A tug of war

By Allison Evans, Assistant Managing Editor, September 1, 2024

The tug of war for scope expansion continues. As both sides are poised to pull the rope — and with it the opposing team — across the line, the Academy’s strength has shown with numerous scope victories so far this year. Scope of practice remains an ongoing area of focus for many dermatologists concerned about the quality and safety of dermatologic care offered by non-physician health care providers.

As more non-physician practitioners encroach on the practice of dermatology and medicine in general, the Academy is engaged in numerous state-level battles to defend the value of dermatologic specialty training and advocate for patient safety.

Physician-led care

“It is the Academy’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,” said Victoria Pasko, the assistant director of state policy for the American Academy of Dermatology Association (AADA).

“The scope battles are not letting up, and legislators are looking to stakeholders to come up with compromises.”

What’s more — the public supports the physician-led team care model. According to four nationwide surveys from the AMA’s Scope of Practice Partnership, 84% of respondents prefer a physician to have primary responsibility for the diagnosis and management of their health care, and 91% said that a physician’s years of medical education and training are vital to optimal patient care.

“We are very much seeing a continuation of many of the battles we’ve already seen,” said Lisa Albany, JD, director of state policy at the AADA. “We are at a place where more and more non-physicians, including dental hygienists, want to be able to administer products like botulinum toxin and fillers. The scope battles are not letting up, and legislators are looking to stakeholders to come up with compromises.”

Compromise

In Virginia, for example, nurse practitioners were required to have five years of collaboration with a physician before they could practice independently. A bill passed this year reducing that collaboration requirement to three years. “The nurse practitioners had been fighting to make it two years, so this is an example of the types of compromises we’re seeing,” said Albany.

While this was a compromised win, staying involved ensured that the collaboration language wasn’t weakened, which had been proposed in the original bill, said Aliya Courtney Hines, MD, PhD, FAAD, chair of the Academy’s State Policy Committee. In addition, “they were able to get language into the bill that was passed that’s going to require data collection on nurses who are practicing independently in Virginia to get a better sense of the outcomes of that legislation. We will have objective information about whether these bills are achieving the goals they’re meant to achieve, and that will be incredibly valuable as we move forward.”

While it’s not a slam dunk, “We’re still winning because we’ll be getting data that we can use as we work in other areas,” Dr. Hines said. “Acquiring that objective information is what we’ll need to focus our efforts on as we continue to counter arguments made about access.”

Complications

“Most legislators aren’t seeing the complications that our physicians are seeing in the office,” said Albany. Knowledge of vascular anatomy is crucial for all filler injections. While intravascular injection is possible at any location on the face, certain locations carry a higher risk of complications, including filler embolization, necrosis, visual abnormalities, blindness, and stroke.

This year, the ramifications of unsupervised, undertrained non-physicians practicing medicine have been spotlighted in the media. “There was a med spa in New Mexico in which three patients contracted HIV from platelet-rich plasma injections, and there was a med spa in California where a woman developed a Mycobacterium abscessus infection from mesotherapy, said Alexander Gross, MD, FAAD, chair of the Academy’s Scope of Practice Workgroup. “There have also been a number of cases of patients developing granulomatous dermatitis from microneedling. What these stories have in common is that the people performing these procedures are not physicians, and frequently, there’s not even a physician supervisor available,” he said.

“We need to focus on educating policymakers not only on the vast differences in education and training between physicians, particularly specialists, and non-physicians, but also the necessity that any provider must understand and be able to respond to possible complications,” Dr. Gross said.

“We’re really getting to a level where people are not necessarily appropriately trained,” he added. “If you’re injecting filler and you end up with necrosis because you injected or compressed an artery, who’s going to take care of that patient? It’s not likely that the dentist or the esthetician would know how to deal with those complications.”

Cost effectiveness

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.

Research shows that dermatologists are more effective than PAs in diagnosing skin cancer. In a 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.

State-level battles

New Hampshire

The AADA recently battled an optometry bill in New Hampshire, House Bill 1410, which would have authorized optometrists to perform surgical procedures, including removal of lesions on the face, to use lasers, and inject potent medications without the necessary medical education and surgical training it takes to safely perform these procedures. “We were engaged through comment letters, and we had New Hampshire Society of Dermatology President Andrew Kim, MD, FAAD, testify, so we were able to successfully defeat that legislation. On the other side, however, there was another bill that would increase scope for physician assistants, and that bill unfortunately passed,” Albany said.

Washington, D.C.

In November of 2023, the D.C. Department of Health introduced a bill called the Health Occupations Revision General Amendment Act. “It was essentially a comprehensive rewrite of the laws overseeing health care professional licensing and regulation in D.C,” said Klint Peebles, MD, FAAD, advocacy committee chair and member of the board of directors of the Medical Society of the District of Columbia (MSDC), vice chair of the AMA’s Dermatology Section Council, and member of the Academy’s Council on Government Affairs and Health Policy. “As it was written, it would have completely overhauled scope of practice, putting allied health professionals in oversight positions and removing the physician from the center of the care team, among many other concerning actions.” The bill would equate years of medical training with certificate programs and non-medical college degrees while addressing the spectrum of allied health professionals, including APRNs, audiologists, nurse anesthetists, chiropractors, optometrists, physical therapists, podiatrists, pharmacists, and others. “It really was one of the most expansive and shocking proposals that I’ve seen in terms of scope expansion,” Dr. Peebles said.

“As soon as we saw the bill, MSDC assembled a multispecialty consortium that included dermatology, anesthesiology, ophthalmology, and other key parties,” said Dr. Peebles. “We also applied for and received an AMA Scope of Practice Partnership grant, which helped inject much-needed money into advertising, public awareness, and educational campaigns.”

“We conducted several polls and surveys to determine the extent of physician interest and engagement in the bill and found that almost 90% of D.C. physicians opposed the bill in its entirety,” Dr. Peebles said.

The bill attempted to reduce the number of physicians serving on the Board of Medicine in D.C. from 10 to six while adding two PAs, a chiropractor, a podiatrist, and an acupuncturist. “The win here is that while two PAs were added to the board, the number of physician seats was only reduced by one instead of four, which maintained the physician majority on the board,” said Dr. Peebles.

The bill would have provided major scope expansion to optometrists, including prescribing authority, treatment of medical conditions, and more, all of which were removed from the final bill. Further, athletic trainers and physical therapists would have been classified as medical providers and would be permitted to order certain tests and perform some treatments unsupervised. Those were reduced in the final bill and DC Health was given more regulatory oversight over those professions.

“Additionally, the original bill would have provided major scope expansion to podiatrists, allowing them to diagnose, treat, and care for all structures and tissues from the ankle to the knee as well as the ability to treat wrists and soft tissue in the hands, which is incredibly bizarre,” Dr. Peebles noted. They also would have been allowed to oversee the administration of anesthesia as part of treatment, but the bulk of these provisions were removed such that they are only allowed to administer local anesthesia.

“From the dermatology perspective, there is concern that these scope expansions as originally written could conceivably allow podiatrists to manage skin conditions on the hands as well as upper extremity nail disease, among others,” Dr. Peebles explained. For the most part, much of that was removed from the bill that passed.

“We definitely had wins, and we had losses,” Dr. Peebles said. APRNs are able to practice independently; however, many other scope expansions were prevented. “If not for everyone’s hard and diligent work over many months, the original bill would have been enacted as written, which would have been a huge loss for the house of medicine and likely copied across other states,” Dr. Peebles added.

Arizona

In Arizona, dentists have already been granted the ability to inject Botox and fillers. Arizona Senate Bill 1269 proposed to expand the scope of practice for dental hygienists to include the administration of Botox and dermal fillers for both therapeutic and cosmetic purposes. The bill outlines that dental hygienists can administer these substances under direct supervision of a licensed dentist after completing required continuing education, and under general supervision if they have at least six months of experience and have completed a minimum of 75 injections under direct supervision within a two-year period.

“This is a particularly complicated argument when one considers the fact that estheticians, who have less training than a dental hygienist, are able to do these things in Arizona,” said Arizona dermatologist David Baltazar, DO, FAAD, who has been active in advocacy efforts since 2020.

Initially, the Arizona Medical Association was neutral on the bill; Dr. Baltazar, who’s on the board of directors for the Arizona Medical Association, had to do a lot of work to get the society to sway from a neutral position to one of opposition. “A lot of people don’t know why we shouldn’t allow this. Why is it dangerous for people who don’t have the training to administer neuromodulators and fillers? What’s at stake with the passage of these bills?”

Although much of scope expansion is a slippery slope, Dr. Baltazar, working in concert with the AADA and the Arizona Medical Association, was able to get SB 1269 defeated.

“This issue prompted the passage of a resolution in the AMA House of Delegates to make sure that we’re opposing similar scope of practice expansion bills by dentists and dental hygienists,” Albany said. Another subject of one of the AMA House of Delegates resolutions is the ability of a nurse practitioner or a physician assistant to easily change specialties. The AADA is working to educate legislators on the concern that a PA — with no training in dermatology — can now easily practice dermatology independently. “By increasing scope of practice for PAs and NPs, legislators are allowing them to do what physicians can’t do — change specialties,” Albany said.

Wisconsin

Another win for the Academy happened earlier this year when Wisconsin Gov. Tony Evers vetoed legislation that would grant four types of advanced practice registered nurses the ability to practice independently after 3,840 hours.

In his veto message, Gov. Evers stated that the bill did not provide for “adequate experience requirements, titling protections, and safeguards for patients who may be treated for chronic pain management.” Gov. Evers vetoed a similar bill during the previous session.

South Dakota

“For the last three years, South Dakota physician assistants have tried to expand their scope of practice, and we were told that they were going to keep bringing the bill back again. This year, they did not due to the hard work of the house of medicine with help from the AMA’s Scope of Practice Partnership grant,” Albany said. While not a clear-cut win in South Dakota, Albany explained that it was a silent victory. “Sometimes ending up with the status quo is actually a win.”

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, Albany noted. There is no evidence that eliminating the supervisory relationship will improve access to care.

The AMA completed a geographic mapping initiative that demonstrated 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. Furthermore, “the number of NPs doubled nationally between 2010 and 2017, yet there has been no noticeable increase in NPs within rural, underserved areas. There’s not necessarily a correlation between increasing scope and access to care,” added Dr. Gross.

“As Academy members, we need to keep working on branding ourselves as the experts in skin, hair, and nails. The Academy has a lot of resources that physicians can use to educate the public that we’re board-certified dermatologists and we’re the experts,” Dr. Gross said. Access resources on promoting the specialty.

“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. 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 will take on even greater importance in your legislators’ eyes,” Dr. Gross said.

“We want to make sure that the public and legislators know that the best care is provided when the physician is the head of the care team.”

Dr. Hines recommends members invite their legislator to their office to shadow them for a day. “They’ll be able to see firsthand what you’re doing and the patients you’re taking care of.”

“We have an important message to get out there. We want to make sure that the public and legislators know that the best care is provided when the physician is the head of the care team,” Dr. Hines said. While the Academy supports physician-led team-based care, it recognizes that non-physician clinicians play a valuable role in the delivery of health care, she added.

The Academy has a Scope of Practice Toolkit on its website, which includes sample letters of opposition, sample scope testimony, and other resources, Dr. Gross said. “It’s alarming that all these non-physician practitioners are trying to increase their scope, and state legislatures, to a certain extent, are allowing them to do it. It’s critical that dermatologists stay on the forefront of battling these scope issues,” Dr. Gross added.

If getting involved in advocacy efforts seems overwhelming or time-consuming, it doesn’t have to be, said Dr. Hines. “Maybe one of the easiest ways to get involved is to go to the Academy’s Take Action website and fill in a pre-populated letter to your member of Congress, which takes about two minutes.”

Scope is not just a dermatology problem. “Sooner or later, it’s going to come for any and every specialty,” Dr. Baltazar said.

Additional DermWorld Resources