AAOS Now

Published 6/1/2015
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lMaureen Leahy

Tips for Limiting Scope of Practice Expansion

Defining the scope of practice for a healthcare provider is often challenging, particularly when nonphysician providers want to step beyond traditional roles. However, it is patients who are most at risk when physicians and nonphysician healthcare providers are allowed to administer musculoskeletal treatment outside of their areas of training and experience.

During an educational symposium at the 2015 National Orthopaedic Leadership Conference, moderated by Brian G. Smith, MD, panelists Brian S. Parsley, MD, and Bobby Hillert of the Texas Orthopaedic Association (TOA); William E. Kobler, MD, of the American Medical Association (AMA) and William G. Cimino, MD, of the Connecticut Orthopaedic Society (COS), discussed how state and specialty societies can work together on scope of practice issues. In Texas, noted Mr. Hillert, TOA executive director, allied health professionals, particularly physical therapists, have made numerous attempts to expand scope of practice.

Dr. Cimino shared the experiences of the COS to ensure proper podiatric scope of practice in that state. A foot and ankle specialist in solo practice, Dr. Cimino is the immediate past president of the COS and the state’s representative on the AAOS Board of Councilors (BOC).

“Podiatric scope of practice expansion is not a problem for orthopaedists or foot and ankle surgeons.  Rather it is a patient safety issue,” he said. “Many currently practicing podiatrists have either no postgraduate residency training or as little as 2 years of training. It wasn’t until 2013 that podiatry residency programs began to require 3 years of postgraduate training.”

Saying so doesn’t make it so
Efforts by Connecticut podiatrists to expand their scope of practice date back to 1984 when the Connecticut Board of Examiners in Podiatry issued a declaratory ruling that the ankle is part of the foot and therefore within the podiatrists’ scope of practice. In response, the Connecticut State Medical Society sued the Podiatry Board, and in 1987, the Superior Court of Connecticut ruled that the foot and the ankle are distinct anatomic structures and that scope of practice can be expanded only through legislation, not declaratory rulings.

Over the years, as podiatrists in Connecticut continued to lobby to include ankle care in their scope of practice, the COS worked diligently with public health officials and legislative experts to establish reasonable limits for podiatric care.

In 2006, the Connecticut legislature passed a bill that gave board-certified, board-qualified podiatrists medical and nonsurgical ankle treatment privileges. “Although the bill did not grant podiatrists ankle surgery privileges, it certainly opened the door,” Dr. Cimino said. Resulting arbitration led to an agreed-upon definition of the ankle and a licensure program for ankle surgery permits.

“This was very important because it enabled us to define the geography,” Dr. Cimino said. “We knew that podiatrists would eventually get ankle surgery privileges. In many states, ankle surgery is within the scope of practice for all podiatrists—including those who only have training in nonsurgical care and forefoot surgery. We wanted to ensure that only podiatrists who had received sufficient training in ankle surgery could get an ankle surgery permit. We sought to enact parameters that would limit them to performing procedures that they were capable of doing. As a result, we were successful in ensuring that treatment of tibial pilon fractures and total ankle replacement procedures would remain outside podiatric scope of practice,” he said.

Pearls and pitfalls
What can other orthopaedic state societies and surgeons learn from the COS’ efforts to limit scope of practice expansion?

First of all, every scope of practice change has an associated price tag, according to Dr. Cimino. “Medical society efforts, lobbying efforts, and dollars significantly influence the decisions of legislators,” he said. “Secondly, scope of practice legislative processes don’t happen on a whim—they are often well-conceived strategies that are many years in the making.”

He added that orthopaedic surgeons need to be proactive and at the forefront of ensuring that musculoskeletal care is provided by properly trained professionals. In doing so, it’s important to emphasize patient safety rather than turf battles or economics. “You must also emphasize training differences, the number of years of training, and the quality of training between orthopaedic surgeons and other providers,” Dr. Cimino said.

Just as important as developing long-term relationships with legislators, he pointed out, is realizing that passage of legislation may be a foregone conclusion. “As we learned in 2006, podiatrists were going to get ankle privileges and ankle surgical privileges. We had to devise a strategy to ensure some degree of safety for patients; once scope of practice is increased, it’s rarely decreased and the changes become permanent,” Dr. Cimino said.

In addition, any time a scope of practice bill is proposed, it’s important that the bill identifies who will be implementing the statute. “If the language is not clear, the department of public health will interpret the statute the way it wants. A good piece of legislation with well-defined implementation procedures is key,” he said.

However, the orthopaedic community may be its own worst enemy when it comes to limiting podiatric scope of practice expansion, according to Dr. Cimino. He noted that the number of states with ankle privileges for podiatrists grew from 17 in 1997 to 43 in 2011—a 165 percent increase.

“Orthopaedic groups are hiring podiatrists to perform foot care, which gives podiatrists credibility and legitimacy, elevating their status,” he said. “In addition, podiatrists are training residents in some orthopaedic residency programs, and podiatrists are being trained by attending orthopaedic surgeons on orthopaedic surgery rotations, including cases beyond their current scope of practice.”

Dr. Cimino added that an equal number of podiatrists and orthopaedic surgeons are entering the work force each year. “However, less than 10 percent of the orthopaedic surgeons do foot and ankle fellowships,” he said.

When it comes to protecting orthopaedic surgeons’ scope of practice, the best defense is a good offense, Dr. Cimino concluded. “Orthopaedic surgeons need to join and participate in state medical and state orthopaedic societies. Perhaps most importantly, we need to contribute to the Orthopaedic Political Action Committee (PAC). If you’re not on the table, you’re on the menu; the best way to get a seat at the table is through the Orthopaedic PAC.”

Another example of good offense is the AAOS participation in the AMA’s Scope of Practice Partnership, noted Dr. Kobler. The AAOS not only is a member of the Partnership, but also has a seat on the steering committee.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Advocacy Reaches Patients
During the NOLC, attendees experienced the effectiveness of patient advocacy firsthand. Stephen G.J. Eckrich, MD, BOC representative from South Dakota, discussed the Patient Choice Initiative in his state. When insurance companies implemented closed networks, physicians put together a coalition led by the South Dakota State Orthopaedic Society. The ballot initiative, which included engaging patients at the grassroots level and using a multifaceted media campaign, allowed any healthcare provider to join an insurance company’s network, assuming the provider agreed to the company’s terms and conditions and worked within the company’s coverage area, a concept known as “any willing provider.” It passed in the 2014 election.

In California, Prop 46 sought to overturn many aspects of the Medical Injury Compensation Reform Act (MICRA) of 1975. BOC representative Basil Besh, MD, provided an overview of its successful defeat in the 2014 election.

The 2015 NOLC also hosted the first Advocacy Forum for Spouses and Other Patient Advocates, which proved to be a great success. The group of more than 20 advocates focused on fragility fractures and their impact on the nation’s healthcare system. AAOS Diversity Award Winner Bonnie Simpson Mason, MD, the featured keynote speaker, discussed musculoskeletal advocacy and her personal journey. Dr. Mason founded Nth Dimensions Educational Solutions, Inc., which works to increase the numbers of women and underrepresented minorities in the field of orthopaedics.

During breakout sessions, attendees brainstormed ideas for moving forward. The proposals included having patient advocates attend the Hill training, increasing interaction with state societies, and facilitating communications among advocates through an email registry.