AAFP Warns of More Harm in Scope-of-Practice Executive Order

Team-based Care Must Be Physician-led, Academy Says

January 21, 2020 10:18 am News Staff

The AAFP has again objected to a recent executive order that would disrupt team-based primary care, reduce federal supervision and licensure safeguards, and relegate patients in rural and underserved communities to potentially compromised treatment.

[physicians reviewing chart]

The order's proposed expansion of scope of practice for advanced practice registered nurses and physician assistants "would fundamentally diminish the standard of care for patients and dismantle the physician-led team-based care model in Medicare and Medicaid," said the AAFP's Jan. 14 letter.(3 page PDF)  

It was sent to CMS Administrator Seema Verma, M.P.H., and signed by Board Chair John Cullen, M.D., of Valdez, Alaska.

The Academy was writing in response to a Dec. 26 request for additional feedback(www.cms.gov) on the Trump administration's order titled "Protecting and Improving Medicare for Our Nation's Seniors" that was published in the Oct. 8 Federal Register.(www.govinfo.gov)  

The order, announced Oct. 3, had already drawn forceful objection from the Academy.  

"The AAFP opposes recommendations included in the executive order that seek to eliminate supervision requirements and create parity in payments between physicians and nonphysician providers," said the AAFP's Oct. 11 letter(2 page PDF) to President Donald Trump. "We strongly disagree that greater collaboration can be achieved through independent practice for nonphysicians."

The more recent correspondence protested changes to Medicare contained in the order, including the elimination of supervision and licensure requirements that are more stringent than other applicable federal or state laws.

"The AAFP implores CMS to continue to base scope of practice regulations and program guidance of health care professionals on standardized training criteria and demonstrated experience and competence in patient care," the letter said.

"The AAFP strongly supports agency efforts to reduce administrative burdens throughout the Medicare and Medicaid programs, consistent with a letter(4 page PDF) sent Oct. 29, 2019, by national and state physician organizations, but the AAFP must strongly oppose the (executive order's) broad yet vague language … lifting supervision requirements of nonphysician providers."

APRNs and PAs, the letter added, "are valuable health care clinicians whose scope of practice should correspond to, but not exceed, their level of knowledge, skill, experience, training (using competency training measures) and licensure."

"The AAFP opposes allowing APRNs or PAs the ability to independently provide patient care or other unsupervised services with no physician supervision/collaboration," the Academy wrote.

Pointing to a Kaiser Family Foundation study(www.kff.org) tracking outcomes in states that have allowed such expanded and unrestricted practice, the Academy wrote that primary care shortages were ongoing in the studied areas even with an expanded scope of practice for APRN -- a paradox with negative consequences for patients.

"No patient, especially those in rural and underserved areas, should be relegated to a lower level of care by clinicians with lesser training by virtue of their ZIP code," the letter said.

Reinforcing that threat to patients, the Academy reminded CMS of a JAMA Internal Medicine study(jamanetwork.com) suggesting that "expanding the authority and use of nurse practitioners can expose patients to inappropriate prescriptions and X-rays, add unnecessary costs to the patient, risk exacerbation of bacterial resistance and threaten unnecessary radiation exposure."

"Due to their comprehensive training," the Academy continued, "family physicians have the expertise to deliver care in the primary care setting, where APRNs or PAs would more likely refer to higher-cost specialty care due to their more limited education, experience and training."

"Given family physicians' extensive education and training, we believe patient safety and quality of care are best served by ensuring that the services provided by APRNs and PAs continue to be delivered with the supervision of a physician," the letter concluded.

Related AAFP News Coverage
2019 Congress of Delegates
FPs Fight to Retain Full Scope, Ensure High-quality Care

(9/30/2019)

New Research Shows Family Medicine Scope Is Shrinking
But Stats Suggest Improved Training in Past Decade

(2/6/2019)

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