TMA Joins Fight Against Scope Creep in “Sweeping” Federal Legislation
By Emma Freer


Organized medicine is banding together to oppose a piece of federal legislation that advocates say would expand the scope of practice for nonphysician practitioners (NPPs) like nurses and physician assistants at the expense of Medicare and Medicaid patients.

The American Medical Association, the Texas Medical Association, and scores of other national specialty and state medical associations raised concerns about the Improving Care and Access to Nurses, or “I CAN,” Act (House Resolution 8812) by U.S. Rep. Lucille Roybal-Allard (D-California) in a Nov. 2 letter to House leaders.

“[W]e are deeply concerned that this broad, sweeping bill endangers the care of Medicare and Medicaid patients by expanding the types of services NPPs can perform and removing physician involvement in patient care,” they wrote. “This legislation would allow NPPs to perform tasks and services outside their education and training and could result in increased utilization of services, increased costs, and lower quality of care for our patients.”

The signatories point out that patients expect physicians to participate in their health care services. For instance, in a 2021 AMA survey of U.S. voters, 95% of respondents said it’s important for a physician to be involved in their diagnosis and treatment decisions.

Organized medicine also questioned claims that expanding the scope of practice for NPPs would increase patient access to care in rural or underserved areas.

“In reviewing the actual practice locations of primary care physicians compared to NPPs, it is clear that physicians and nonphysicians tend to practice in the same areas of the state,” medicine wrote.

Although NPPs are important members of the health care workforce, they cannot replace physicians, according to the letter, which highlights the discrepancies in education, residency, and clinical requirements across different licenses.

A physician completes four years of medical school plus three to seven years of residency, including up to 16,000 hours of clinical training, according to AMA. In contrast, a nurse practitioner completes only two to three years of graduate-level education and 500 to 720 hours of clinical training.

“The reality is that NPPs do not have the education and training to make these determinations, and we should not be offering a lower standard of care or clinical expertise for our nation’s Medicare and Medicaid patients,” AMA, TMA, and others wrote.

In addition, the signatories cite studies showing NPPs are more likely than physicians to overuse diagnostic imaging and other services, overprescribe opioids, and over-engage specialists. These decisions, in turn, “increase health care costs, threaten patient safety, and lead to poorer health care outcomes.”

Amid these general concerns, they address two specific provisions of the I CAN Act. As proposed, it would remove supervision requirements for certified registered nurse anesthetists, which they argue are critical to patient safety.

“The current rule represents a well-established and functional compromise approach to physician clinical supervision,” they write. “The unique structure of the rule sets a minimum physician supervision standard, while giving flexibility to states to utilize higher levels of clinical oversight or to ‘opt-out’ of the rule.”

The bill also includes a section that the signatories say lacks clarity and could lead to unintended consequences, such as preventing Medicare administrative contractors from limiting the types of NPPs who can provide certain covered services within their jurisdiction.

The bill, which was filed Sept. 13, has been referred to the House committees on Energy and Commerce and on Ways and Means.

Last Updated On

November 21, 2022

Originally Published On

November 18, 2022

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Emma Freer

Associate Editor

(512) 370-1383

Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

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