We Should Be Concerned About This AMA Resolution

[Guest Paula]

in forwarded message:

 

 

From:

President Delaney <

president@aapa.org

>

Date:

June 7, 2013, 6:00:30 PM EDT

To:

President Delaney <

president@aapa.org

>

Subject:

Information on AMA Resolution

 

 

June 7, 2013

Dear Constituent Organization Presidents and AAPA Medical Liaisons,

First, thank you for playing such a significant leadership role in AAPA and our profession. I am contacting you today regarding an important issue. As you know, PAs and physicians work in close alignment in the clinical setting, and that is generally the case in the policy arena as well.

However, there is concern about a resolution that will be considered by the American Medical Association (AMA) House of Delegates and I am contacting you to assure that you are informed, and to enlist your assistance in working with physician groups to address this resolution. The AMA House of Delegates convenes on Saturday, June 15.

By way of background, in 2010 the AMA HOD considered a resolution on pain management and invasive procedures. It was referred to committee for revision and we have been awaiting the revised report and resolution.

Report 16 of the AMA Board of Trustees

has been recently released. The recommendations begin on page 19. As you will see, they are very restrictive, do not display an understanding of the way doctors and PAs work together, and have the potential to be very limiting to physician-PA teams.

The AAPA Board of Directors, working with AAPA AMA liaison Mary P. Ettari, MPH, PA, is preparing a strategy for the AMA HOD which includes working with you, our leaders and liaisons.

As noted in the abbreviated form of the resolution included at the bottom of this message, the resolution expands the definition of surgery to include “repair or removal of an organ or tissue,” and says that “surgery is performed for the purpose of structurally altering the human body.” Although parts of the resolution are somewhat unclear, the implication is that surgery is to be performed only by physicians. If adopted as presented, the resolution will call certain aspects of medical practice, which are currently performed by PAs and well within the standard of care in many specialties across the country, into question.

Additionally, the resolution states that “invasive procedures employing radiologic imaging are within the practice of medicine and should be performed only by physicians with appropriate training and credentialing.” Recently added language in the resolution holds that “technical aspects of certain invasive procedures may be performed by appropriately trained, licensed or certified, credentialed non-physicians under direct and/or personal supervision of a physician.” Direct or personal supervision requires the physician to be in the facility or in the room where the procedure is being performed.

Please review

the list of AMA delegates in your state or specialty

and contact any physicians who you feel are likely to understand the problems with this resolution and describe your concern and the concern of the PA profession. Ideally these prohibitions should not apply to PAs who are practicing as members of physician-PA teams. Doctors should have the flexibility to delegate to PAs within the parameters of state law.

Physician leaders who are not delegates should also be encouraged to discuss this issue with AMA delegates, so feel free to share your concerns with them. We also would encourage you to share this information with other PA leaders to seek their suggestions and input and to assure full integration of the PA community.

As always, AAPA’s approach to this issue will be patient-focused and team based. Our specific ask is that the resolution be amended to state unequivocally that PAs practicing in accordance with state law should not be restricted by this policy.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[MedicinePower]

:confused:Huh?:confused:

[Guest Paula]

The definition of surgery and who can perform it may restrict PAs from suturing, closing surgical sites, performing shave or punch biopsies, I&D's, joint injections...etc. All of these procedures we do now. The resolution states that only PHYSICIANS are trained to perform surgery. Plus, PAs work in interventional radiology and it appears the AMA wants more restrictions on who can and cannot perform interventional radiology. If delegated to a PA they are saying it must be only under DIRECT supervision. These restrictions will hurt the PA profession and any physicians who rely on PAs to perform procedures will be hampered. AMA is not our friend. Never has been, never will be.

[MedicinePower]

The definition of surgery and who can perform it may restrict PAs from suturing, closing surgical sites, performing shave or punch biopsies, I&D's, joint injections...etc. All of these procedures we do now. The resolution states that only PHYSICIANS are trained to perform surgery. Plus, PAs work in interventional radiology and it appears the AMA wants more restrictions on who can and cannot perform interventional radiology. If delegated to a PA they are saying it must be only under DIRECT supervision. These restrictions will hurt the PA profession and any physicians who rely on PAs to perform procedures will be hampered. AMA is not our friend. Never has been, never will be.

 

That is concerning but not very shocking. Your original post was extremely long but didn't contain any content. Can you check it?

[lolWUT?]

We should be concerned about the AAPA sitting on their hands and not doing anything about it.

[Guest Paula]

[TABLE]

[TR]

[TD]B

[/TD]

[TD=width: 88]BOT 16

[/TD]

[TD=width: 783]Invasive Procedures

The Board of Trustees recommends that the following recommendations be adopted in lieu of Resolution 218-A-11, and the remainder of the report be filed.

1. That our American Medical Association (AMA) reaffirm Policies H-160.947, H-160.950, H-360.987, H-410.958, H-475.983, H-475.986, H-475.988, H-475.989, D-35.984 and D-35.990.

2. That our AMA modify Policy H-475.983 Definition of Surgery by deletion and addition to read as follows:

H-475.983 Definition of Surgery

and Other Invasive Procedures

Our AMA adopts the following definition of “surgery” from American College of Surgeons Statement ST 11:

Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues

as well as repair, removal or transplant of an organ or tissue,

and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reductions for major dislocations or fractures, or otherwise altered by mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of diagnostic or therapeutic substances

or placement of any medical device

into body cavities,

the vascular system,

internal organs, joints,

the spine,

sensory organs, and the central

or peripheral

nervous system also is considered to be surgery (this does not include the administration by nursing personnel of some injections, subcutaneous, intramuscular, and intravenous,

or the placement of peripheral IVs with or without ultrasound guidance by an appropriately trained and credentialed individual,

when ordered by a physician). All of these surgical procedures are invasive, including those that are performed with lasers

or assisted by robotics,

and the risks of any surgical procedure are not eliminated by using a light knife, laser,

or heat source

in place of a metal knife, or scalpel.

In addition to the above, invasive procedures also include interventions in the course of diagnosing or treating pain which is chronic, persistent and intractable, or occurs outside of a surgical, obstetrical, or post-operative course of care, as described in AMA Policy H-00.000 Invasive Procedures for the Treatment of Chronic Pain, Including Procedures Using Fluoroscopy [Reference to this policy is contingent on the House of Delegates’ adoption of Recommendation 2]

.

Patient safety and quality of care are paramount and, therefore, patients should be assured that individuals who perform these types of invasive procedures are licensed physicians (defined as doctors of medicine or osteopathy) who meet appropriate professional standards.

Surgical and invasive procedures require physician level training. However, technical aspects of certain invasive procedures may be performed by appropriately trained, licensed or certified, credentialed non-physicians under direct and/or personal supervision of a physician who possesses appropriate training and privileges in the performance of the procedure being supervised, and in compliance with local, state, and federal regulations. Invasive procedures employing radiologic imaging are within the practice of medicine and should be performed only by physicians with appropriate training and credentialing.

3. That our AMA adopt the following guidelines on Invasive Procedures for the Treatment of Chronic Pain, Including Procedures Using Fluoroscopy:

Interventional chronic pain management means the diagnosis and treatment of pain-related disorders with the application of interventional techniques in managing sub-acute, chronic, persistent, and intractable pain. The practice of pain management includes comprehensive assessment of the patient, diagnosis of the cause of the patient’s pain, evaluation of alternative treatment options, selection of appropriate treatment options, termination of prescribed treatment options when appropriate, follow-up care, the diagnosis and management of complications, and collaboration with other health care providers.

Invasive procedures include interventions throughout the course of diagnosing or treating pain which is chronic, persistent and intractable, or occurs outside of a surgical, obstetrical, or post-operative course of care. Interventional techniques include:

1. ablation of targeted nerves;

2. procedures involving any portion of the spine, spinal cord, sympathetic nerves or block of major peripheral nerves, including percutaneous precision needle placement within the spinal column with placement of drugs such as local anesthetics, steroids, and analgesics, in the spinal column under fluoroscopic guidance or any other radiographic or imaging modality; and

3. surgical techniques, such as laser or endoscopic diskectomy, or placement of intrathecal infusion pumps, and/or spinal cord stimulators.

This does not apply to major joint injections (except sacroiliac injections), soft tissue injections or epidurals for surgical anesthesia or labor analgesia.

When used for interventional pain management purposes such procedures do not consist solely of administration of anesthesia; rather, they are interactive procedures in which the physician is called upon to make continuing adjustments based on medical inference and judgments. In such instances, it is not the procedure itself, but the purpose and manner in which such procedures are utilized, that demand the ongoing application of direct and immediate medical judgment. These procedures are therefore within the practice of medicine, and should be performed only by physicians with appropriate training and credentialing.

[/TD]

[/TR]

[/TABLE]

 

 

Sorry, half of the post got cut off. This is from the body of the document. The letter is fro, President Delaney to Constituent organizations and others in leadership positions. Also, I meant Interventional Pain Management rather than radiology. There is other language in the full document about interventional radiology.

 

 

 

 

 

 

 

 

 

[rev ronin]

So if the AMA changes the definition of surgery... so what? The AMA, like the AAPA, only represents a diminishing number of the professionals, and they don't have direct control over any regulation, credentialing, or licensing. I can't see insurers deciding to stop paying PAs for e.g. punch biopsies just because the AMA passes a resolution.

[KMD16]

Agreed with above.

 

Hospitals bylaw supersede AMA policies.

 

If it's inexpensive utilizing PA for certain procedures, insurance carrier will continue to utilize PA services.

 

Laws governing PA practice varies state by state.

[jdtpac]

We should be concerned about the AAPA sitting on their hands and not doing anything about it.

 

your comment is just an example of why students, like yourself, sometimes have no understanding of professional issues they are making comment on. The Academy is not "sitting on their hands" evidenced by the letter that President Delaney sent out to all of the constituent organization presidents and leaders informing them about the issue in soliciting their support. let me give you a quick lesson on medical professional organizations politics.

 

The AAPA has a liaison with the AMA and enjoys official "observer status"in their house of delegates which gives them the opportunity to receive materials/resolutions in advance of them being discussed during the AMA HOD. This gives the Academy the opportunity to inform its membership/leadership about these issues affording them ability to contact the physician delegates to the AMA HOD and make these physicians aware of our Academy's position on certain issues. This is typically called "lobbying for support". President Delaney's letter is an attempt to inform PA leaders about this issue and have the discussed these issues with their physician contact. The Academy has been able to have some influence/input on many issues/resolution the AMA has created policy statements in the past. If Academy is successful in garnering enough support to oppose this proposed resolution we might be able to to influence the AMA delegates to defeat the resolution.

 

I'm happy to see PA students come to the forum to learn more about the profession but I can't always agree with the uninformed/uneducated comments that are made.

[jdtpac]

So if the AMA changes the definition of surgery... so what? The AMA, like the AAPA, only represents a diminishing number of the professionals, and they don't have direct control over any regulation, credentialing, or licensing. I can't see insurers deciding to stop paying PAs for e.g. punch biopsies just because the AMA passes a resolution.

 

I think you underestimate the influence the AMA still has on establishing public opinion and policy. Insurance companies, including those that under-write Medicare/Medicaid policies, jump on every opportunity they can to save a penny! your hospital privileges and even your state laws may grant you the authority to provide a wider range of services to your patients that are not always reimbursed by insurance providers;i.e., not all surgical procedures that a surgeon believes requires an assistant will be reimbursed for that assistant's services regardless if that service is provided by physician, PA, APN or RNFA.

[bradtPA]

I don't think it will pass, but I will be sure to put in my two cents worth against it with the NC Medical Society, of which PAs are allowed to be members....

[rev ronin]

[...] Insurance companies, including those that under-write Medicare/Medicaid policies, jump on every opportunity they can to save a penny! [...]

 

... precisely, which is why reducing the ability of lower-compensated professionals to do those services is never in the insurance industry's best interest, absent a compelling quality of care reason, which almost certainly does not exist. Reducing the supply of professionals doing minor surgical procedures would not save insurance companies or insured patients any money at all--if anything, quite the opposite. Ultimately, I expect that insurers, not the AAPA will be the drivers behind successful expansion of PA/NP scope of practice, from a purely supply and demand economic perspective.

[taotaox1]

I guess the AMA is trying to make sure that NP's, who they have minimal control over, become the predominate mid-level. They are taking a crap in their own cheerios if you ask me....

[Guest Paula]

AAPA, AFPPA and PAFT are all addressing the issue. Individual PAs can speak to their physician partners and ask them to request that AMA pulls the resolution. It is important that PAs are involved in all of these issues regardless whether or not you work in the specific field that is targeted. AMA still has influence on public policy as they seem to be the ones that speak against the PAs (and NPs).

[GreatChecko]

Anyone know where this proposal came from. Is there some group within the AMA that longs for the 60's?

[burnpac]

This is much ado about nothing, for the simple reason that AMA HOD policy statements are just that. Statements of beliefs and values. In this environment, with the full implementation of the affordable care act months away, there is not one state legislature that is going to limit scope of practice of PAs or NPs when you look at the stark reality of the ratio of patients to providers. In fact, multiple state legislatures are looking at expanding PAs and other's scope of practice to function at the height of training as well as working to remove barriers to physician PA team practice. This is pathetic and self serving, and a prime example of a "solution" looking for a problem. Pass it, or don't pass it; it won't make a bit of difference in the trends unleased by the ACA. Your scope of practice is determined by your state legislature, and your surgical privileges are determined by your medical staff. Neither entity is going roll back decades of positive experience just because the AMA desires it to protect their own rice bowl.

[jmj11]

I do take it with a grain of salt. Too many physicians stand to loose a lot if we are hobbled. Some days I would like to mail the good-ole-boys at the AMA a giant pacifier.

[fuma102]

"surgical and invasive procedures require physician level training. However, technical aspects of certain invasive procedures may be performed by appropriately trained, licensed or certified, credentialed non-physicians under direct and/or personal supervision of a physician who possesses appropriate training and privileges in the performance of the procedure being supervised, and in compliance with local, state, and federal regulations. Invasive procedures employing radiologic imaging are within the practice of medicine and should be performed only by physicians with appropriate training and credentialing. (Modify HOD Policy) "

 

so basically, state law and hospital credentialing are what you need to be aware of. All my charts have attending cosignatures, and basically every quasi-risky procedure I do gets a fly by with the attending (shoulder reduction, central line...), and gets documented that I discussed the case with them.

 

Im not overly concerned anything is going to change in NY or rural areas, you'd have the MDs pulling their hair out and screwing rural areas royally.

 

Sounds like a few really pissed off attendings dont want to give up their turf and are fighting a losing battle, and given the focus on CRNAs, I wouldnt be surprised if many were anesthesiologists who long for the good ol' days.

 

EDs, ORs, IR, and ICUs aint going to change much.

[JWestenhofer]

As a PA working in dermatology, I am very concerned about this. I do a lot of punch biopsies, shave excisions, and elliptical excisions. Of course, I administer local anesthesia and suturing. This would greatly affect my usefulness in my current position.

[Guest Paula]

This is much ado about nothing, for the simple reason that AMA HOD policy statements are just that. Statements of beliefs and values. In this environment, with the full implementation of the affordable care act months away, there is not one state legislature that is going to limit scope of practice of PAs or NPs when you look at the stark reality of the ratio of patients to providers. In fact, multiple state legislatures are looking at expanding PAs and other's scope of practice to function at the height of training as well as working to remove barriers to physician PA team practice. This is pathetic and self serving, and a prime example of a "solution" looking for a problem. Pass it, or don't pass it; it won't make a bit of difference in the trends unleased by the ACA. Your scope of practice is determined by your state legislature, and your surgical privileges are determined by your medical staff. Neither entity is going roll back decades of positive experience just because the AMA desires it to protect their own rice bowl.

 

I agree that this won't change state practice laws for PAs and the ACA should be something that will protect our profession to some degree. AAPA has been addressing it and I hear that many surgical groups and physicians who this might hurt are starting to respond. It is important to get defeated so the AMA knows that AAPA, PAFT and AFPPA won't stand for their bullying and we will fight for our PA practice rights.

[HopefulPA]

This is what our State Chapter has done. Hopefully other States Chapters are doing the same.

 

Recently you may have received some alarming news from the AAPA that the AMA House of Delegates is considering a resolution, BOD 16, that would severely limit a PA's ability to do invasive procedures. The AMA's Annual Meeting is this weekend and MAPA is hopeful that some of actions that were taken between MAPA and AAPA will be successful.

 

Upon hearing of this issue, MAPA contacted the Michigan State Medical Society and worked closely with their staff and physicians to try to defeat the resolution or amend it to exclude PAs. In response to MAPA's involvement, AAPA provided an amendment and MAPA worked with MSMS to ensure that their delegates would not only support the amendment, but also take an active role in pushing for its passage if there are indications the resolution is going to pass.

 

The amendment would read as follows:

 

“Nothing in this section is intended to limit the ability of licensed physicians to delegate to appropriately trained and licensed physician assistants who are practicing with physician supervision as required by state law.”

 

In addition to these measures, MAPA has worked with key PAs to speak to their physicians who are delegates or alternates on the AMA HOD.

 

Again, we are hopeful that these actions will help dissuade the AMA from placing unreasonable restrictions upon PAs that would affect practice efficiencies and ultimately impact patient care.

 

Ron Stavale, President

Michigan Academy of Physician Assistants

[quarternote]

I'm sorry if this is a repost. I scanned the comments and didn't see this but am in a hurry. Below is a link to a petition.

 

https://www.change.org/petitions/ama-house-of-delegates-resolution-218-a-11-restricting-pa-practice-support-removal-of-this-resolution-that-would-restrict-pa-practice?utm_campaign=friend_inviter_chat&utm_medium=facebook&utm_source=share_petition&utm_term=permissions_dialog_false

[Staplemyfoot]

Doubt this will pass, there is already a shortage of providers.

[burnpac]

Check out my Friday Blog posted on Physicians Practice online today regarding BOT Report 16 and the AMA HOD.

 

http://www.physicianspractice.com/blog/ama-looks-restrict-physician-assistant-role-healthcare-teams

 

It will be interesting to see how the physician audience of this site responds.... :-)

[Hemegroup]

http://www.change.org/petitions/ama-house-of-delegates-resolution-218-a-11-restricting-pa-practice-support-removal-of-this-resolution-that-would-restrict-pa-practice?utm_campaign=signature_receipt&utm_medium=email&utm_source=share_petition