Forty years ago the AMA established a committee to "contain and eliminate" chiropractice 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
The AMA was forced to abandon its campaign against chiropractors because they fought back and sued the AMA for restraint of trade. Almost 20 years after the judge in that case 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 and restrain psychologists and any other non-physician practitioners that they do not approve of. They are doing this not by engaging in an illegal boycott as they did against the chiropractors but by restricting what 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 psychologists. 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.
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 resolution is as follows:
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 33rd 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; (Note: the above healthcare professions are in economic competition with physicians)
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.
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 Ð an amount expected to increase as more societies and associations join its ranks.
It is clear that psychologists are being targeted by organized medicine in order to prop up The "dwindling band of psychiatrists." The AMA can care less about patient care. Their main concern is money and make no mistake about this. They contend that they do not have information on psychologists licensing and credentialing. Have they not seen the licensing laws? If the profession of psychology does not directly confront this challenge to our scope of practice, we will not survive given the amount of money the AMA is raising to get their way. Our APA stand by "fiddling while Rome is burning." The actions by the AMA raises not only a restraint of trade issue but also may be addressed under the RICO statute. NAPPP already has an attorney looking these issues over. We will confront organized medicine and psychiatry on these issues. We will seek an alliance with the other healthcare professions under attack and see if they want join us. We cannot let others define our scope of practice. We cannot allow others use our patients interests against them and us. We need to be proactive!!