Jennifer Lotter, PA-C, is a physician associate at the National Heart, Lung, and Blood Institute at the National Institutes of Health (NIH) in Bethesda, Maryland, and serves as chair of NIH’s Nurse Practitioner/Physician Associate Scientific Interest Group.
As a physician associate (PA) specializing in hematology, my personal experience working with physicians at all levels of training has been an overwhelmingly positive one — one in which we work as a team and collaborate to provide the best possible care to patients. I realize this may not be true for all advanced practitioners (APs), but the foundation of patient care should be to set all egos aside and work together to put patients first.
In recent months, my inbox has been filled with highlights of a very public exchange between two high-profile professional organizations, the American Medical Association (AMA) and the American Association of Physician Associates (AAPA), as they defend their respective stances on the issue of “scope creep.” As the debate around this issue continues to progress and develop, I find myself rather unsettled by the idea that my professional organization and the one representing my closest colleagues seem to be at odds as to what “putting patients first” actually means.
According to the AMA, “scope creep” describes the “expansion of the medical services and procedures non-physician health professionals are allowed to perform.”1 The primary argument from the AMA is that patients have the best outcomes with physician-led care and that allowing non-physicians more permissive license to diagnose, prescribe, and be reimbursed for patient care is a threat to patient safety. In response, the AAPA has accused the AMA of spreading misinformation and using fear mongering about “scope creep” to control and suppress modernized practice rules as patients face shortages in health care. The result is that these organizations have taken opposing advocacy positions on legislation that would expand practice abilities and remove limitations for PAs.
What do the PA modernization bills in question actually advocate for? In my practicing home state of Maryland, Governor Wes Moore signed the PA Modernization Act into law in 2024, marking the first major change to PA practice law in Maryland in 25 years.2 The bill transforms the PA-physician relationship from a delegation agreement to a collaboration agreement, recognizing the role that PAs play in health care settings and the collaborative nature of their work with physician colleagues. The act also removes certain administrative barriers and allows PAs to practice under their own education, training, and experience. Modernization bills in other states, such as Arkansas, remove the legal requirement for most PAs with 8,000 hours of clinical practice to have a written agreement with a specific physician.3 Similarly, in Montana the act moves the relationship between PAs and physicians from supervision to collaboration and removes the legal requirement for most PAs with 8,000 hours of clinical practice to have a written agreement with a specific physician.3 The AMA believes that the language used in these modernization bills to expand scope of practice would dismantle the care team.4
The initial letter from the AAPA to the AMA, dated July 30, 2024, stresses that the AMA “scope creep” campaign maintains outdated practices and preserves antiquated notions of provider hierarchy and that questioning the capabilities of PAs “undermines their contributions to the healthcare system nationwide and erodes public trust.”5 The letter goes on to encourage “collaboration, rather than competition” in order to build an effective health care system. The AMA very noticeably did not respond to the first letter by the requested deadline of August 30, prompting a second letter from the AAPA on September 3. This second letter included the results of a survey with more than 4,900 responses from PAs sharing their opinions of how the AMA “scope creep” campaign has had a negative effect on the PA profession, the relationships between PAs and their patients, and the health care system at large.6
The AMA is one of the only national organizations that has created hundreds of advocacy tools for the field of medicine to use when fighting against laws and regulations that expand scope of practice. The AMA “scope creep” campaign is not limited to PA modernization but includes advocacy against expanding the scope of practice for many other non-physician providers, including nurse practitioners, nurse anesthetists, chiropractors, pharmacists, and dentists. In 2023 alone, the AMA obstructed more than 100 bills aimed at expanding access to care and modernizing health care laws.5
The idea that expanding non-physician scope of practice would threaten patient safety is an issue at the forefront of the AMA’s “scope creep” campaign and at the center of the AAPA’s misinformation accusations. One observational study used by the AAPA to counter the argument that giving PAs greater practice authority would compromise patient safety compared 10 years (2010-2019) of medical malpractice payment report data from the National Practitioner Data Bank with the laws and regulations of states during the same period.7 This study suggests that removing restrictive laws and regulations to PA practice does not increase overall risks to patients nor increase rates of malpractice within the U.S. health care system. Additional safety studies should be conducted in an effort to limit the spread of misinformation.
Where to go from here? The health care team is changing, especially in the post-COVID era. Additional studies on the dynamics of care teams, especially an assessment of what is actually happening in practice, would provide helpful information moving forward. Giving APs more privileges does not mean those same privileges will be taken away from physicians or that physician-led care is in jeopardy. Rather than drive a division between providers, professional organizations must promote positive partnerships and collaborations among the care team to truly prioritize what is best for the patient.
Jennifer Lotter, PA-C
Associate Editor
References
- Robeznieks A. Inside the AMA’s wide-ranging fight against scope creep. June 13, 2022. Accessed December 5, 2024. https://www.ama-assn.org/practice-management/scope-practice/inside-ama-s-wide-ranging-fight-against-scope-creep.
- American Academy of Physician Associates. Maryland governor signs PA practice modernization bill into law. May 16, 2024. Accessed December 5, 2024. https://www.aapa.org/news-central/2024/05/maryland-governor-signs-pa-practice-modernization-bill-into-law/.
- American Academy of Physician Associates. PA act modernization bills advance in several states. March 17, 2023. Accessed December 5, 2024. https://www.aapa.org/news-central/2023/03/pa-act-modernization-bills-advance-in-several-states/.
- American Medical Association. AMA response to AAPA on scope of practice. September 19, 2024. Accessed December 23, 2024. https://www.aapa.org/wp-content/uploads/2024/09/AMA-Letter-Response-to-AAPA-FINAL.pdf.
- American Academy of Physician Associates. Letter regarding AMA’s campaign against PAs. July 30, 2024. Accessed December 23, 2024. https://www.aapa.org/wp-content/uploads/2024/07/AAPA-Letter-to-AMA_FINAL_24.07.30.pdf.
- American Academy of Physician Associates. Second request for meeting with AMA. September 3, 2024. Accessed December 23, 2024. https://www.aapa.org/download/135695/.
- DePalma SM, DePalma M, Kolhoff S, et al. Medical malpractice payment reports of physician assistants/associates related to state practice laws and regulations. J Med Reg. 2023;109(4):27–37.
The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology, NIH, or the U.S. government unless so stated.
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