AMA Creates "Partnership" to Limit Other Providers' Scope of Practice

More than 40 years ago, the American Medical Association (AMA) made its first attempt at destroying the chiropractic profession when it formed the Committee on Quackery in November 1963. Interestingly enough, the committee's original name was the Committee on Chiropractic, but the name was later changed so as to not lend credibility to the chiropractic profession. The primary objective of the Committee on Quackery was to "contain and eliminate" chiropractic as a recognized health care service in the United States. While its efforts were ultimately unsuccessful, its activities are believed to have delayed the full integration of chiropractic into the health care marketplace for several years.¹

Now, more than 30 years after the committee was disbanded, and almost 20 years after Judge Susan Getzendanner issued an historic ruling that found the AMA guilty of engaging in a conspiracy to contain and eliminate chiropractic, the medical association appears ready to embark on a new campaign to damage the chiropractic profession, not by engaging in an illegal boycott or prohibiting its members from associating with chiropractors, but by restricting what chiropractors and other health care providers are allowed to do in the course of their own practice.

In a move that appears to be aimed at stopping the growth of essentially all health care practitioners except for medical doctors and doctors of osteopathy, the AMA House of Delegates has adopted a resolution that calls for the association, in conjunction with an AMA-supported entity known as the Scope of Practice Partnership, to study the qualifications, education and academic requirements of "limited licensure health care providers and limited independent practitioners" such as doctors of chiropractic, acupuncturists and naturopathic physicians. The resolution, adopted at the AMA's most recent interim meeting in Dallas also calls for the association to allocate more than $170,000 to help fund and publish the study, and to provide a report of its findings when the House of Delegates convenes at the AMA's 2006 annual meeting in Chicago.²

"While nonphysician providers have been, and will continue to be, important elements in the provision of health care, it is important that our patients know and receive the care that only physicians are uniquely qualified to provide," said Dr. Michael Maves, the AMA's executive vice president and CEO. Maves added that the main purpose for the creation of the Scope of Practice Partnership is "to ensure quality care for patients."³

The AMA's alleged concerns over patient care may stem from the fact that increasing numbers of consumers, dissatisfied with the traditional system of health care in the United States, are turning to providers other than medical doctors for treatment. According to a 2004 survey, 36 percent of all American adults (an estimated 74 million Americans) used at least one type of complementary and alternative medicine in the past year. The same survey found that 28 percent of people who used CAM did so because they believed that "conventional medical treatments would not help them with their health problem."⁴

In addition, the number of states allowing for the practice of certain types of CAM has increased dramatically in the past few decades. Chiropractic has had scope of practice laws in effect in every state in the U.S. since 1974, while 43 states allow for the practice of acupuncture by nonphysician acupuncturists, 36 states allow for the practice of massage therapy, and 15 states regulate the practice of naturopathy.

The AMA's resolution, introduced by a delegation from the Texas Medical Association at the interim meeting, calls into question the standards for admission, training and testing of limited licensure health care providers on the claim that these standards "are neither well-defined nor generally known by physicians or public members" who evaluate them or review the quality of care they provide. It also questions the education and certification standards of limited licensure providers, and requests that the AMA, the Scope of Practice Partnership and members of the Federation of State Medical Boards conduct a thorough study of such providers. The full text of the resolution² is as follows:

Resolution 814 - Limited Licensure Health Care Provider Training and Certification Standards

Whereas, The physicians of America voluntarily perform a vital role through initial and subsequent credentialing and privileging of limited licensure health care providers at health care facilities and through peer review of the quality of care provided by these providers at these facilities; and

Whereas, In comparison to the uniform national standards of undergraduate and graduate medical education and board certification for physicians, the education and certification standards for limited licensure health care providers may not be uniform nor well-defined nor generally understood by physicians and the public; and

Whereas, The American public and health care facilities' governing boards rely upon physicians to be well-informed about the education, training, and certification standards of all health care professionals when performing voluntary credentialing, privileging, and peer-review; and

Whereas, State legislatures, courts, and regulatory agencies frequently call upon the opinions and/or testimony of informed physicians when they consider the public's safety and qualifications in relation to the statutory limitations of practice of limited licensure health care providers; and

Whereas, While our American Medical Association has well defined the training and certification of 65 allied health professionals in its 33^rd edition of Health Professions Career and Education Directory, 2005-2006, there is no similar source of information on such limited licensure health care providers as chiropractors, optometrists, nurse anesthetists, advanced practice nurses, podiatrists, or psychologists; and

Whereas, The standards for admission, graduate education, postgraduate training, education, testing, graduation, board certification, board governance, ethics, professional discipline, and licensing of limited licensure health care providers are neither well-defined nor generally known by physicians or public members who voluntarily evaluate and recommend them, grant them privileges, and conduct peer review of the quality of care they provide; and

Whereas, the uniformity of training, autonomy of accrediting organizations, independence of peer review, and the role played by the professions' trade associations of limited licensure health care providers are neither well-defined nor generally known by physicians or public members who voluntarily evaluate and recommend them, grant them privileges, and conduct peer review of the quality of care they provide; therefore be it

RESOLVED, That our American Medical Association along with the Scope of Practice Partnership and interested Federation partners, study the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of the limited licensure health care providers, and limited independent practitioners, as identified by the Scope of Practice Partnership, and report back at the 2006 Annual Meeting.

A fiscal note that accompanies the resolution allocates $171,975 to fund the work associated with Resolution 814, including staffing, publishing the results of the study, and input of legal counsel.

Interestingly, the original version of the resolution singled out chiropractors as one of six groups of health care providers - and the only one that could be considered "alternative" - to be studied by the AMA. (The other five were advanced practice nurses, nurse anesthetists, optometrists, podiatrists and psychologists.)

As for the Scope of Practice Partnership, few firm details about the organization exist on the AMA's Web site; in some instances, it also is referred to as a steering committee or a task force. A search of the AMA's Web site finds the first mention of the partnership in a list of resolutions and report recommendations from the AMA House of Delegates 2004 Interim Meeting. The document notes that the association's Advocacy Resource Center is "actively involved in supporting the federation of medicine's efforts to oppose inappropriate scope of practice expansions that threaten the health of the public," but provides little information otherwise.⁵

In an excerpt of an Aug. 20, 2005 speech to the board of directors of the American Society of Anesthesiologists (also on the AMA's site), AMA President J. Edward Hill, MD, provides some background information on the organization's creation, saying that the association helped to create the Scope of Practice Partnership to counter "various and troubling encroachments on physician practice." Dr. Hill also details some of his feelings about working with allied health professionals.⁶

"Like you, the AMA respects the health care professionals who work with us in our offices and in hospitals, and who can function as physician 'extenders,' in areas where physicians are in great demand and short supply," Hill is quoted as saying. "In my rural practice, for example, I have worked with midwives with great success. However, the operative word in the previous sentence is 'with,' meaning, 'in cooperation with,' or 'as part of a physician-led team.' However, not all allied health professionals see it this way."

According to Hill, the AMA will house and staff the partnership, and provide a basic level of support, with additional support provided by state and specialty societies. An executive committee will be created and charged with reviewing relevant issues and prioritizing scope-of-practice concerns on a state-by-state basis. The partnership also will fund studies to "closely examine the education and training of allied health professionals, and provide this information as a point of comparison for legislators."

An article in the March 2006 issue of Psychiatric News, the American Psychiatric Association's newspaper, includes further details on the partnership's structure and purpose.⁷ According to the article, the partnership was formed "in an effort to marshal the medical community's resources against the growing threat of expanding scope of practice for allied health professionals." It currently is comprised of six state medical associations (California, Colorado, Maine, Massachusetts, New Mexico and Texas), along with six specialty groups (the American Academy of Ophthalmology, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Orthopedic Surgeons, American Psychiatric Association, American Society of Anesthesiology, and American Society of Plastic Surgeons).

Each of the 12 founding members of the partnership has pledged to contribute $25,000 annually to the entity; the funds will be used "to fund research that helps refute the key arguments allied health professionals use to advance their measures in state legislatures." Funding also will be used to "help medical specialty societies and state medical associations fight expansions in nonmedical scope of practice" and to "fund campaigns to stop scope-of-practice legislation in states where such bills appear likely to advance."

While the number of societies involved in the partnership is relatively small at present, APA Medical Director, James H. Scully Jr., MD, expects the partnership to expand to all 50 states, and to establish relationships with every state medical board and association in the U.S. It is believed that such a coordinated effort would send a message to legislators that "scope-of-practice issues are not turf issues for one or another specialty, but are concerns of the profession of medicine."

When combined with the $170,000 the AMA has allocated to pay for staff and study publication as part of its "basic level of support," the Scope of Practice Partnership is already believed to have a minimum of $470,000 at its disposal. Based on the pledges from its founding members, the partnership will continue to receive a minimum of $300,000 in additional funding each year - an amount expected to increase as more societies and associations join its ranks.

The Profession Comments on Partnership

The introduction of Resolution 814 and the formation of the Scope of Practice Partnership have been met with skepticism by the chiropractic profession's leaders, who believe the AMA's intention is not to "ensure quality care for patients," as claimed by Dr. Maves, but to use the partnership and the study to discredit chiropractors and other health care providers in the eyes of state and federal legislators. As of press time, Dynamic Chiropractic had received several statements from chiropractic organizations and individuals:

"After nearly a century of struggling with the relentless negativity by allopathic medicine against chiropractic medicine, I thought the Wilk trial would bring an end to it, and for awhile, it seemed that the 'turf war' was diminishing," remarked James F. Winterstein, DC, president of National University of Health Sciences. ⁸ "However, within the past several years ,it seems to be expanding once again, as organized medicine is encouraging its members to engage in legislative strategies to contain and restrict expansion of practice scope of various nonallopathic health care providers. This is being done under the guise of patient protection, just as it was during the Wilk trial. Meanwhile, allopathic iatrogenic disorders and loss of life continue unabated.

"I wonder if the irony is lost on the public. If patient care is the true concern, then it is well past time that physician members of all professions find a way to work in concert - to become colleagues rather than competitors. No one has all the answers - there is no panacea for human illness. The allopathic profession, in my opinion, brings great shame upon itself with this reversion to self-aggrandizing turfism."

The American Chiropractic Association expressed similar concerns about the partnership and its potential effect on the practice of chiropractic:

"The ACA and state chiropractic associations will vigorously oppose any efforts by the AMA to limit or otherwise restrict the state authorized care provided to patients by licensed doctors of chiropractic. These actions by organized medicine will only limit access to providers who have the education, expertise and experience to provide safe, quality health care services to the public."⁹

The results of the AMA/Scope of Practice Partnership study are expected to be presented at the House of Delegates' 2006 Annual Meeting in June. In the meantime, expect a veritable slew of responses from leaders and organizations within the chiropractic and other health care professions. Look for an update on the AMA Scope of Practice Partnership and its potential effects on the practice of chiropractic in an upcoming issue of'DC.

References

1. Simpson KJ. The Iowa Plan and the activities of the Committee on Quackery. Chiropractic Journal of Australia 1997;27:5-12.
2. Resolution 814: Limited Licensure Health Care Provider Training and Certification Standards.
3. Croasdale M. Physician task force confronts scope-of-practice legislation. American Medical News Feb. 13, 2006.
4. Barnes P, Powell-Griner E, McFann K, et al. CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002. Published by the National Center for Complementary and Alternative Medicine, May 27, 2004.
5. Follow-Up on Implementation of Resolutions and Report Recommendations. AMA House of Delegates Interim Meeting, Dec. 4-7, 2004.
6. Hill JE. Cooperation is critical: AMA and ASA working together. Published Aug. 20, 2005.
7. Daly R. AMA forms coalition to thwart non-M.D. practice expansion. Psychiatry News March 2006;41(5).
8. E-mail from Dr. James Winterstein to Dynamic Chiropractic, May 10, 2006.
9. E-mail from the American Chiropractic Association to Dynamic Chiropractic, May 15, 2006.