In establishing the existence of a medical impairment, Social Security Administration relies on objective medical evidence from an acceptable medical source (AMS). The current rules recognize licensed physicians, psychologists, optometrists, podiatrists, and speech language pathologists as AMSs. Specifically excluded from the AMS list are nurse practitioners, physician assistants, licensed clinical social workers, naturopaths, chiropractors, audiologists, and therapists, though their opinions may be used to evaluate the severity of an impairment. Such exclusions, however lump these medical sources alongside other non-medical sources such as family, neighbors, and employers.
In recently proposed revisions, Social Security Administration has recognized significant changes in the national healthcare workforce and the manner in which people now receive healthcare. The proposed revisions would seek to include audiologists and Advanced Practical Registered Nurses (including Certified Nurse Midwives, Nurse Practitioners, Certified Nurse Anesthetists, and Clinical Nurse Specialists) as AMSs, citing to increased percentages of healthcare services from these providers, as well as their extensive education, training, and certification requirements. The proposed rules also invite comments on whether to include physician assistants and licensed clinical social workers on the AMS list.
Like other mid-level practitioners, the number of certified physician assistants has increased in recent years, growing 35.9% from 2010 to 2015. The Bureau of Labor Statistics projects a “much faster than average” growth rate for the profession. State licensure requirements are rigorous for physician assistants, as they include graduation from an accredited program and passing a national certifying examination. Most programs award master’s degrees, and require healthcare experience for admission. In order to maintain their licensure, physician assistants must undertake continuing medical education and pass the national certifying exam every six years, contrasted with the one-time examination requirements of a medical board for physicians or a state bar examination for attorneys.
While physician assistants and nurse practitioners are not necessarily interchangeable due to differing training models, the quality of care they provide is indistinguishable in day-to-day practice. Therefore, it makes little sense to include one as an AMS and not the other.
Likewise, the number of licensed clinical social workers is growing at a “faster than normal” rate. Becoming a licensed clinical social worker requires a master’s degree in social work and a minimum of two years supervised clinical experience after graduation. Candidates must also pass a clinical examination to be licensed. Moreover, social workers spend a considerable amount of their time addressing pain management issues with patients. Frequent and extensive contact with patients should make licensed clinical social workers an invaluable source in evaluating their functional limitations.
As Social Security Administration considers adding greater weight to evidence from mid-level medical sources, it should also adopt physician assistants and licensed clinical social workers as AMSs, as these practitioners undergo extensive education, training, and certification, and continue to provide an increased percentage of services in the modern healthcare landscape.
20 CFR 404.1513(a) and 416.913(a)
81 Fed. Reg. 62,567 (Sep. 6, 2016)
81 Fed. Reg. 62,568 (Sep. 6, 2016)
81 Fed. Reg. 62,569 (Sep. 6, 2016)
National Commission on Certification of Physician Assistants at https://www.nccpa.net/Uploads/docs/2015StatisticalProfileofCertifiedPhysicianAssistants.pdf
Bureau of Labor Statistics at http://www.bls.gov/ooh/healthcare/physician-assistants.htm
National Commission on Certification of Physician Assistants at http://www.nccpa.net/BecomingCertified; see also American Academy of Physician Assistants at https://www.aapa.org/career/state-licensing-requirements/
Physician Assistant Education Association. PAEA program directory. http://directory.paeaonline.org.
Virginia Haas, Physician Assistants and Nurse Practitioners Are Not Interchangeable, 29 JAAPA 4, 9-12 (April 2016)
Bureau of Labor Statistics at http://www.bls.gov/ooh/community-and-social-service/social-workers.htm
Bureau of Labor Statistics at http://www.bls.gov/ooh/community-and-social-service/social-workers.htm#tab-4
Association of Social Work Boards at https://www.aswb.org/
Debra Parker Oliver, et. al., Social Work Role in Pain Management with Hospice Caregivers: A National Survey, 5 J. Soc. Work End Life Palliat Care, 1-2 (Jan 2009)