The SOPP and the Coalition for Patients' Rights: Implications of Continuing Interprofessional Tension for PNPs
In stark contrast to these successful alliances is continuing and exacerbating resistance to nurse practitioner (NP) autonomy from physician groups. In fact, ongoing during this unprecedented health care reform era is considerable interdisciplinary disagreement over scope of practice, reimbursement, and regulatory language. NAPNAP regrets that physicians and advanced practice registered nurses (APRNs) have reached a new stage of interdisciplinary discord. Nurses must be aware of two coalitions that are responding in very different ways to current health care trends: the Scope of Practice Partnership (SOPP) and the Coalition for Patient Rights (CPR).
The SOPP is a coalition convened by the American Medical Association (AMA) in 2005 with various physician organizations that engage in tracking scope of practice legislative and regulatory efforts throughout the United States. The SOPP funds investigations into the educational preparation and licensure requirements of health care providers with the goal of opposing autonomous practice of all providers except physicians. The SOPP monitors state legislation and regulation regarding scope of practice qualifications, education, and academic requirements of "non-physician clinicians" and provides this information to its members as well as to media and policy makers. The group is influential with federal and state legislators and proposes to oversee and control practice of all "allied health professionals" in the interest of quality patient care. Initially, state medical societies joining SOPP were from Massachusetts, Colorado, Texas, California, New Mexico and Maine; many other state societies now also participate. In addition to the AMA and its state societies, six medical specialty organizations are also part of the SOPP: The American Society of Anesthesiologists (ASA), American Society of Plastic Surgeons, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Orthopedic Surgeons, American Academy of Ophthalmology, and American Psychiatric Association. Each organization contributes a substantial sum annually to finance SOPP activities.
SOPP targets all providers who are not physicians, not just NPs. Physical therapists and chiropractors have been targeted by SOPP, as well as psychologists desiring prescriptive privileges and pharmacists seeking to directly work with patients in medication adjustment roles. SOPP's use of the term "allied health professionals" for all providers who are not physicians ignores the long autonomous histories of other professions, including nursing. SOPP funds studies to examine "allied health professionals" in order to create reports for legislators, and it actively campaigns against state and federal legislation addressing the practice of NPs and others. Numerous AMA resolutions have been passed that reflect SOPP goals, such as the 2005 AMA Resolution 814 entitled "Limited Licensure Health Care Provider Training and Certification Standards" and the 2009 AMA Report 28 "Collaborative Practice Agreements Between Physicians and Advance Practice Nurses." The SOPP is about compensation for care, turf, and fear of change.
The Coalition for Patients' Rights was formed to oppose AMA and SOPP activities. Thus more than 35 organizations (listed in the Box) came together under leadership of the American Nurses Association to resist SOPP efforts to limit the legal authority of qualified provider groups. The name Coalition for Patients' Rights was chosen to emphasize that patients have the right to choose and access quality care from the many kinds of providers who are not physicians. NAPNAP has been active with this Coalition since its inception in early 2006.
CPR counters claims by medicine that all health professionals should be supervised by physicians and regulated by entities comprised of physicians. Affordable, safe care for the nation requires full use of the entire available workforce. There are more than 3 million health care providers in the United States who are not doctors of medicine or osteopathy. The efforts of all who are legally and educationally qualified are critical to meet the extreme health care demand. All PNPs understand the voracious demand for care, given the increasing survival of those born prematurely, the increase in chronic and complex illnesses, the predicted legacy of childhood precursors of adult disease (e.g., obesity, mental health concerns, and poverty), and the persisting health disparities both nationally and globally. CPR emphasizes multiple professional approaches to quality, access, affordability, and sustainability of health care relationships.
Policy makers appear to be recognizing that NPs are a key part of the solution for workforce shortages, particularly when the goal is to provide care to the 45 million persons currently uninsured in the United States. Physician efforts to restrict NP practice are receiving push-back from some lawmakers, indeed a sign of the effectiveness of nursing's unified lobbying in Washington and at state levels. However, statutory and regulatory language ensuring physician control and supervision of NP practice is apparent in some of the health care reform bills currently under consideration. Where this is particularly noticeable is related to the health care/medical home model of care. The medical home model is well established in pediatrics through state-based demonstration projects funded by the AAP and the Maternal and Child Health Bureau (MCHB). Medicare is now launching medical home demonstration projects in a number of states. AAP/MCHB medical home materials have not used provider-inclusive language and focus on pediatricians' skill building. Particularly in states where NPs have independent practice, this exclusive focus on physician models is not in the best interests of patients or NPs. Using provider-inclusive language and thus ensuring NP roles in medical/health care homes is a goal of CPR as well as multiple NP groups. Leaving NPs out of demonstration projects results in outcomes that do not reflect their efforts and keeps them invisible in health care/medical home systems. NAPNAP's recent revision of the Position Statement on Healthcare/Medical Homes aims to clearly state the value of PNPs' active participation and leadership (NAPNAP, 2009).
NPs have a strong track record of working in rural and underserved regions. Recently the SOPP published a series of maps that attempts to refute this record. The data used in creating the maps are from an unknown source, and these attempts to discredit nursing are most unwelcome. It is essential that NPs see the SOPP for what it is: A method to constrain NPs and other providers who are not physicians from being fully included in health care payment reform. CPR has launched a public relations campaign to refute the SOPP for this divisive movement and to educate consumers about their health care provider choices. Cost containment is a key goal of President Obama's administration, payers, and the public. CPR is growing in its influence.
Unfortunately, physician organizations sometimes discredit the quality of care of other providers in order to remain the main recipients of payment. Clearly, no other provider group is as costly as physician care providers. PNPs know that primary care physicians are much less costly than specialty and subspecialty physicians, so considerable battles exist between those two types of physician providers for reimbursement within evolving payment systems. Physician groups aim to select the kinds of patients that NPs can see and typically state that NPs should not see persons with complex problems or multiple diagnoses, undiagnosed patients, or those with difficult management challenges. This position has been taken in spite of the fact that there is no evidence to indicate that in 45 years NPs have been unsafe or ineffective with any population group. In fact, many NPs are hired to work with complex patients in chronic care or acute care settings. They typically receive far less compensation than physicians for doing so, although recently the gap between NP and primary care physician salaries has narrowed. All NPs must emphasize that there is more work than a single provider group can do, and every available provider needs to be legally permitted to work to the full scope of his or her preparation if the health of the United States is to be improved.
In summary, since 2006, progress has been made in that many more nursing and other health care professional providers are more united and speaking out against the SOPP's reprehensible work. The Coalition for Patients Rights advocates three statements:
1. A national coalition of more than 35 organizations, the Coalition for Patients' Rights, represents more than 3 million licensed health care professionals committed to ensuring comprehensive health care choices for all patients.
2. The Coalition for Patients' Rights advocates for patients, protecting their right to access care from a broad spectrum of health care professionals.
3. There is a divisive movement to restrict the valuable services provided by some health care professionals, which will limit patient access to safe, high-quality, and cost-effective health care.