APSHO Letter to the American Medical Association

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November 3, 2020

Susan R. Bailey, MD
President, AMA

James L. Madara, MD
Chief Executive Officer & Executive Vice President, AMA

American Medical Association
AMA Plaza 330 N. Wabash Ave., Suite 39300
Chicago, IL 60611-5885

Dear Drs. Bailey and Madara,

We are writing on behalf of APSHO, the Advanced Practitioner Society of Hematology and Oncology, to address the AMA’s #StopScopeCreep campaign.  APSHO is a national organization that represents hematology and oncology advanced practitioners (APs, consisting of physician assistants, nurse practitioners, clinical nurse specialists, and pharmacists).  We also write on the behalf of patients with cancer who benefit from the work of oncology APs every day. 

The AMA’s #StopScopeCreep Campaign suggests that care given by APs is not safe care.  A robust amount of scholarly research refutes this claim.  In fact, by lifting burdensome and outdated restrictions on nurse practitioners, physician assistants, and pharmacists during the COVID-19 pandemic, the Centers for Medicare & Medicaid Services and many states demonstrated full confidence in and dependence upon AP practice (AANP, 2020; AAPA, 2020, American Pharmacists Association, 2020). 

Advanced practitioners do not believe that “patient safety is a game,” as was portrayed by the AMA campaign on social media this past weekend.  We do believe that efficient, safe, and accessible care delivery occurs when all healthcare professionals, practicing to the top of their license, education, and clinical competence, work together on behalf of the patient. 

Demands for primary care providers continue to be a concern today and even more so in our future.  By 2025, at least 37 states will experience serious physician shortages (Streeter, Zangaro, & Chattopadhyay, 2017).  Advanced practitioners contribute significantly to primary care, constituting more than 40% of the workforce (HHS/AHRQ, 2018).  Physician recruitment to primary care in underserved areas is poor, but the number of APs delivering primary care in underserved areas has increased (Pohl, Barksdale, & Werner, 2014).  Team-based care, expanded AP scopes of practice, and development of state compacts for licensure have been recommended for the past several years as solutions to this problem.  Unfortunately, in most of the states with provider shortages, APs have restricted scopes of practice (Streeter, Zangaro, & Chattopadhyay, 2017).  And yet, the AMA has consistently lobbied against these recommendations in the face of the most comprehensive and unbiased data available. 

We also point you to the results of a collaborative workforce study between APSHO, the American Society of Clinical Oncology (ASCO), the American Academy of Physician Assistants (AAPA), the Association of Physician Assistants in Oncology (APAO), and the Oncology Nursing Society (ONS).  This study examined the role of APs in oncology in the United States (Bruinooge, et al, 2018).  Conclusions from this study note that with the growing complexity of care, an AP independent model in a collaborative practice setting increased access to quality cancer care. 

APSHO would be pleased to meet with AMA leaders to further the mutual goal we have to improve and expand access to high-quality, cost-efficient healthcare for all Americans.   

Sincerely,

Sandra Kurtin, PhD, ANP-C, AOCN
President, Board of Directors
Advanced Practitioner Society for Hematology and Oncology

Wendy Vogel, MSN, FNP, AOCNP
Executive Director
Advanced Practitioner Society for Hematology and Oncology

References and Resources

AANP.  (2020).  COVID-19 State Emergency Response: Temporarily Suspended and Waived Practice Agreement Requirements.  Accessed at https://www.aanp.org/advocacy/state/covid-19-state-emergency-response-temporarily-suspended-and-waived-practice-agreement-requirements   (Updated periodically.)

AAPA.  (2020).  COVID-19 State Emergency Response: Suspended/Waived Practice Requirements.  Accessed at: https://www.aapa.org/news-central/covid-19-resource-center/covid-19-state-emergency-response/ (Updated periodically.)

American Pharmacists Association (AphA).  (2020).  Pharmacists as Front-Line Responders for COVID-19 Patient Care.  Accessed at https://www.pharmacist.com/sites/default/files/Pharmacists_COVID19_4_3_2020.pdf

Agency for Healthcare Research and Quality (AHRQ). (2018) National Healthcare Quality and Disparities Report. Content last reviewed April 2020., AHRQ: Rockville, MD. Accessed at: https://www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.html

Bruinooge, S., Pickard, T. A., Vogel, W., Hanley, A., Schenkel, C., Garrett-Mayer, E., . . . Williams, S. F. (2018). Understanding the Role of Advanced Practice Providers in Oncology in the United States. Journal of Oncology Practice, 14(9):e518-e532.  DOI: 10.1200/JOP.18.00181

Cairo, J., Muzi, M. A., Ficke, D., Ford-Pierce, S., Goetzke, K., Stumvoll, D., . . . Sanchez, F. A. (2017). Practice Model for Advanced Practice Providers in Oncology. Am Soc Clin Oncol Educ Book, 37, 40-43. doi:10.1200/edbk_175577

CMS.  (2020a). Coronavirus Waivers & Flexibilities.  Accessed at:  https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers

CMS.  (2020b).  Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19.  Accessed at: https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

Hylton, H. M., & Smith, G. L. (2017). Collaborating With Advanced Practice Providers: Impact and Opportunity. Am Soc Clin Oncol Educ Book, 37, e1-e7. doi:10.1200/edbk_175654

Johnson, D., Ouenes, O., Letson, D., de Belen, E., Kubal, T., Czarnecki, C., . . . Peabody, J. (2019). A Direct Comparison of the Clinical Practice Patterns of Advanced Practice Providers and Doctors. Am J Med, 132(11), e778-e785. doi:10.1016/j.amjmed.2019.05.004

Kurtzman ET, Barnow BS. A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians' Patterns of Practice and Quality of Care in Health Centers. Med Care. 2017;55(6):615-622. doi:10.1097/MLR.0000000000000689.

Kurtzman ET, Barnow BS. A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians' Patterns of Practice and Quality of Care in Health Centers. Med Care. 2017;55(6):615-622. doi:10.1097/MLR.0000000000000689.

McCleery, E., Christensen, V., Peterson, K., Humphrey, L., & Helfand, M. (2011). VA Evidence Synthesis Program Reports Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses. In VA Evidence Synthesis Program Evidence Briefs. Washington (DC): Department of Veterans Affairs (US).

Patio, C., Ali, N., Ketner, J., Young, C., Chou, E., Chong, C., & Su, W. (2018). Physician Assistants and Nurse Practitioners in Head and Neck Surgery. Cancer Treat Res, 174, 17-30. doi:10.1007/978-3-319-65421-8_2

Poghosyan, L. & Carthon, J.  (2017).   The untapped potential of the Nurse Practitioner workforce in reducing health disparities. Policy, Politics, & Nursing Practice, 18(2):84-94.  DOI: 10.1177/1527154417721189.

Pohl, J., Barksdale, D., & Werner, K.  (2014).  Revisiting Primary Care Workforce Data: a Future without Barriers for Nurse Practitioners and Physicians.   Health Affairs Blog, July 28, 2014.  Accessed at https://www.healthaffairs.org/do/10.1377/hblog20140728.040428/full/

Rymer JA, Chen AY, Thomas L, et al. Advanced Practice Provider Versus Physician-Only Outpatient Follow-Up After Acute Myocardial Infarction. J Am Heart Assoc. 2018;7(17):e008481. doi:10.1161/JAHA.117.008481.

Shulman, L. N., Sheldon, L. K., & Benz, E. J. (2020). The Future of Cancer Care in the United States-Overcoming Workforce Capacity Limitations. JAMA Oncol, 6(3), 327-328. doi:10.1001/jamaoncol.2019.5358

Streeter, R., Zangaro, G., & Chattopadhyay, A. (2017).  Perspective: Using Results from HRSA’s Health Workforce Simulation Model to Examine the Geography of Primary Care.

Walling, A. M., D'Ambruoso, S. F., Malin, J. L., Hurvitz, S., Zisser, A., Coscarelli, A., . . . Wenger, N. S. (2017). Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic. J Oncol Pract, 13(9), e792-e799. doi:10.1200/jop.2017.020990

Yang Y, Long Q, Jackson SL, et al. Nurse Practitioners, Physician Assistants, and Physicians Are

Comparable in Managing the First Five Years of Diabetes. Am J Med. 2018;131(3):276-283.e2.

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Yen, T. W. F., Laud, P. W., McGinley, E. L., Pezzin, L. E., & Nattinger, A. B. (2020). Prevalence and scope of advanced practice provider oncology care among Medicare beneficiaries with breast cancer. Breast Cancer Res Treat, 179(1), 57-65. doi:10.1007/s10549-019-05447-x