The Advanced Practitioner Society for Hematology and Oncology (APSHO) expresses serious concern regarding the U.S. Department of Education to revise a proposed rule that would exclude NP, PA, Pharmacists, and CNS programs from “professional degree” status. APSHO warns this change could limit financial access to graduate education, worsen oncology workforce shortages, and threaten patient care and outcomes.

IMPORTANT UPDATE:
A public comment period is open until March 2, 2026. APSHO has prepared:

• a customizable comment template for members
• an FAQ document that provides background and answers common questions about the proposal

DEADLINE FOR SUBMITTING OPEN COMMENTS IS MARCH 2, 2026

APSHO has evaluated the subsequent impact of this ruling on oncology patients and on our AP membership. The potential teratogenicity of many cancer therapies and increasing numbers of cancer patients of childbearing age require clear, data-driven information to inform and support patients and their partners in making treatment decisions. The disparate state approaches, rapidly changing legislation, and lack of patient-centered perspective has been detrimental for oncology patients and providers. Furthermore, restricted access to abortion or fertility services disproportionately impacts communities of color, sexual and gender minorities, residents of rural communities and other groups that experience disparities in access to cancer care.

APSHO is committed to partnering with our membership and other organizations to advocate for safe, equitable, accessible and high-quality cancer care. Therefore, we advocate for laws and policies that will restore the ability for oncology providers and patients to pursue treatment options that are informed, commensurate with patient wishes, and offer the best chance of successful outcomes for cancer treatments and their personal well-being.

To learn more read the full press release here: https://www.prweb.com/releases/2022/6/prweb18750738.htm

a. “Extremely rigid collaborative practice agreements and other burdensome forms of physician and dentist supervision are generally not justified by legitimate health and safety concerns,” and
b. “States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.”

To read The Association of Community Cancer Centers (ACCC) full statement on the value of oncology advanced practitioners please see here: https://www.accc-cancer.org/home/news-media/press-releases/news-template/2021/01/27/statement-on-the-value-of-oncology-advanced-practitioners

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.

doi:10.1016/j.amjmed.2017.08.026.

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

Download template comment letter

Dear APSHO Members,

We would like to ask you to send your comments to CMS about the proposed rule for the 2021 calendar year Medicare Physician Fee Schedule released on August 3, 2020 (CMS-174-P). The proposed rule allows CMS coverage of diagnostic tests when supervised by an advanced practitioner. It further enables pharmacists to provide services “incident to” physician or NPP services, such as medication management, when operating under the appropriate level of supervision and consistent with state law. Both of these previous restrictions were lifted during COVID-19 pandemic pursuant to the Public Health Emergency. 

These proposed changes are important to all advanced practitioners as we pursue care of the oncology patient at the highest level of our scope of practice. We want to encourage CMS to continue to evaluate ways to remove unnecessary and outdated practice barriers for APs that are not founded on legitimate health and safety concerns. 

The CMS comment period will end at 5 pm on October 5. Please submit your comments before then to https://beta.regulations.gov/commenton/CMS-2020-0088-1604. APSHO has provided a template for you to personalize and add additional comments if desired (Download Template). A copy of the comments APSHO made regarding this matter may be found here.

Thank you so much for all you do for APSHO, your fellow advanced practitioners, and your patients! 

Sincerely,

Wendy Vogel, MSN, FNP, AOCNP^®
Executive Director, APSHO
On behalf of the APSHO Board of Directors

View PDF of original letter

Seema Verma, MPH
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

September 14, 2020

Dear Administrator Verma,

On behalf of the Advanced Practitioner Society for Hematology and Oncology (APSHO), we acknowledge and very much appreciate your leadership as our communities cope with the challenges of the COVID-19 pandemic. Our organization represents advanced practitioners (APs) in oncology: nurse practitioners, physician assistants, clinical nurse specialists, advanced degree nurses, and pharmacists, many of whom are on the front lines treating patients infected with the COVID-19 virus.

We commend the Centers for Medicare & Medicaid Services’ (CMS) rapid response to the COVID-19 public health emergency that added options to maximize healthcare delivery efficiency and maintain patient access to high-quality medical care. We support the numerous temporary waivers and regulatory changes that authorize APs and other health professionals to practice to the full extent of their education, clinical competence, and experience to meet the needs of our patients.

The improved flexibility in the utilization of the healthcare workforce has been instrumental in sustaining adequate healthcare resources necessary to maintain access to care. If the goal of CMS is to improve long-term patient access to care, these regulatory flexibilities should be transitioned to formal policy, regardless of the COVID-19 public health emergency.

“Now more than ever, we need health care professionals working together.”   

                                                                                                     ~American Medical Association

An efficient and effective healthcare workforce requires that outdated practice rules and regulations be modernized to authorize every health professional to deliver care at  the top of their education, clinical training, and expertise. Efficient and accessible care delivery occurs when APs, physicians, and other healthcare professionals work together to provide quality care tailored to the needs of the patient without burdensome or restrictive administrative and regulatory constraints.

A surprising number of physician organizations want to restrict delivery of safe, high-quality healthcare by APs based on unsubstantiated claims that care quality will suffer if health professionals who are not physicians are authorized to deliver care to the top of their education and expertise. The facts simply do not support such assertions. In fact, objective reports across multiple medical specialties and primary care settings have come to the opposite conclusion (Bruinooge et al., 2018; Cairo et al., 2017; Hylton & Smith, 2017; Johnson et al., 2019; McCleery, Christensen, Peterson, Humphrey, & Helfand, 2011; Patio et al., 2018; Shulman, Sheldon, & Benz, 2020; Walling et al., 2017; Yen, Laud, McGinley, Pezzin, & Nattinger, 2020). Turning back the clock and returning to a rigid mandate of physician-led teams does not serve our patients and communities. By definition, this will limit access to care.

We endorse building on the President's Executive Order #13890, Protecting and Improving Medicare for our Nation's Seniors and the Health and Human Services (HHS) report “Reforming America’s Health Care System Through Choice and Competition.” The HHS report specifically recommends:

1) “Extremely rigid collaborative practice agreements and other burdensome forms of physician and dentist supervision are generally not justified by legitimate health and safety concerns,” and
2) “States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.”

We appreciate your continued commitment to removing unnecessary practice barriers and expanding patient access to needed healthcare services. By promoting policies and regulations that maximize the education and skill sets of all health professionals, states, and communities are empowered to make informed decisions to improve access to quality healthcare tailored to their individual circumstances, available resources, and unique patient needs. 

Timely and appropriate patient access to quality care, patient satisfaction, and the effective use of resources should be the driving force in an efficient healthcare system. Efforts aimed at protecting professional turf only serve to hinder these aims. We strongly urge you to make permanent the waivers and regulatory changes put in place during the COVID-19 public health emergency.  

Sincerely,

Sandra Kurtin, PhD, ANP-C, AOCN®
President, Advanced Practitioner Society for Hematology and Oncology (APSHO)

References

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. Oncol Nurs Forum, 45(6), 786-800. doi:10.1188/18.Onf.786-800

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

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

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

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

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

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

APSHO is dedicated to the support of the advanced practitioner in oncology regardless of race, gender, sexual orientation, or religious belief. Now is the time to take a stand against the racism that profoundly impacts the lives of clinicians and our patients. The oncology community is stronger and wiser due to the diversity of our members. We cannot reach our full potential without the underpinnings of equality and respect that every human deserves.

Issued by APSHO Board of Directors, June 2020.

The novel coronavirus SARS-CoV-2 and its resulting disease state, COVID-19, pose a direct threat to overburdened US healthcare systems, as well as to healthcare providers, including advanced practitioners (APs) in oncology. The threat is not only health-related, but also professional, psychological, and financial. The impact of such challenges on oncology APs directly impacts the delivery, access, cost-effectiveness, and quality of patient care.

US Unemployment Crisis

The US Department of Labor released the March 2020 unemployment numbers on April 3, 2020 (U.S. Department of Labor, 2020). This report noted that the unemployment rate rose to 4.4% during March. The number of unemployed persons rose from 1.4 million to 7.1 million between February and March 2020. This sharp rise was attributed primarily to the effects of the coronavirus and efforts to contain it. Much of this increase in unemployment occurred in persons who were on temporary layoff (including furloughed persons), increasing from 1.0 million to 1.8 million. There was also a 1.4 million increase in individuals working part time for economic reasons from February to March 2020, with the increase primarily occurring due to slack work or business conditions. It is imperative to note that the March reporting period predated many business and school closures that occurred in March after the survey. While job losses occurred among all major worker groups, the report stated that notable increases occurred in healthcare-related jobs.

Financial Impact in the Healthcare Setting

Physician practices are experiencing adverse financial repercussions, with decreases in revenue and declines in patient volumes. A recent survey by the Medical Group Management Association (2020) of medical practices stated that 22% of practices surveyed had laid off employees and 48% had furloughed employees. These practices projected that by the beginning of May 2020, 36% would have laid off employees and 60% would have furloughed employees. A  HealthLandscape (2020) report stated that the potential impact of medical office closures due to COVID-19 pandemic would increase the county-level shortages (counties with more than 3,500 people per family medicine provider) from 750 counties by the end of March 2020 to 1,841 counties.

Hospitals and healthcare systems across the United States are being negatively impacted by the COVID-19 pandemic and resulting financial crisis. Adding additional ICU beds and supplemental personal protective equipment (PPE) in preparation for an anticipated increase of intensive services has come with a high price tag (Bartsch et al., 2020; Neighmond, 2020; Society for Healthcare Organization Procurement Professionals, 2020). Revenues have decreased for elective surgeries and procedures, routine care, and screenings.

There are negative downstream financial concerns as well, with many Americans losing their healthcare insurance due to job loss. To meet immediate financial concerns, responses have varied, but in many instances, include laying off or furloughing healthcare workers, including oncology APs (Paavola, 2020). Other efforts to reduce costs include reassignment of healthcare providers, including those in oncology, to higher volume areas; reduction of pay; reduction of work hours; and reduction of benefits such as paid time off accumulation and employer retirement contributions.

On April 3, 2020, Alatrum, a nonprofit research firm for government insurers, released a report that revealed a loss of 43,000 healthcare jobs in the first month of the COVID-19 economic crisis (Turner, 2020). These losses were focused in ambulatory care settings that included physician and dental offices, as well as other practices. Conversely, one of the biggest challenges many healthcare systems face is the need to expand the workforce to accommodate increased patient loads due to the COVID-19 pandemic.

Expanding the Workforce

The US Centers for Medicare & Medicaid Services (CMS) issued a blanket waiver on March 30, 2020, that allows hospitals to utilize APs to the full scope of practice in accordance with a state’s emergency preparedness or pandemic plan (CMS, 2020a; CMS 2020b; US Department of Health and Human Services, 2020a). This waiver will allow APs to work at the top extent of their training and licensure, thus increasing the workforce capabilities (US Department of Health can Human Services, 2020b). This waiver allowed multiple other restrictions to be lifted as well. Services that required direct supervision by a physician or other practitioner can be provided virtually using real-time audio/video technology (CMS, 2020b). Patients may now be under the care of an AP (nurse practitioner or physician assistant) while hospitalized (in accordance with the state’s emergency preparedness or pandemic plan). Advanced practitioners do not have to be licensed by the state in which they are providing services and may seek an 1135-based licensure waiver from CMS (if allowed by the state). This CMS waiver allows healthcare systems and hospitals to hire clinicians by removal of previous barriers that may have existed. Healthcare providers may enroll in Medicare temporarily to provide care during this pandemic. Other restrictions have been lifted as well.

 However, states have restrictive laws that may prohibit instituting these waivers; such obstacles must be resolved at the state level. There are differing state legislation approaches occurring in this emergent time, particularly with regard to APs’ scope of practice (AANP, 2020; AAPA, 2020, NASPA, 2020). Multiple professional organizations have appealed to state governments to issue orders to allow full scope of practice for APs, and many states have successfully passed legislation or enacted executive orders to address the pandemic crisis (ASHP, 2020, APA, 2020). States may limit increased scope of practice in various ways, such as allowing only those with a certain number of years of experience to practice at higher levels.

Caring for Individuals at Highest Risk

Another significant challenge during the COVID-19 pandemic is how best to care for a vulnerable population during this time. Individuals with cancer who are infected with COVID-19 are at higher risk for severe events, including death (Liang, et al, 2020). Those who have had chemotherapy within a few weeks of infection have poorer outcomes. Because of this, oncology healthcare providers are taking tremendous defensive measures. Personal protection provisions for cancer patients are essential. Oncology healthcare providers must have adequate personal protective equipment. Across the country, cancer centers are restricting visitors and companions in response to the known vulnerability of this population. Clinical trials are affected: recruitment may be hampered, protocols have deviations, and some patients may have to discontinue study drugs.

Prior to the COVID-19 pandemic, many Americans did not have affordable access to primary care. As noted above, there has been an unprecedented rise in the unemployment rate. It is projected that more than 7 million Americans will lose their healthcare insurance during this pandemic (Woolhandler & Himmelstein, 2020). States that turned down the Medicaid expansion through the Patient Protection and the Affordable Care Act will likely be the hardest hit, with the potential of a 40% uninsured rate. Prior to the pandemic, more than 25% of those with private insurance had an insurance policy deductible of $2000 or more (Kaiser Family Foundation, 2019).

Converging Issues and Unintended Consequences

Prior to the COVID-19 pandemic, there were shortages of oncology healthcare professionals in the United States. During this pandemic many hospital systems, academic institutions, and practices are furloughing staff, decreasing salaries, and cutting benefits to offset the loss in revenue as a result of mandatory limited exposure practices. Millions of Americans are losing their healthcare insurance. There are shortages of personal protective equipment. Oncology professionals are being diverted to treat COVID-positive patients, including APs, who are expected play a vital role in oncology care due to the projected (and current) shortages of oncologists. All of these converging issues could lead to the following unintended downstream consequences with the potential to adversely affect healthcare systems, medical professions, and patient outcomes:

1.     Increased exposure risk for oncology patients due to:

a.     Need for ongoing treatment requiring essential in-person visits to medical facilities for provider visits, diagnostic testing, and infusion services

b.     Limited personal protective supplies for patients and oncology professional

c.     Oncology professionals increased exposure to COVID-19-positive patients

2.     Decreased access to healthcare services related to pandemic delays and financial distress will lead to:

a.     Postponed cancer screenings that will lead to delays in cancer diagnosis, resulting in poorer outcomes

b.     Changes in the public’s view of the types of healthcare that should be required versus what can be considered discretionary

3.     Layoffs, furloughs, pay cuts, and loss of benefits to an already stressed workforce may contribute to:

a.     Increased shortages of oncology healthcare clinicians, including APs

b.     Increased shortages of primary care and subspecialty providers required for interdisciplinary management of complex oncology care

c.     Difficulty recruiting healthcare professionals, including hematology and oncology

d.     Financial burden associated with recruitment and retention of skilled, knowledgeable oncology healthcare practitioners

e.     Loss of trust in the healthcare system by patients, providers, healthcare workers, and the general public

4.     Increased “burnout” among healthcare professionals due to:

a.     Increased workloads with workload surge expected after COVID-19 crisis subsides

b.     Increased financial distress

c.     Loss of paid time off and/or sick leave to relieve furlough-related financial distress

APSHO’s Position

Based on these converging issues and the anticipated unintended downstream consequences of the COVID-19 pandemic, it is the position of APSHO that:

1.     All advanced practitioners should be allowed to practice at the top of their licensure.

2.     Oncology patients should be protected from potential COVID-19 exposure while receiving cancer treatment during the immediate crisis, reopening phases, and any potential surge. Methods employed should include:

a.     Screening of all staff and patients for COVID-19 symptoms

b.     Limiting visitors to the oncology care facility

c.     Supplying adequate personal protective equipment for oncology professionals, staff, and patients

d.     Providing oncology professionals the option to opt out of COVID-19 care without fear of retribution

3.     Healthcare facilities and employers should consider creative alternatives to revenue recovery methods, such as:

a.     Labor pools to redeploy and assign employees

b.     Optimizing outpatient services while maintaining COVID-19 precautions by extending hours, adjusting staffing, etc.

c.     Utilizing “downtime” to increase skills/knowledge of health-care providers

d.     Offering early retirement incentives for eligible staff and providers where volume recovery is not anticipated

4.     Healthcare facilities, employers, and government officials should consider:

a.     Offering disaster pay for hours lost

b.     Creating a relief fund for employees

c.     Providing retroactive pay for furloughed employees

d.     Permitting furloughed employees to work in other healthcare systems without fear of reprisals.

5.     Healthcare facilities, employers, and government officials should consider ways to assist employees to continue working under stressful working conditions by:

a.     Offering staff childcare

b.     Offering alternate housing for COVID-19-exposed employees to avoid the stress to the healthcare provider of potentially infecting their family

c.     Providing appropriate personal protective equipment

d.     Providing real-time, accurate and transparent information

6.     Healthcare facilities/systems should continue to provide essential medical services in the community while maintaining COVID-19 precautions by:

a.     Allocating healthcare resources including healthcare providers in a rational, ethic and organized manner

b.     Creative scheduling of patients/testing to continue required screenings and diagnostic testing

Statement published by APSHO Board of Directors, June 2020.

 

References

American Academy of PAs. (2020). COVID-19 state emergency response: Suspended/waived practice requirements. Retrieved from https://www.aapa.org/news-central/covid-19-resource-center/covid-19-state-emergency-response/

American Association of Nurse Practitioners. (2020). COVID-19 state emergency response: Temporarily suspended and waived practice agreement requirements. Retrieved from https://www.aanp.org/advocacy/state/covid-19-state-emergency-response-temporarily-suspended-and-waived-practice-agreement-requirements

American Pharmacists Association (APA); . (2020). Pharmacists as front-line responders for COVID-19 patient care. Retrieved from https://www.pharmacist.com/sites/default/files/Pharmacists_COVID19_4_3_2020.pdf

American Society of Health-System Pharmacists (ASHP). (2020). Pharmacy readiness for coronavirus disease 2019 (COVID-19). Retrieved from https://www.ashp.org/-/media/assets/advocacy-issues/docs/Pharmacy-Readiness-for-Coronavirus-Disease-2019-COVID-19-STATE.ashx

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