but rather to elucidate the real — and sometimes severe — consequences that may arise when the supervisory link between physician and PA is broken,” Dr. Lim said. “Together, physicians and PAs are best able to provide high-quality care, increased access to care, and decreased costs.”
Win: South Dakota defeats PA scope expansion legislation
The South Dakota State Medical Association (SDSMA) led a two-year advocacy effort that resulted in the South Dakota Senate rejecting the expansion of PA scope of practice in SB 134. The legislation would authorize PAs to practice independently upon completion of 1,040 hours of clinical practice. During the transition period, a PA would practice with a collaborative practice agreement with another PA who has at least 4,000 hours of clinical practice, Albany explained.
This legislation is an outlier, as most states require physician supervision of PAs. Only four states have a similar practice hours approach — all requiring significantly more hours of practice and all with additional safeguards in place. The SDSMA received grants from the AMA Scope of Practice Partnership for its 2021 and 2022 efforts.
Win: Wisconsin governor vetoed APRN bill
In April, Wisconsin Gov. Tony Evers vetoed SB 394, which would have given advanced practice registered nurses (APRN) the ability to practice independently. The AADA worked closely with the Wisconsin Dermatological Society (WDS) and Wisconsin Medical Society (WMS) to support their opposition efforts.
“The legislation would have removed physician supervision/collaboration requirements of NPs, nurse anesthetists, and clinical nurse specialists after 3,840 clinical care hours in their respective APRN role with a physician or dentist. For nurse midwives, the legislation would have removed the collaboration requirement altogether,” Albany said. Over the past 12 months, the AADA submitted joint comment letters with WDS, activated grassroots, and worked with Wisconsin medical societies, she added.
In his veto, Gov. Evers wrote, “I object to altering current licensure standards for APRNs, allowing practices functionally equivalent to those of physicians or potentially omitting physicians from a patient’s care altogether notwithstanding significant differences in required education, training, and experience.”
A slippery slope
Read how non-physician providers seek authority to perform cosmetic medical procedures, threatening patient safety and the value of specialty medical training.
Arizona dentists
In March, Arizona Gov. Doug Ducey signed off on SB 1074, in which the legislature overwhelmingly approved allowing dentists to administer botulinum toxin A and dermal fillers for cosmetic purposes, despite pleas to veto the legislation by the AADA, ASDSA, Arizona Dermatology & Dermatologic Surgery Society, and other medical societies. Previously, dentists in Arizona could use botulinum toxin A for medical purposes such as treatment for TMJ disorders or overproduction of saliva. The law is expected to take effect in September.
Medical spas
In New Hampshire, the AADA advocated against legislation that would have allowed naturopaths to serve as medical directors in the medical spa setting. The legislation was sent to a study, effectively defeating the bill this session, and providing an opportunity to improve the language. “While this is a victory of sorts, it is likely not laid to rest,” Albany said.
In Kentucky, the AADA joined the ASDSA and the American Society for Laser Medicine and Surgery through written comments in opposing medical spa legislation that would allow PAs, nurses, dentists, optometrists, cosmetologists, and estheticians to delegate to other non-physicians and perform esthetic procedures, such as ablative laser procedures, which clearly constitutes the practice of medicine.
This group of non-physicians would also be authorized to own a medical spa, Albany noted. “Although the bill passed the House, it did not receive a Senate committee hearing in part because a physician legislator chaired the Senate Health Committee. The Kentucky Board of Cosmetology requested the bill sponsor not move the bill any farther. This issue will be discussed during the interim, once the Kentucky Legislature adjourns.”
Education and training
Research shows that dermatologists are more effective than PAs in diagnosing skin cancer. In one JAAD study, researchers examined data from 33,000 skin cancer screenings in more than 20,000 patients at University of Pittsburgh Medical Center-affiliated offices from 2011 through 2015. Compared to dermatologists, PAs needed to perform more biopsies to detect melanoma and nonmelanoma skin cancer. To diagnose one case of melanoma, the number needed to biopsy was 39.4 for PAs and 25.4 for dermatologists.
Furthermore, a task force report of the Physician Assistant Education Association concluded that the current education system trains PAs to practice under the supervision or collaboration with physicians. The report states, “We do not support the elimination of legal provisions that require a collaborating physician for PAs, because of the potentially far-reaching implications for PA education and for new PA graduates.”
Access to care
Policymakers often find access to care to be one of the most compelling reasons for expanding non-physician scope of practice. However, existing law does not prevent PAs from currently practicing in rural and underserved areas, Dr. Haas said. There is no evidence that eliminating the supervisory relationship will improve access to care.
The American Medical Association completed a geographic mapping initiative that demonstrates that non-physician health care providers are not located in rural or underserved areas, but concentrated in the same geographic areas as physicians, Albany said.
Ten years ago, Colorado granted independent practice to nurse practitioners and there has been no improvement in access to care in rural Colorado, Dr. Lim said. Furthermore, the number of NPs doubled nationally between 2010 and 2017, yet there has been no noticeable increase in NPs within rural, underserved areas.
Cost
Proponents of PA and NP independent practice argue that physicians are too costly to hire and too expensive for the health care system. Evidence has shown these claims to be false. Several sources illustrate how physicians bring high value to physician-led health care teams by preventing overutilization.
Notably, a recent examination of cost data for the South Mississippi system’s accountable care organization (ACO) revealed that care provided by nonphysician providers working on their own patient panels was more expensive than care delivered by doctors. “The evidence is there,” Dr. Lim said. “It’s our job as advocates and stewards of medicine to educate our legislators.”
Defeating bills
Collaboration and grassroots efforts are key to successfully opposing these bills. “When bills like these are introduced, there is often very little time — on the order of weeks — to mount a strong opposition. Meanwhile, proponents of the bill have had months to years drafting and refining the language of the bill,” Dr. Lim said.
The AADA, ASDSA, AMA, and other national organizations obviously play a big part in developing position statements and providing direction and resources. However, local and state medical societies are pivotal to outreach in more direct ways within their own communities. “It’s easy to gloss over a form email from a national organization. A personalized email, text message, or phone call is far less likely to be missed,” Dr. Lim said.
This is not just a dermatology problem, Dr. Haas noted. “There are other specialties with similar scope issues. Find them, build a big coalition, and use everybody’s resources to maximize efforts.”
