AAFP Sees Harms to Team-based Care in VA Interim Final Rule

“Our nation’s veterans deserve high-quality health care that is overseen by physicians,” the groups said in their Jan. 7 letter to the Department of Veterans Affairs. “The undersigned organizations strongly oppose the IFR and urge the VA to rescind the IFR and consider policy alternatives that prioritize physician-led, team-based care.”

The letter was addressed to VA Secretary Robert Wilkie, J.D., during his final days at the agency’s helm. Dat Tran has since has been named acting VA head, pending Senate confirmation of Denis McDonough, President Joe Biden’s nominee for the job.

Among the Academy’s co-signatories were the AMA, the American College of Physicians and 49 state medical societies.

The letter commented on an IFR titled “Authority of VA Professionals to Practice Health Care,” published Nov. 12 in the Federal Register. It permits virtually all VA-employed non-physician health care staff to practice without the clinical supervision of physicians, regardless of a state’s scope-of-practice law.

Care from nonphysician team members, the letter said, remains integral to patients’ well-being but “cannot substitute for physicians, especially when it comes to diagnosing complex medical conditions, developing comprehensive treatment plans, ensuring that procedures are properly performed and managing highly involved and complicated patient cases.”

“Nowhere is this more important than at the VA, which delivers multifaceted medical care to veterans, including those with traumatic brain injuries and other serious medical and mental health issues,” the groups added.

The Academy and numerous other medical organizations raised similar concerns last summer when the VA, responding to COVID-19, issued a directive allowing certified registered nurse anesthetists at VA medical facilities to practice without physician oversight during the national health emergency. That move, the groups said in a June 24 letter to Wilkie, “threatens the health and safety of veterans and their families.”

The AAFP and its co-signatories this time pointed to a number of reasons why the VA should rescind its November IFR.

The VA violated the Administrative Procedure Act when it issued the IFR without an adequate public comment period, the letter charged — resulting in a failure “to adequately consider the rights of the states, the training of its personnel and the long-term safety of our nations’ veterans.”

More important, the groups said, the rule does not adequately account for the “stark differences” in education and training that separate physicians from nonphysicians.

“No other health care professionals come close to the level of training required of physicians,” the letter said. “With more than 10,000 hours of clinical experience, physicians are uniquely qualified to lead health care teams. By contrast, nurse practitioners must complete only two to three years of graduate-level education and 500-720 hours of clinical training. Physician-assistant programs are two years in length and require 2,000 hours of clinical care.

“The VA removing scope-of-practice safeguards will allow for nonphysician providers that have not been adequately trained to perform procedures that are outside the scope of their licensure, ultimately leading to a lower standard of care for veterans.”

This is further complicated by the IFR’s circumventing of state licensing boards at a time when multiple Government Accountability Office audits have rated the VA’s oversight of medical professionals inadequate, the letter added.

“By implementing this IFR, the VA is making it difficult for state boards to oversee the practitioners that they license and will likely make it tougher to discipline NPPs that inadequately care for patients due to a lack of clarity about these practitioners’ scope of practice. Since it has been shown that the VA is unable to adequately oversee health care providers, it is vital to rescind the IFR and ensure that state licensing boards can adequately supervise their NPPs to ensure the highest quality of care for veterans.”