ASPS Responds to a Wave of Scope of Practice Expansion Bills

Non-physician providers have long sought the ability to practice medicine in a variety of capacities, ranging from procedures that are outside their training in the case of occupations like optometry or dentistry to full independent practice in the case physician assistants (PAs) and nurse practitioners (NPs). In 2021, movement in this area has quickened.

As efforts to expand scope of practice increase, ASPS remains active in both identifying these trends and working with state and regional plastic surgery society partners to oppose specific bills with significant implications for plastic surgeons and their patients.

Nurse practitioner and physician assistant independent practice

Non-physician advocacy organizations are aggressively working to advance policy that provides greater autonomy for their members, and in many instances, these efforts have been successful. Unrestricted independent practice for nurse practitioners (NPs) currently exists in 23 states. Full independent practice for physician assistants is legal in at least four states.

To date, there are 22 non-physician independent practice bills in various state legislatures throughout the country. Some of the bills, like legislation introduced in Tennessee and Mississippi, would increase the number of states with complete, unrestricted independent practice for NPs. Others, such as a bill in Alabama, would expand restricted independent practice of NPs to allow for not only independent prescriptive authority, but also for supervision of lesser-qualified NPs. In states like Utah and Florida, proposed legislation would allow for the independent practice of physician assistants.

ASPS has worked closely with local, state and regional plastic surgery societies to oppose bills that would expand the scope of NPs to allow for independent practice. Ongoing advocacy efforts include collaborations with the Florida Society of Plastic Surgeons, Southeastern Society of Plastic and Reconstructive Surgeons, Tennessee Society of Plastic Surgeons, Virginia Society of Plastic Surgeons and Utah Plastic Surgery Society.

Low-cost, high-volume clinics and practice drift in medical spas

In public comments provided in 2017, the American Med Spa Association estimated that the growth trajectory of the industry would be 8% year over year until 2022. The Association even stated that due to its growth, it "can no longer be considered a subset of plastic surgery or cosmetic dermatology, especially because 70% of the doctors that own and work in medical spas are non-core."

Despite the fact that the majority of practitioners in medical spas are non-core, regulations in various states nationwide have generally granted greater freedom for providers than restrictions and standards intended to ensure quality care. The safety implications of medical spas have come sharply into focus at times over the last decade-plus, but it has typically taken high-profile cases of patient harm to result in a public policy response.

Perhaps the best recent examples of these cases leading to large-scale safety regulation came in in Florida and Maryland. With the latter, an outbreak of severe invasive infections led to requirements that all office-based surgery centers performing more than minimally invasive procedures be accredited. In Florida, the growth of low-cost, high-volume surgery centers led to a substantial corporate presence that valued speed and turnover over safety and quality work. This in turn led to an epidemic of patient harm, finally pushing the states to place guardrails on the industry that better protected it from repeat offenders.

Naturopaths practicing aspects of medicine

In Maryland, legislation was proposed that would allow naturopaths – holistic healers who are licensed but who do not receive medical education and training – to perform and oversee procedures that fall within the practice of medicine, including prescribing drugs and devices. ASPS collaborated with the Maryland Society of Plastic Surgeons (MSPS) to oppose the bill, and in a January 29 letter encouraged legislators to "uphold the high level of patient care that has been established and allow the practice of medicine only by health care providers who meet appropriate education, training and professional standards."

Optometrist injections

There have been movements in various states aimed at expanding the scope of optometrists. A bill introduced in the current session of the Oregon Legislature seeks to open the door for optometrists to administer injections into the eyelid and surrounding tissues. Concerned that it was too narrow in its list of surgical exclusions – a common tactic employed by optometrist lobbying groups as a way of expanding scope through implication – ASPS worked closely with the Northwest Society of Plastic Surgeons (NWSPS) to oppose the legislation.

Similar legislation in Iowa would not only expand the scope of optometrists, but also place significant authority with the state's optometry board. The bill proposes a required one-day training to qualify optometrists to provide injections. In a letter to the Professional Licensure Division of the state's Department of Health, ASPS opposed the legislation, calling the prerequisite training it outlines, "woefully and egregiously insufficient."

Dentist scope of practice

In a rare show of support for efforts to undo administrative overreach rather than advocate for increased oversight and regulation, ASPS and the Northeastern Society of Plastic Surgeons (NESPS) submitted comments this month to the Maine State Legislature recommending more specific prohibitions on administration of botulinum toxins and dermal fillers.

In a February 8 letter to Maine legislators, ASPS and NESPS noted concerns with the proposed bill and highlighted "serious patient risks involved with allowing these injections into the dental scope of practice given the fact that dentists lack clinical training to perform surgery outside of the oral cavity."

Fighting to protect the practice

ASPS stands firmly in opposition to non-medical professionals performing surgery. The Society will continue to work with its local, state and regional partners to oppose legislative and regulatory action that threatens both the practice of medicine and patient safety.