The following is adapted from a presentation given by Donald A. Balasa, JD, MBA, on September 12, 2005, at the 49th AAMA Annual Convention in Colorado Springs, Colo.

One of the three main purposes of the American Association of Medical Assistants (AAMA) is to “protect medical assistants’ right to practice.” Because of some major changes in the strategies to accomplish this purpose, I will be presenting a historical perspective on how the AAMA has sought, and is seeking, to protect the right to practice and to increase legal recognition of the Certified Medical Assistant® (CMA) credential. We will focus on the period of 1980 to the present. I am a firm believer in Santayana’s maxim that those who do not learn from the mistakes of history are doomed to repeat them, and I will proceed accordingly.

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1. The nomenclature of professional credentialing is confusing. Essentially, however, there are two categories of credentials—mandatory and voluntary. Credentialing mandated by law is usually called licensure (although there are prominent exceptions). A license may be defined as a mandatory credential that is required to practice a profession, or a part of a profession. A voluntary credential may be defined as a credential that is not required to practice a profession (or some aspects of a profession) legally. Certification is the term most often used to refer to voluntary credentialing (although there are prominent exceptions).

2. From approximately 1980 to 1985, there was a growing sentiment that the AAMA should pursue licensing of medical assistants. Licensure was thought to be the key to greater professional recognition and higher salaries.

3. The 1985 House of Delegates (Lexington, Kentucky) approved the following recommendation:

Therefore, the Ad Hoc Committee to Develop a Position Statement regarding licensure vs. certification recommends that AAMA advocate the credentialing of medical assistants through certification, with mandatory revalidation [recertification]. A record of Certified Medical Assistants maintained by AAMA should serve as the verification of certification status.

It is the conclusion of the members of the Ad Hoc Committee to Develop a Position Statement that AAMA should remain a professional association promoting voluntary certification of those working in physicians’ offices and other ambulatory health care facilities, as well as in hospitals and nursing homes. Certification offers status and definition to the practitioner; provides a means of establishing a national standard of care with regard to the legal duty of the medical assistant to the patient; offers the employer guidelines for hiring qualified staff, as well as a pool of applicants; provides an environment for continuing education to take place for medical assistants; and is cost effective. The Certifying Board can act as a registrar and maintain a registry.

4. Why did the 1985 Ad Hoc Committee reject licensure? Partly, because the mindset of state legislators at that time was that there should be no additional licensing unless it could be demonstrated empirically that the absence of licensure was posing a significant threat to the health and safety of the public. The Council of State Governments, a body that issued policy guidelines for states, urged the defeat of any licensure legislation unless the following two questions could be answered satisfactorily:

• In what way will the unregulated practice clearly endanger the health, safety, and welfare of the public, and is the potential for harm easily recognizable and not remote or dependent on tenuous argument?

• Can the public be effectively protected by means other than licensure, such as regulation of the delegating and overseeing professionals [in the case of medical assistants, primarily physicians]?

The Ad Hoc Committee realized that it would be very difficult to prove that: (a) the lack of licensure of medical assistants was harming the public; and (b) even if the public were being harmed, stricter regulation of the delegation practices of physicians would not be just as effective a means of removing the threat.

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5. After 1985, the policy and practice of the AAMA has been: (a) to interpret state statutes and regulations, and to advocate for enactment of legislation and rules, that protect any medical assistant’s (regardless of education or credentialing) right to be delegated a reasonable scope of procedures; and (b) to attempt to inform and persuade physicians and other hiring decision makers about the advantages of hiring CMAs as opposed to other medical assistants.

6. In fact, the AAMA has made (and continues to make) many concerted efforts to “market” the importance and value of CMAs to medical students, resident physicians, physicians, and other employers of medical assistants.

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7. The AAMA became an Official Observer to the American Medical Association (AMA) House of Delegates. The AMA has not been willing to urge its state medical societies to include the phrase “medical assistant” in the state medical practice acts and/or the regulations of the state boards of medical examiners.

8. The Federation of State Medical Boards was approached by the AAMA, and was not in favor of including the terms “medical assistant” or “Certified Medical Assistant® (CMA)” in its model legislation and regulations, or of suggesting the inclusion of such language by the boards of medical examiners of the 50 states and of the other American jurisdictions.

9. The AAMA asked the American Academy of Physician Assistants (AAPA) to be an ally in the pursuit of legal recognition. The AAPA has been helpful to the AAMA in many ways, but has not been willing to offer major support with these legal recognition efforts.

10. Beginning in the mid-1990s, efforts were initiated to amend laws and policies so that there would be a differentiation between CMAs and other medical assistants.

• The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was not willing to establish credentialing standards for its category of “unlicensed auxiliary personnel.”

• When malpractice insurance carriers were warned about the increased legal exposure from delegation to uncredentialed medical assistants, they either sought to restrict certain procedures to registered nurses (RNs) and licensed practical/vocational nurses (LP/VNs), or were willing to accept any medical assisting credential as acceptable proof of competency.

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11. In approximately 1999, AAMA policy and procedure shifted toward attempting to persuade state boards of medical examiners and state medical societies to establish—by regulation or legislation—a limited permit in injections for medical assistants. The AAMA’s position was that only CMAs who had graduated from an accredited program should be allowed to be delegated the administration of medication by injections.

12. This strategy has not been successful because: (a) state boards of medical examiners and state medical societies have been pursuing other priorities, and generally have not wanted to devote government affairs resources to such limited permit initiatives; (b) in a few states, the medical boards and medical societies have had less political clout (in this policy domain) than state boards of nursing and state nursing organizations; and (c) limited permit laws that were enacted were not understood by many employers and/or were not enforced to a sufficient extent by the boards of medicine.

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13. In the beginning years of the twenty-first century, a greater emphasis has been placed on exploring federal and national coalitions, such as the Alliance for Quality Medical Imaging and Radiation Therapy (Alliance) and the Coalition for Phlebotomy Personnel Standards (Coalition).

• The Alliance is advocating for passage of the Consumer Assurance of Radiologic Excellence (CARE) bill in Congress. This bill would establish mandatory credentialing and educational requirements for radiologic technologists and other imaging professionals, and would impact those medical assistants who are permitted to do limited scope radiography.

• The Coalition is lobbying for state laws that would establish mandatory testing and educational requirements for all health personnel doing phlebotomy.

14. As of 2003, the AAMA is shifting its public policy focus to approaching state boards of nursing and departments of public health in pursuit of regulations (and, less frequently, legislation) that would allow only CMAs (and, in some cases, American Medical Technologists [AMT] Registered Medical Assistants [RMAs]) to be delegated injections. The AAMA is also recommending that such medical assistants be graduates of a medical assisting program accredited by either the Commission on Accreditation of Allied Health Education Programs (CAAHEP) or the Accrediting Bureau of Health Education Schools (ABHES).

15. In the last eight months, the AAMA has started working closely with the National Council of State Boards of Nursing (NCSBN) on these matters. The NCSBN has been very cooperative, and has already changed its model documents to lessen the confusion between Certified Medical Assistants (CMAs) and medication assistants-certified (MA-C).

16. For most states at this time, the most effective strategy for gaining legal recognition of Certified Medical Assistants appears to be the one that led to North Dakota CMAs regaining the right to be delegated injections. (See CMA Today, Sep/Oct 2005, “North Dakota CMAs Regain Injections.”)

As the American Association of Medical Assistants approaches its 50th Annual Convention, there are increasingly positive signs that the new strategies are working. The wording in a Utah bill was changed from “certified medication assistant” to “medication assistant-certified” after this author informed the sponsor of the change in the NCSBN’s model legislation. In addition, the NCSBN has asked the AAMA to provide input to its task force on medication assistants.

Comments regarding this shift in legal strategy are welcome and may be sent to Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or by calling 800/228-2262.

Questions? Contact Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or 800/228-2262.