Scoping Things Out: Scope of Practice Expansion in Arizona
By Jason Jameson, MD, FACS, Urologist & Board Secretary of the Arizona Medical Association
From the top of legislators’ desks to the patient exam room — that’s the path our health care regulation travels, and there are very few stops in between.
Before its fate is decided by the governor, health care legislation spends most of its life at the Arizona State Capitol, being debated by the 90 individuals that comprise the state legislature. It’s perhaps not surprising that the composition of Arizona’s legislature has, historically, included very few medical professionals (we are busy enough as it is). If we take the most recent legislative session, for example, less than 6% of legislators have a background in health care, and only one of them is a physician.
Obviously, a body of individuals where the majority has no medical background making decisions about health care seems ironic, and it is, but it can work effectively with the right advocates, backstops, and collective mindset in place.
That being said, the stakes are high in this arena, and there are many different schools of thought. This is no more apparent than when considering the most notorious type of health care legislation at the Arizona State Capitol (and across the nation, for that matter): scope of practice expansion proposals.
This year, no less than six scope bills were introduced to the state legislature, and they’ve kept health care lobbyists very busy. Arizona’s fixation on scope issues is on trend with the nation at-large; according to the American Medical Association, more than 70 bills related to scope expansion were introduced in state legislatures last year.
Scope expansion bills are generated by one class of medical professionals with the goal of expanding the range of health care services they’re legally able to provide patients. Recurring scope proposals are often focused on changing the roles of medical professionals in primary care, anesthesiology, optometry, behavioral health, and more.
Scope proposals always have implications for patient care and the larger health care team, which is why they have instigated complex, passionate debates among health care professionals for decades. While the discussions may be difficult, they are essential, and every party to the conversation is bound by the same responsibility: to further health and patient care in Arizona.
Contrary to popular perception, physicians are not opposed to every form of scope expansion. There are cases in which scope expansion is appropriate, so long as it is backed by sufficient education, training, and supervision. In these cases, a reshuffling of responsibilities can boost the efficiency of the entire health care team.
In many instances, however, proposals for scope expansion are not justified, and they often promote dangerous changes to our health care system. The door to patients being harmed is knocked wide open when unsupervised practitioners administer care or perform procedures they were not adequately trained to perform.
On top of a misalignment between the desired scope of practice and actual professional ability, a majority of harmful expansion proposals often override the foundational medical concept of ‘team-based care,’ defined by the AMA as “a collaborative system in which team members share responsibilities to achieve high-quality patient care.”
In more than one way, team-based care is a lot like America’s favorite sport. As is the case in football, each player on the health care team fulfills a specific position with unique responsibilities tailored to their strengths. While physicians, who have the most education and training in the medical field, are naturally positioned to function as the quarterback, any and every player can be an MVP. In fact, without the right players in the right positions, it is nearly impossible to win the game or in this case, provide optimal patient care.
Many bills over the years have directly contradicted the concept of team-based care, proposing that a member of the health care team be allowed to strike out on their own and practice independently from the coordinated efforts of others. Often, this proposal is propped up with the narrative that these newly independent practitioners will open medical practices in underserved and rural areas, in turn increasing access to care.
In theory, creating an opportunity for more independent medical practices seems to be a plausible solution to health care workforce shortages and stunted access to care. In reality, however, easing professional regulations and reducing the standards of patient care has no meaningful impact on patients’ ability to receive care.
So, some proponents would say, ‘it may not impact access to care, but it will reduce costs for patients, which is equally important.’ This claim is not supported by recent data, however. In fact, the data points to the opposite; studies have shown that health care costs increase significantly when health care teams are disbanded, even up to 441%.
According to a recent report from an accountable care organization (ACO) in Mississippi, “…spending was $43 higher per member, per month for patients whose primary health professional was a nonphysician instead of a doctor… When risk-adjusted for patient complexity, the difference was $119 per member, per month…,” which increased healthcare spending by millions of dollars for this ACO.
While there may be many variables contributing to this statistic, one is that physicians’ additional education and training prepare them to maximize the quality of patient care while minimizing costs.
We need to have the right advocates.
Ultimately, the impact a health care policy will have on the quality of patient care must be the deciding factor for whether it’s implemented. But with very few medical professionals on tap at the legislature, a vivid picture of the policy’s consequences may get lost or distorted in the process.
That’s why it’s vital that we have the right advocates. It takes a concerted effort by dedicated, experienced lobbyists to drive home the facts about all health care policies but especially scope of practice bills.
Luckily, the physician and patient community has powerful allies, including the Arizona Medical Association, which leads the House of Medicine. ArMA’s advocacy team has decades of experience, and they spend over 4,000 hours educating legislators, collaborating with stakeholders, and pushing monumental legislation.
We need to have strong backstops.
With anything that has the potential to impact people’s lives, you need as many backstops as possible to ensure we stay on track to a brighter future. In addition to our stellar advocates, Arizona has a nifty tool called the Sunrise Review Process.
The Sunrise Review Process is a data-informed analysis that is completed before a proposal that increases scope of practice is considered by a state legislature. As such, it is a critical tool used by legislators and the public to vet proposed scope of practice expansions. Through this process, legislators and others receive a data-informed analysis of the proposed expansion, which aids them in making accurate, informed, and patient-focused decisions. This review process is entirely free, minimally invasive, and extremely effective at protecting public health.
Despite all the positives of this process, it was at risk of being repealed just earlier this year. Critics argued that the process hindered small or poorly funded groups from making a request and, instead of proposing changes to the process, introduced legislation to repeal it completely.
Luckily, we did have the right advocates in place, and the physician community’s concerns were heard by Governor Katie Hobbs, who vetoed the repeal and committed to working with all stakeholders on optimizing the process in the future.
This is a significant win for patient care, and while the Sunrise Review Process may be challenged again in the future, the physician community looks forward to participating in discussions about improving the process as needed.
We need to have the right collective mindsets.
Knowing that conversations about scope of practice will continue to unfold, I can’t emphasize the importance of maintaining a collective mindset enough. Every member of the health care team is vital, and we are just that, a team. If we don’t coordinate our responsibilities, skills, and strengths, then we can’t achieve our full potential.
We provide the best care when we work together, so we must put aside our differences to approach each scope proposal with a rational mind, keeping our ultimate goal of optimizing patient care at the forefront of our minds.
That is the only way we can do right by our patients.
About the Author:
Jason Jameson, MD, FACS, is a Urologist affiliated with the Phoenix Veteran Affairs Health Care System, an adjunct assistant professor at Mayo Clinic in Arizona, and a clinical assistant professor at the University of Arizona College of Medicine–Phoenix. Dr. Jameson earned his medical degree at the University of Iowa and then completed his urologic residency at the University of Utah. He has served as the AUA Alternate Delegate to the American Medical Association since 2019. He is also the Health Policy Committee Vice Chair for the Western Section AUA. Dr. Jameson previously served as president of the Arizona Urologic Society and is currently a board member of the Arizona Medical Association, as Secretary.