Advanced Practice Providers - An APP’s Scope of Practice

"An advanced practice provider’s scope of practice can vary drastically depending on where you practice; listen to the ASCO Education’s third episode of the advanced practice providers series, and learn more from our co-hosts, Todd Pickard (MD Anderson Cancer Center) and Dr. Stephanie Williams, (Northwestern University Feinberg School of Medicine), along with guest speaker Heather Hylton (K Health) on what scope of practice is, who or what defines it, and why knowing this information is critical to your oncology care team success.

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TRANSCRIPT

Todd:  Hello everyone, and welcome back to the ASCO Education Podcast, and the third episode of the Advanced Practice Provider series. I'm Todd Pickard, your co-host for this series, along with Dr. Stephanie Williams.

We'd also like to introduce you to our guest panelist today, Heather Hylton. Heather, why don't you share a bit about yourself, what you do, and where you're from.

Heather: Sure. Well, thank you so much. It's a pleasure to join you in this podcast. My name is Heather Hylton. I'm a physician assistant based in New York.

Most of my career has been in oncology, but I've been fortunate to have been able to serve in administrative and clinical roles in organizations in multiple states. So, I'm currently working in the remote care space, and I'm excited to bring this experience to our conversation.

Todd:And Stephanie, why don't you remind our listeners today about your background, and why you have so much experience and really just have a really true appreciation for working with advanced practice providers.

Stephanie: Thanks, Todd. I've worked in oncology for almost 40 years and I've had the opportunity to work with advanced practice providers, both physician assistants, and nurse practitioners for a couple of decades now.

I've been in stem cell transplants and cellular therapy, and they’re absolutely integral to our practice, both inpatient and outpatient in that particular field.

Todd:  Well, in today's episode, we're going to be talking about advanced practice providers’ scope of practice; what it is, what it means, who defines it, and why it is important for oncology APPs to know and understand what their scope of practice is.

So, why don't we jump right in? So, I think it's important to define scope of practice first. So, I would like to just offer a little bit of a perspective around that language of scope of practice.

Generally speaking, it is what is allowed by law at any particular state for an advanced practice provider to perform care on patients; what types of patients they can see, what kind of medications they can prescribe and write, what kind of activities they can be in, what kinds of relationships they have to have with other providers and delegating or collaborating physicians.

So, generally speaking, a scope of practice can be very, very broad or it can be very, very narrow. And it really depends on the state and how the state defines it.

So, I'm going to ask Heather to jump in here and can you provide an example or a story, or a case that comes to mind that helps illustrate scope of practice for an APP?

Heather: Sure, I'd be happy to, you know, in terms of how I think about this, very simply stated is, what it is that I'm permitted to do as an advanced practice provider. And the boundaries, as you said around this, are really determined by a number of factors.

So, education, training, experience, my competency, federal law in some cases, state laws, regulations. And this may also include, as you mentioned, specific physician collaboration requirements, facility policy, clinical privileges that are granted by that facility, sometimes payer policy factors in, and then of course, the needs of the patient.

So, one very common question that comes up in the oncology space is, can APPs order or prescribe systemic therapy? And the answer of course, is really going to be determined by going through that checklist of the entities that determine if this is something that that APP can actually do.

So, one example I have is a facility where the module that they utilized for ordering systemic therapy provided system rates only to physicians. And the facility that had been using that module before APPs were widely integrated.

So, there were some innocent assumptions made that the absence of the APPs in the module meant it was “illegal” for APPs to order systemic therapy.

So, in working with this group, we were able to go through this checklist. So, there were no federal or state restrictions on this particular clinical activity, but it needed to be written into the facility policy.

So, criteria for establishing competency were devised. And then an education training plan was designed, implemented, and driving systemic therapy became part of that privileges requests from the APP, and then the systems' rights issues were also addressed.

So, this was truly a success story in being able to safely expand the number of clinicians, who were able to prescribe systemic therapy in a busy and growing facility.

Stephanie: Heather, what does it mean to you (this is a term that our administrators throw around a lot and our nurse managers throw around as well) to practice at the top of your license, whether you're a nurse, physician assistant, or an advanced practice nurse; what is the top of your license?

Heather:  Well, this is a hot topic. And top-of-license practice really comes down to role optimization. It is just good business. It means that the patients and the caregiver's needs are being met by the professional with the appropriate training, experience and competency for each function or task that the professional performs.

And from an engagement standpoint (which I know is not the topic of our conversation today, but it is important) we know that people want to engage in work that they find meaningful.

While that definition certainly is individualized, a common thread is being able to leverage that education, training and experience you have to help others. And often, the reason why we really pursued our careers.

Todd: I think this is such an important topic to talk about, is the top of license practice, because it really impacts all of us, Stephanie.

You know, as physicians, you want to do what you've been trained to do, which is to assess a patient, have a differential diagnosis, do a diagnostic workup, arrive at a diagnosis, create a treatment plan, and have that treatment plan implemented so that you can care for the patient. And APPs are the same way.

So, when you have folks, whoever they are, whether they are the nurse or the advanced practice provider or the physician or the social worker or the pharmacist, whoever it is; if they are utilized in a way that does not take into account all the skills and competencies that they have to deploy and provide for that patient, they're really working below the top of license.

As an example, if you had an APP go from room to room to room with you seeing patients and the only thing that you had the APP doing was scribing, that APP is working well below their licensure.

And in fact it's incredibly wasteful with limited resources in healthcare, to have folks who have lots of skills and competencies working at a level where you really should have a different member of the team providing that service. Like if you need a scribe, you should get a scribe.

And so, I think that kind of illustration really makes it salient to folks to think about; we should all work to stretch the knowledge and skills and competencies that we spent so much time developing in all of our training and our certification. Because otherwise, it's just wasteful. And as Heather said, it's not very satisfying.

Stephanie: Todd, I think that those are excellent points that you bring out and I think that's very important for people to realize that APPs aren't scribes, they aren't there to extend me. They're there to help me as a physician in my practice, to help the patients actually. And then we should work together as a team to give the best patient care that we can.

But many times I see my colleagues, just as you said, going from room to room with their APP and expecting the APP, you know, “I'll pontificate and tell you do this, that, that and the other, and then you go out there.”

I think also from a career and job satisfaction rating, it's really important to have that team around that can help each other out. And I think that really does help in terms of decreasing burnout and other things like that.

Todd: So, Heather, can you give us some idea of how is scope of practice defined at a state or an institutional level? How do people arrive at those kinds of decisions or, you know, how does an institution decide what the scope of practice is? How does it work?

Heather: Taking a step back and just, you know, kind of thinking about it through different lenses. So, you know, in contrast to physicians whose scope of practice has minimal variability from state to state, we know that there can be a bit more state to state variability for APPs.

And the regulatory bodies or agencies can also be different. And there may be multiple agencies that weigh in on what that APP can do within a particular state.

And so, it's certainly important to be familiar with the Practice Act for each state in which you are licensed. And I would also add onto this, in certain geographic areas, this may be particularly relevant to you if you are in a practice that has multiple locations in multiple states, but we'll come back to that a little bit later.

But, you know, again, kind of going through your checklist, starting off, looking at what the Practice Act says, and these can all be written up in many different ways. Sometimes it comes across as what I would call like a laundry list, which when you first read it, seems pretty straightforward, but it can also kind of lead you into some issues because if it isn't on there, then what does that mean?

Some Practice Acts are written up really more on the basis of what activities are excluded or things that you cannot do as an APP. And then some are just kept very broad, which sometimes makes people uncomfortable, but I would encourage you to not be uncomfortable with that because sometimes, they're written this way in order to give you more flexibility to set that scope of practice at facility level, which is ideally where you really want to be cited. You don't want to create something more limiting or more restrictive than what the state actually allows you to do.

Todd: That is a critically important point and one that in my 24 years as an advanced practice provider who happens to be a PA, that has come up often and frequently is, “Well, it doesn't say this” or, “It doesn't specifically exclude that. And so, we're uncomfortable.”

And my response is, “Well, that gives us an opportunity to create this space”, because, you know, many times, as you point out, Heather, these kind of ambiguities are written intentionally, so that local practice decisions can be made, so that physicians and advanced practice nurses and PAs can decide as a team, how do we work?

You know, in my state, it was very specific that they wanted APPs and physicians to collaborate on ‘what does our practice look like?’ And every local level, outside of those very large kind of rules about who can prescribe and who can pronounce a patient dead or write a restraining order — outside of those very large things, they really want us, they want the care team to figure it out and to do it in a way that's best for our patients.

I think that is the best approach, is when we get to decide how we work. You know, the places, some of the states that have these laundry lists, you're right, Heather, it seems like, “Oh, that's easy,” but then you're like, “wait a minute, there's only 10 things on this list and we do, you know, 57, what does that mean?”

And so, I think it can be very disadvantageous when you have those lists. And I do think it's important to think through these things, work with your legal colleagues to analyze these things, and then take an approach, stake out some territory, you know, once you've gotten informed and say, “This is what our scope looks like, we've all talked about it and this is how we're going to work as a team.”

So, that's wonderful when you've got that level of flexibility. I think that's really great.

Stephanie: Does insurance reimbursement play any role in terms of scope of practice, either locally or nationally?

Heather:  It absolutely can. And it's important to know, for example, if you are in a practice, where you're seeing Medicare patients, to understand Medicare conditions of participation.

If you are in a practice where you are taking care of patients with Medicaid or certainly private payers as well, like understanding what is actually in those contracts, so that you can make sure that you are either updating them if you need to, or making sure that what you need to be able to bill for is billable within those contracts.

Todd: It's really interesting because I always have a sense of feeling like I need to cringe when somebody says we can't do this because of a reimbursement issue, and also, partially laugh.

And the reason why I have both of those reactions is it's typically a misunderstanding, because saying that we won't reimburse for oxygen unless a physician's order is present to prescribe the oxygen does not equate to only a physician can do this.

And so, you constantly have to kind of explore these issues and say, “Okay, so yes they use the word physician, but as an APP who has a collaborative delegatory relationship with a physician, and according to my state license and scope of practice, I write physician orders.”

So, if you connect those dots, if I, as the APP, have written the physician order for the oxygen, it meets your criteria. It doesn't say a person who holds a medical license, it says physician order.

And so, I think that's where you have to really constantly be on guard about these misconceptions, misunderstandings, and these ambiguities.

And as Heather said, working with APPs, you just have to say, “Look, there's going to be ambiguities, we're going to work it out, we're going to figure it out. And, you know, reimbursement is important.”

But you have to remind folks that reimbursement doesn't define practice, it defines how you get paid.

Stephanie: Excellent point, Todd. Excellent.

Heather: I'll add a story to that as well. When I first came to New York, I became aware of a situation where the narrative at a particular facility was that a major private payer would not reimburse for services provided by PAs.

Now, I thought that was a little strange, but, you know, I was a new kid in town, but at that time — there are more now, but at that time there were 10,000 PAs in New York. That's a pretty big number. And so, I thought, you know, I probably would've heard something about this if this major payer would not reimburse for these services.

So, to help with the situation, I started doing the research, you know, looking at specific information from the payer, checking with connections at other facilities to learn about any issues that they may have experienced with this payer, checking with our national organization and so forth. And really, nothing was coming up, suggested that the payer would not buy reimbursement for services provided by PAs.

And ultimately, it came down to something very simple, which was the facility just didn't have this in their payer contract, they hadn't needed it up to that point. So, it made perfect sense and it was fixed once the issue was identified.

So, this goes back to just being very vigilant about the research that you're doing. And sometimes, it takes a little time to get to the solution, but really that perseverance does pay off.

Todd: Heather, I'm sitting here, I'm laughing because I just had a recent example of where the right and the left hand within a state had no idea what was happening.

So, an employer who does ambulatory outpatient treatments at different retail locations (we'll just leave it at that) there was this concept that PAs as an example, were ineligible because of the state requirements that then were reflected in this company's policy.

And what was so interesting is that a PA colleague of mine started investigating and I said, “Well, what does the state law say?” And she went and she looked and she said, “Oh, it was changed last year that this thing that was causing this policy in this employer was changed.” And I said, “Well, does the company know that the law was changed?”

So, she reached out to the medical director who was a physician, whose daughter was happening to want to go to PA school. So, she had an in, she had an in right away, which serendipity does play a part here. And she said, “Did you know that the state law changed?” And they said, “No.”

And so, she sent them the state law and then within a week, the medical director said, “Oh, just so you know, we're hiring PAs now, we've updated our internal policies to reflect state law.”

So, sometimes it's just these small things that people forget the details, that when something changes, you have to reflect that in your policies of companies or institutions or your practice group.

And that's the one thing that I think is so different for APPs from physicians. Physicians are kind of just granted this big broad authority and it rarely changes. It's very stoic and it's kind of fixed. But for APPs it is constantly in flux, constantly in flux.

And that's just the nature of it. I don't know why it's been that way. We've organically developed this in the United States over the past 50 years, maybe 50 years from now, it'll be different, but right now, it's not.

And so, I think that's the important thing is there's more space out there for advanced practice, scope of practice and top of licensure, than you think is possible. It just requires a little work.

Heather: I will say that I 100% agree and, you know, when you take a step back from some of these, like these Practice Acts, they tell a story about the climate in the state and the history in the state.

And it's quite fascinating if you like that. I'm not the most fun person at a party, but, you know, these things, they tell a story and it gives you a good sense of what's actually going on in the micro environment in that state.

In the last year plus, I've spent a lot of time reviewing Practice Acts of most of the states of the union, and so, I have this ability to really compare. And I also know which states I really, really like and which ones are a little bit more challenging.

But there are things like even legislation that’s left over from the industrial revolution that's actually influenced how a particular pharmacy interprets, you know, whether or not they can accept a prescription without a counter signature from a physician.

And so, some of these things, like when you start drawing some of these lines, it becomes very interesting and it definitely comes down to some interpretation as well.

So, always being able to work with a good legal team or people who do understand Practice Act information and working with your state resources as well, as well as your national organizations can be very impactful.

Todd:  I would also say step one is to pull up whatever Practice Act is influencing something and read it. They are in English, they're not in Latin or French, they're in English.

And many times, you can find something very plainly said. Other times you do need your legal friends to help you understand, “Okay, now what does this mean? I read the words but it's not clear.”

But sometimes it will say, you know, “An APP may prescribe a controlled substance.” Period. So, oh, well, there's an answer right there. Now, there may be a how-to section later, in another part of the regulatory or administrative code within a state, but for the most part is, don't be afraid to look, don't be afraid to phone a friend and explore and ask questions.

Stephanie:  You're eligible though for controlled substance licenses nationally, right? A DEA number?

Todd:  That's a hot topic.

Stephanie:  Is it?

Heather: There may be other things that you need to do within a state as well in order to prescribe.

So, for example, in Massachusetts, even to prescribe legend drugs, you need a Mass Controlled Substance Registration, because any substance that's not a DEA scheduled substance is considered a category 6 substance in Massachusetts.

So, if I'm going to write a prescription for Omeprazole, I need to have a Massachusetts Controlled Substance Registration, as any prescriber would in the state.

So, again, some of these little nuances, making sure that you're very familiar with that and doing the research.

Stephanie: So Heather, you're in New York, I'm sure you get patients from Massachusetts. So, you have to make certain that you can prescribe both in New York and Massachusetts and probably, Rhode Island and all the states around there?

Heather: Well, you bring up a really good point, which is, you know,when you are in a practice that has locations in multiple states, and we can talk about telehealth a little bit later.

But if you are in a medical group that has practice sites, say in Connecticut, Massachusetts, and New York, licensed in all three states, and you work at sites in all three states, say you're an APP who likes to float and you make these commutes each day.

So, all three states may have significant differences in their Practice Acts or what you need to do in order to optimize your practice in that state. And that includes collaboration requirements.

So, some states have the ability for nurse practitioners to have autonomous practice, but there may be other steps where you may need a particular license, in order to be able to do that within that state.

So, again, being very aware of those steps that you need to take is really important.

Stephanie: So, Heather, you mentioned telehealth, which is a big topic through COVID. I don't really have to tell people how big a topic that is. So, what are the changes or what is going to happen with that now that we're “getting to the other end of COVID”?

Heather:  That's a big question mark, right? So, certainly, the advancement of telehealth was an important development during the pandemic. And many states have a separate set of laws, regulations that govern delivery of healthcare services through telehealth.

So, if your practice is utilizing telehealth to deliver medical services, it's necessary to be fluent in this information. So, this can include important information such as how a patient provider relationship is established. And, you know, it may also include information on prescribing practices, what may or may not be permitted or the conditions under which a prescription can be provided and so forth.

And so, some states relaxed telehealth-related rules under state of emergency declarations. And so, making sure that you are up-to-date on this as some of those rules have returned to the pre-pandemic state and some of those relaxations actually became permanent.

And of course, if you're billing for these services, knowing the payer requirements and then the policies and procedures you need to follow, in order to bill for those services.

And where the patient is physically located at the time that the service is being provided, is the state in which you need to be licensed in order to provide that service.

So, if Todd is performing a telehealth service for a patient in Oklahoma and he's not licensed in Oklahoma, he won't be able to see that patient.

Todd:  It's really strange because telehealth has brought a different layer of perspective around scope of practice and licensure that we hadn't really faced as much before, right?

So, for example, I've been a PA for 24 years. I have been able to call across state lines and interact with patients and talk to them on the phone, get updates on their surgery, if they're having, you know, a postoperative infection, get them an antibiotic and do that kind of work forever.

But as soon as you add that technology and that billing entity called a telehealth encounter or a virtual encounter, it becomes a different animal all of a sudden. And this really came to light during the pandemic.

And we quickly realized all of these things made it impossible. And that's why all the states did all of these emergency declarations saying, “Just forget it, just take care of people.”

But now that we're getting past that, we're kind of going backwards, not because anything bad happened, but because folks are saying, “Well, we want to go back to the older ways where, you know, every state could have differences in regulations and make folks pay those professional fees to get licensure.”

So, it'll be interesting to see how this space develops, particularly since our patients are becoming more consumers. Really, they want to talk to who they want to talk to, when they want to talk to them, and they want service here and now.

And I think we're going to have to continue to respond and adapt to that. And some places will lead and some places will lag. But those lagging places quickly are going to start having conversations within the state and our legislators will respond. I mean, politically, it will change over time. It just, you know, matters how quickly.

So, it's really an interesting thing to watch unfold in real time.

Stephanie: Heather, any final remarks, concerns, advice to those out there, both physicians and advanced practice providers, about how to handle questions about, my God, what is your scope of practice?

Heather:  I'm so glad you asked Stephanie because I have a list I might be able to pass them along. So, here we go.

Do take the time to review the state Practice Act information and laws and regulations and of course facility policy governing a practice where you are.

And as the license holder, you are responsible for knowing what you are permitted to do. Please do not make any assumptions about others' knowledge of this. Unfortunately, I've seen people get caught up in that and always own it, yourself.

Generally, recommend facility policy not be more restrictive than what is permitted under the Practice Act of the state. Fact check, challenge your assumptions, and if you haven't had the chance to already do so, do check out the ASCO Advanced Practice Provider Onboarding and Practice Guide for more resources.

Stephanie: Well, I'd like to thank Heather for her excellent insight into this very complicated topic.

Todd, as always, is always on top of everything. And sharing both your experiences and your ideas with us on APP scope of practice, which can vary quite drastically depending upon the state and also the type of institution you practice in.

Stay tuned for our next episode. Until next time, take care.

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