Battling scope expansions in Colorado
Ask the Expert
By Victoria Houghton, Managing Editor, June 1, 2022
DermWorld spoke to Geoffrey Lim, MD, FAAD, legislative trustee for the Colorado Dermatologic Society Executive Board, about its efforts with the American Academy of Dermatology Association (AADA) to advocate against state scope of practice expansions.
DermWorld: In a win for Colorado patients and dermatologists, the Colorado House of Representatives rejected legislation that would have allowed physician assistants (PA) to practice independently. Tell us about the bill.
DermWorld: Why did the Colorado Dermatologic Society (CDS) oppose this bill?
Dr. Lim: The most concerning aspect of HB22-1095 was that PAs in Colorado would be able to practice independently, which would completely fragment the physician-led, team-based standard of care. As physicians, we understand the value of our medical education, which goes well beyond medical school to include internship, residency, and elective fellowships over an average period of 7-11 years. PAs spend 26 months in basic medical training before entering the work force, which represents a stark difference in education, hence the need for physician supervision and safeguards to ensure patient safety, access to quality care, and decreased costs. The CDS opposed HB22-1095 because its members understand that education matters, not simply the number of years of clinical experience.
Scope of practice
Learn more about the Academy’s advocacy efforts against scope of practice rules that threaten patient care and safety.
DermWorld: Tell us about your advocacy efforts.
Dr. Lim: This is the second consecutive year that the CDS has faced a bill that threatens the critical link between physicians and PAs. Having testified the year before, I had a better sense of what state legislators valued in the health care system: namely, access to quality care and decreasing the cost of health care. Preparation was paramount, not only to address the numerous peer-reviewed, evidence-based studies that support physician-led, team-based care, but also to provide real-life examples of patients adversely affected by extraneous testing, misdiagnosis, and lack of adequate treatment when physicians are 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. Together, physicians and PAs are best able to provide high-quality care, increased access to care, and decreased costs.
The inherent challenge with testifying is that each testimony can be no longer than three minutes. For an issue as broad and complex as this, three minutes is grossly insufficient. Consequently, it was important to collaborate with other constituents who opposed HB22-1095 so that our message was clear, concise, and not repetitive. Though difficult, testifying goes a long way to provide a real human experience to the legislators. It is a great way to develop and maintain relationships with state representatives, many of whom do not have experience in health care other than being a patient themselves. As a result, it provided me with a unique opportunity to be their source of counsel.
DermWorld: The CDS and the Colorado Medical Society (CMS) — with the support of the AADA, AMA, and ASDSA — worked together to battle this bill. Tell us about the role collaboration played in your successful advocacy efforts.
Dr. Lim: Simply put, collaboration was key to successfully opposing HB22-1095. When bills such as this 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. As a result, the CDS had to work very closely with the CMS, AADA, ASDSA, and AMA to pool our resources in organizing talking points, drafting letters to legislators, engaging membership to take action, recruiting physicians and others to testify, and identifying key legislators who aligned or would potentially align with our opposition to the bill. I am particularly grateful to our CDS, AADA, and ASDSA staff members, as they were invaluable throughout the entire process. We are all very lucky to have them as a part of our dermatologic organizations.
DermWorld: Based on your experiences this year advocating with your state legislature, how valuable is grassroots advocacy?
Dr. Lim: The defeat of HB22-1095 was entirely a grassroots effort. What started as a small email chain among the CDS board members — as well as between some of my personal friends and colleagues within the field — grew to a broad, active dialogue involving large group emails, text messages, phone calls, and social media platforms. Many dermatologists, physicians, and patients were not even aware this bill was being considered on the Colorado House floor prior to the grassroots efforts. It was a powerful lesson in that advocacy starts at identifying the subject matter and generating awareness.
Advocacy is the investment in our future. My father, also a dermatologist, instilled in me the importance of advocating early in one’s career. The legislative process operates at a much slower pace than the pace at which we run our clinics, and he would often allude to the fact that the future of our specialty is determined by the actions we take today. “Plus,” with an earnest look he’d ask, “If you don’t do it, then who will?” I have always admired his passion for advocating for our profession and patients. For me, there has been no better example of how the voice of a solo, privately practicing dermatologist in a remote part of the country can make a lasting, valuable impact.
Grassroots advocacy is just as important — and sometimes more important — than larger organizational advocacy or lobbyist efforts to getting the message across. 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. Therein lies the value of grassroots advocacy: Intimacy is impactful.
Ask the AADA expert
Read more from AADA staff about what dermatology can expect in the future with scope legislation.
DermWorld: What were some of the key talking points used when educating lawmakers about the dangers of PA independent practice?
Dr. Lim: Above all, when combating any scope of practice expansion bill, the focus must be on patient safety. Eliminating PA supervision risks a system-wide increase in misdiagnosis, adverse outcomes, unnecessary testing, inappropriate prescriptions, and increased health care costs. This isn’t smoke and mirrors. We have a mounting body of evidence to support this claim and that training does, indeed, matter. The truth is, we want PAs to succeed in the treatment of their patients, because ultimately, these are our patients, too.
Proponents of HB22-1095 argued that it is about collaboration, not independent practice, but that was misleading. The bill removed all authority and oversight of PAs by physicians, leaving any consultations or referrals to the sole discretion of the PA. That is the definition of independence.
DermWorld: What about the access to care and cost arguments that are often utilized by proponents of bills like HB22-1095?
Dr. Lim: HB22-1095 did not require nor encourage PAs to move to rural or underserved areas. Presently, a geographic mapping initiative of the AMA demonstrates that non-physician health care providers are not located in rural or underserved areas, but rather are concentrated in the same geographic areas as physicians. Additionally, the state of Colorado has not seen any improvement in access to care in rural Colorado since granting independent practice to nurse practitioners 10 years ago. Instead, we have already seen PAs and nurse practitioners well outside of the scope of practice that they were intended for, namely primary care. Furthermore, the number of nurse practitioners doubled nationally between 2010 and 2017, yet there has been no noticeable increase in nurse practitioners within rural, underserved areas. The practice patterns of nurse practitioners offer a real-world preview of what mid-level providers intend to do with independence from their physician-led teams, and there is no indication that PAs would behave any differently.
Regarding cost, proponents of PA independent practice argued that physicians are too costly to hire and too expensive for the health care system. This claim is false. By contrast, we have several sources that illustrate how physicians bring high value to physician-led health care teams by preventing overutilization. After all, who is more qualified to determine appropriateness of a test, medication, or procedure than a physician? 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. Again, the evidence is there. It’s our job as advocates and stewards of medicine to educate our legislators.
AADA advocacy
Read more about the AADA’s advocacy priorities.
DermWorld: What were some of your arguments regarding training and education?
Dr. Lim: In addition to the stark difference in training paths between physicians and PAs, educators of PAs do not believe the PA curriculum adequately prepares PAs to practice without physician supervision, collaboration, or oversight. A task force report (PDF) of the Physician Assistant Education Association concluded that the current education system trains PAs to practice under the supervision or collaboration with physicians.
Patients have voiced their concern over scope of practice expansion, too. According to four nationwide surveys, 84% of respondents prefer a physician to have primary responsibility for diagnosing and managing their health care, and 91% of respondents said that a physician’s years of medical education and training are vital to optimal patient care, especially in the event of a complication or medical emergency.
Finally, some states, including Colorado, have already allowed independent practice by nurse practitioners. PAs have argued that their training is at least as long, if not longer, than that of nurse practitioners. For all of the reasons listed herein, an argument may be made to re-evaluate independent practices of any non-physician in the name of patient safety and to preserve the standard of care. Furthermore, PAs follow the medical model, which is regulated by the Board of Medicine. The standard of care is that of a physician under the Board of Medicine, and therefore independent practice by PAs is in direct violation of the standard of care.
DermWorld: Scope of practice expansions for non-physician providers is a reoccurring theme in state legislation throughout the country. What advice do you have for other states and Academy members who are also up against these dangerous bills that threaten patient care and safety?
Dr. Lim: Identify the issues and make them known among your constituents and society members. Deploy your grassroots armies. Collaborate with societies at the national, state, and local levels. Establish and maintain relationships with local legislators. Make time in your schedule for advocacy. Understand that legislative processes can move painfully slow. Most of all, know that you (yes, YOU!) can make a difference.
Geoffrey Lim, MD, FAAD, is the legislative trustee for the Colorado Dermatologic Society Executive Board.
