Letter to Department of Veterans Affairs Regarding Scope of Practice Policy

Dear Secretary Wilkie:

The undersigned medical associations and medical specialty societies are writing to register 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 underlying Directive 1899 (Directive). The undersigned organizations urge the Secretary to amend Directive 1899 as it relates to allowing non-physician healthcare professionals in 32 specialties to operate “within the full scope of their license, registration, or certification” and rescind the Memorandum as it relates to encouraging all VA medical facilities to allow CRNAs to practice without physician oversight during the national health emergency.

The undersigned organizations are very concerned Directive 1899 preempts state scope of practice laws. Directive 1899 memorializes U.S. Department of Veterans Affairs (VA) policy allowing VA health care professionals to practice across state lines and establishes new policy allowing VA health care professionals to operate within the full scope of their license, registration, or certification. This combination in effect circumvents state scope of practice laws for the 32 health care professionals defined in the directive. Such a far-reaching expansion is overly broad, unnecessary and threatens the health and safety of patients within the VA system. As state scope of practice laws vary across these professions and across states, we urge the Secretary to amend the directive to defer to state scope of practice laws, similar to the language related to psychologists in Appendix B of the Directive.

The undersigned organizations also encourage the Secretary to rescind the Memorandum as it relates to encouraging all VA medical facilities to allow CRNAs to practice without physician oversight during the national health emergency. Throughout the coronavirus pandemic physicians, nurses, and the entire health care community have been working side-by-side caring for patients and saving lives. The AMA supports these temporary emergency efforts that allow physicians to practice across state lines to quickly expand the physician workforce in areas of need. Our success as a nation in flattening the curve of this pandemic is due in no small part to this shared focus and shared responsibility. Now more than ever, we need health care professionals working together as part of physician-led health care teams--not in silos. Therefore, it is deeply troubling, that the VA is directing all VA medical facilities to amend their by-laws to allow CRNAs to practice without physician oversight.

Like most healthcare systems, the pandemic has forced the VA to reassess how it uses human resources. Non-essential surgeries have been cancelled during the pandemic, giving the VA flexibility to deploy physicians and other healthcare professionals where the need is greatest. As such, there are more than enough physicians to provide care and oversight during this time. Thus, removing physician oversight requirements of CRNAs at the VA is overly broad, inconsistent with the situation as it is unfolding outside of the VA, and unnecessary to address the immediate needs raised during the COVID-19 pandemic. This action by the VA will only serve to disrupt continuity of care and cause confusion among health care teams and their patients.

It was this knowledge that prompted West Virginia Governor James C. Justice, II to promptly issue Executive Order No. 12-20, on March 26, 2020, reinstating physician supervision of CRNAs during the public health emergency.1 As such, it is unclear why the VA has deemed the expansion at issue as necessary. Such measures are not necessary to improve patient access to care and take away from a higher quality team-based approach. More importantly, a lack of proper oversight threatens the health and safety of veterans and their families.

For all the reasons outlined above, the undersigned organizations strongly urge you to amend Directive 1899 and rescind the Memorandum. Such broad expansions of scope of practice deserve thoughtful discourse where all sides are allowed to be heard and all available evidence is considered. Thank you in advance for your attention to this important matter.

Sincerely,

American Medical Association
AMDA - The Society for Post-Acute and Long-Term Care Medicine
American Academy of Allergy, Asthma & Immunology
American Academy of Dermatology Association
American Academy of Emergency Medicine
American Academy of Family Physicians
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Physical Medicine and Rehabilitation
American Association for Hand Surgery
American Association of Hip and Knee Surgeons
American Association of Neurological Surgeons
American Association of Orthopaedic Surgeons
American College of Emergency Physicians
American College of Medical Genetics and Genomics
American College of Osteopathic Surgeons
American College of Physicians
American College of Radiology
American College of Surgeons
American Medical Women’s Association
American Orthopaedic Foot & Ankle Society
American Osteopathic Association
American Psychiatric Association
American Rhinologic Society
American Society for Clinical Pathology
American Society for Dermatologic Surgery Association
American Society for Gastrointestinal Endoscopy
American Society for Laser Medicine and Surgery
American Society of Anesthesiologists
American Society of Cataract & Refractive Surgery
American Society of Echocardiography
American Society of General Surgeons
American Society of Plastic Surgeons
American Urological Association
Association of Academic Physiatrists
Association of University Radiologists
College of American Pathologists
Congress of Neurological Surgeons
International Society for the Advancement Spine Surgery
National Association of Medical Examiners
Society for Cardiovascular Angiography and Interventions
Society of Interventional Radiology
Spine Intervention Society

Medical Association of the State of Alabama
Arizona Medical Association
Arkansas Medical Society
California Medical Association
Colorado Medical Society
Connecticut State Medical Society
Medical Society of Delaware
Medical Society of the District of Columbia
Florida Medical Association Inc
Medical Association of Georgia
Hawaii Medical Association
Idaho Medical Association
Illinois State Medical Society
Indiana State Medical Association
Iowa Medical Society
Kentucky Medical Association
Louisiana State Medical Society
Maine Medical Association
MedChi, The Maryland State Medical Society
Massachusetts Medical Society
Michigan State Medical Society
Minnesota Medical Association
Mississippi State Medical Association
Missouri State Medical Association
Montana Medical Association
Nebraska Medical Association
Nevada State Medical Association
New Hampshire Medical Society
Medical Society of New Jersey
New Mexico Medical Society
Medical Society of the State of New York
North Dakota Medical Association
Ohio State Medical Association
Oklahoma State Medical Association
Pennsylvania Medical Society
Rhode Island Medical Society
South Carolina Medical Association
South Dakota State Medical Association
Tennessee Medical Association
Texas Medical Association
Utah Medical Association
Vermont Medical Society
Medical Society of Virginia
Washington State Medical Association
Wisconsin Medical Society
Wyoming Medical Society

(This letter was also sent to Richard Stone, MD, Executive in Charge, Veterans Health Administration of the U.S. Department of Veterans Affairs.)