Presidential order could revive turf war over Medicare requirement for physician supervision

An executive order signed earlier this month by President Donald Trump calls for changes in Medicare regulations that limit healthcare professionals from practicing at the top of their profession.

The order could add fuel to the ongoing turf war between physicians and nonphysician practitioners over whether they should be allowed to practice independently without doctor supervision.

The doctors have already gone on record, sending a letter (PDF) this week urging Health and Human Services Secretary Alex Azar not to make changes to requirements for the supervision and reimbursement of non-physician medical professionals.

The letter was signed by the American Medical Association, the country’s largest physician organization, and more than 100 other groups that represent hundreds of thousands of physicians.

Their concerns were raised by a provision in the October 3 executive order signed by President Donald Trump for “Protecting and Improving Medicare for our Nation’s Seniors.”

A section of the executive order, which the physician groups said is “broad yet vague,” directs Azar to propose “a regulation that would eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements of the Medicare program that are more stringent than applicable federal or state laws require and that limit professionals from practicing at the top of their profession.”

The president’s executive order directs Azar to act within one year. 

The physician groups urged Azar not to propose any regulation to eliminate or weaken current Medicare requirements that physicians must supervise non-physician professionals. The physician groups said the supervision requirement is “a critical safeguard to ensure the health and safety of Medicare patients and the cornerstone of the widely adopted team-based approach to healthcare.”

“Scope of practice of healthcare professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics,” the groups wrote. “While all healthcare professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”

Before proposing any change, the physician groups said the administration should consider the differences in education and training of non-physician healthcare professionals. Physicians, who have seven or more years of postgraduate education and more than 10,000 hours of clinical experience, should lead healthcare teams, they said.

The groups were also concerned with language in the executive order that would require the HHS secretary to propose a regulation that would affect the reimbursement of physicians and non-physicians established under the Social Security Act. They said such a change would need a rewrite of the underlying statute and they urged Azar not to pursue the proposal.

Just how much authority non-physician practitioners should have to practice on their own is a controversial question.

Physician groups have long opposed legislative efforts to grant independent practice to non-physician practitioners. A resolution by the AMA in 2017 to oppose any legislation to allow non-physician practitioners to practice independent of doctor supervision drew fire from the American Nurses Association and the American Association of Nurse Practitioners that such an effort protects physicians and not patients.

Nonphysician practitioners, including nurse practitioners, are filling a gap in rural areas, where primary care doctors are in short supply.