This letter is in response to the Health Care Professional Practice in VA Memorandum issued by the Office of the Under Secretary of Health on April 21, 2020, and the underlying Directive 1899.
A copy of the letter is below:
June 26, 2020
The Honorable Robert Wilkie Secretary
U.S. Department of Veterans Affairs (VA)
810 Vermont Ave., NW
Washington, DC 20420
Dear Secretary Wilkie:
On behalf of the more than 151,000 physicians and medical students represented by the American Osteopathic Association and the undersigned osteopathic state and specialty organizations, we write to express our serious concerns with the Health Care Professional Practice in VA Memorandum (Memorandum) issued by the Office of the Under Secretary of Health on April 21, 2020, and the underlying Directive 1899 (Directive). Together, these documents preempt state scope of practice laws designed to protect the health and safety of the public by ensuring that patients are seen by appropriately qualified medical professionals. Therefore, we urge you to amend the Directive to defer to state scope of practice laws and rescind the Memorandum as it relates to independent practice by Certified Registered Nurse Anesthetists (CRNAs).
Directive 1899 reconfirms the VA’s policy allowing VA health care professionals to provide care across state lines; it also creates a new policy to allow these professionals to practice to the fullest extent of their license, registration or certification. Together, these policies circumvent state laws that require physician supervision of, or collaboration with, the 32 health care professionals covered by the Directive, and undermine patient safety. The Memorandum also encourages all VA medical facilities to allow CRNAs to practice without physician oversight during the national health emergency. Both the Directive and the Memorandum ignore the collective nature of successful efforts by health care professionals to fight the pandemic and create silos which hamper coordinated treatment and transparency for patients, who overwhelmingly prefer physician involvement in their care.*
* Baselice & Associates conducted a telephone survey on behalf of the AMA Scope of Practice Partnership between March 8–12, 2012. Baselice & Associates surveyed 801 adults nationwide. The overall margin of error is +/- 3.5 percent at the 95 percent level. Another survey conducted in 2018 reflected similar results (see https://www.ama-assn.org/practice-management/payment-delivery-models/physician-led-team-based-care).
Our organizations support the “team” approach to medical care because the physician-led medical model ensures that professionals with complete medical education and training are adequately involved in patient care. All physicians in the United States must meet the same education, training and testing requirements and practice in supervised environments that afford progressively greater autonomy before ultimately becoming eligible to treat patients on their own. These requirements ensure that patients are treated safely and with the same standard of care regardless of their location or insurance coverage. They also uniquely prepare physicians to understand and recognize the subtle differences between many minor ailments (i.e. common cold, indigestion) that share similar symptoms with serious ones (i.e. pneumonia, heart attack), which is especially important when treating an emerging, complex disease like the novel Coronavirus (COVID-19).
While we fully support the VA’s goal of increasing access to health care, we are concerned that granting other health care professionals similar practice rights to physicians, without requiring them to complete similar education, training and testing, could create a two-tier health care system and dilute the safety standards that our profession is constantly trying to advance.
The requirements for licensure as a DO or a medical doctor (MD) in the United States are substantially similar, and include:
- Four years of medical school, which includes two years of didactic study totaling upwards of 750 lecture/practice learning hours just within the first two years, plus two more years of clinical rotations done in community hospitals, major medical centers and doctors’ offices.
- Physicians also complete a comprehensive, three-part licensing examination series designed to test their knowledge and ability to safely deliver care to patients before they are granted a license to independently practice medicine.
- 12,000 to 16,000 hours of supervised postgraduate medical education (“residencies”) completed over the course of three to seven years, during which DO and MD physicians develop advanced knowledge and clinical skills relating to a wide variety of patient conditions.
- DOs and MDs are then eligible to sit for the examination process to obtain board certification in their chosen specialty.
Non-physician clinician requirements vary by profession and state, but many are similar to CRNA requirements, which include*:
- One year of experience in an acute care setting following an undergraduate degree.
- A two-year master’s degree.
- No supervised postgraduate “residency” training.
- A single, national certifying examination created by an organization comprised of other CRNAs.
By eliminating physician oversight of CRNAs in VA facilities and expanding the scope of practice for 32 types of health care professionals in VA facilities, even in states that have laws to the contrary, the VA’s new policies disregard the decades of evidence and experience behind established medical school and graduate medical education programs and circumvent current, standardized requirements for medical licensure across the United States.
The AOA and the undersigned osteopathic state and specialty organizations believe that all patients deserve access to high-quality medical care provided by a fully trained and licensed physician. Non-physician clinicians do not have the extensive medical education and training that physicians receive which prepares them to understand medical treatment of disease, complex case management and safe prescribing practices – especially in the case of a challenging infectious disease like COVID-19, which has been shown to be more complex and more lethal in patients with other chronic conditions. Granting these individuals the ability to practice similarly to a physician without any evidence regarding patient safety outcomes – and in some cases, in direct conflict with state laws – could put the health of veterans and their families at risk. Therefore, we urge you to amend Directive 1899 to defer to state scope of practice laws and rescind the Memorandum as it relates to CRNA independent practice.
American Osteopathic Association
American Academy of Osteopathy
American College of Osteopathic Emergency Physicians
American College of Osteopathic Family Physicians
American College of Osteopathic Internists
American College of Osteopathic Obstetricians and Gynecologists
American College of Osteopathic Pediatricians
American College of Osteopathic Surgeons
American Osteopathic Academy of Orthopedics
American Osteopathic College of Anesthesiologists
American Osteopathic College of Occupational and Preventive Medicine
American Osteopathic College of Radiology
American Osteopathic Society of Rheumatic Diseases
American Osteopathic Association of Prolotherapy Regenerative Medicine
Arizona Osteopathic Medical Association
Association of Military Osteopathic Physicians & Surgeons
Florida Osteopathic Medical Association
Georgia Osteopathic Medical Association
Hawaii Association of Osteopathic Physicians & Surgeons
Idaho Osteopathic Physicians Association
Indiana Osteopathic Association
Iowa Osteopathic Medical Association
Kansas Association of Osteopathic Medicine
Kentucky Osteopathic Medical Association
Louisiana Osteopathic Medical Association
Maine Osteopathic Association
Massachusetts Osteopathic Society
Michigan Osteopathic Association
Minnesota Osteopathic Medical Society
Mississippi Osteopathic Medical Association
Missouri Association of Osteopathic Physicians and Surgeons
North Carolina Osteopathic Medical Association
New Jersey Association of Osteopathic Physicians and Surgeons
Ohio Osteopathic Association
Oklahoma Osteopathic Association
Osteopathic Physicians & Surgeons of California
Osteopathic Physicians and Surgeons of Oregon
Pennsylvania Osteopathic Medical Association
South Carolina Osteopathic Medical Society
Tennessee Osteopathic Medical Association
Texas Osteopathic Medical Association
Vermont State Association of Osteopathic Physicians and Surgeons
Virginia Osteopathic Medical Association
Washington Osteopathic Medical Association
West Virginia Osteopathic Medical Association
Wisconsin Association of Osteopathic Physicians & Surgeons