Push for midlevel role in veterinary medicine expands

Proposals in Colorado, Florida test appetite for change

Published: February 28, 2024

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Illustration courtesy of Clark & Enersen/Colorado State University
If all goes according to plan, students in the inaugural Master of Veterinary Clinical Care program at Colorado State University College of Veterinary and Biomedical Sciences will attend fourth quarter classes in the upgraded and expanded Veterinary Health and Education Complex (above) in 2026. Meanwhile, Colorado voters may be asked in November to decide if the state will create a new midlevel position in veterinary medicine for some of those graduates.

Colorado and Florida have emerged as battlefronts in the drive to create a veterinary midlevel practitioner role, a position comparable to that of a nurse practitioner or physician assistant in human medicine.

Advocates for change introduced a bill in Florida last month that would create a registered veterinary professional associate (VPA) position. It passed in the House with a unanimous vote today. Other supporters filed a ballot initiative in Colorado to create a state credential for VPAs.

The VPA, as defined in both measures, would have a scope of practice that includes duties and tasks once restricted to veterinarians, such as diagnosing conditions, providing prognoses and surgically neutering patients through spaying and castration.

The bill and ballot initiative are part of a coordinated effort by animal welfare groups that also are backing moves in both states to relax in-person exam requirements for veterinary telemedicine providers.

"The reason they're married to each other is because they together will allow veterinarians to provide a broader spectrum of care to their clientele and even attract new patients who may otherwise never have gone to a veterinarian," said Kevin O'Neill, vice president of state affairs for the American Society for the Prevention of Cruelty to Animals, a leading promoter of all four measures.

Dr. Apryl Steele, chief executive of the Dumb Friends League, which runs multiple shelters and a hospital that provides subsidized veterinary care in Colorado, sees the need for VPAs as urgent.

In brief

"I truly believe there is a severe veterinary workforce shortage, both of veterinarians and veterinary technicians," she said. "From an animal welfare point of view, sick and injured animals are going without care and will continue to go without care if we don't do something about it."

Creating a midlevel position faces stout opposition from the American Veterinary Medical Association and several state VMAs, including Colorado's.

The AVMA has stated that future projections of workforce needs are based on inaccurate data that "are being used to drive proposed long-term changes — like the [midlevel position] — that will negatively reverberate across the profession … and pose threats to animal health and welfare, food safety, and public health." 

The AVMA noted in an email to the VIN News Service that based on the unprecedented expansion of class sizes at existing veterinary colleges along with three new schools graduating students for the first time in 2023, 2024 and 2025, respectively, "there will be an adequate number of general practice veterinarians in the near future."

Meanwhile, the AVMA said, the more immediate focus should be "on wellbeing and staff retention, improving the productivity of veterinary teams and enabling veterinary technicians to use the full extent of their training and experience on the job."

Another established professional group, the National Association of Veterinary Technicians in America, has been lukewarm on the midlevel position. A survey of its members in 2022 found that credentialed veterinary technicians "have interest in the 'mid-level practitioner' concept but as a goal or long-term project to be accomplished over time, not as an issue that needs to be addressed right now."

Technicians more urgently want to see improvements in pay, title protection and being allowed to work to the full extent of their license and training.

Florida's Veterinary Workforce Innovation Act, as it is called, now moves to the Senate.

In Colorado, supporters of the ballot measure, known as Initiative 145, will need to collect valid signatures of more than 124,000 registered voters to qualify the initiative for the November ballot.

Comparing the measures

While the roles proposed in Colorado and Florida are new, Arkansas last year established a somewhat similar position: It created the first-ever state certification for a veterinary technician specialist. It builds on an existing national veterinary technician specialist certification program.

In Arkansas, a VTS has the authority — if working in collaboration with a veterinarian — to diagnose, develop treatment plans and establish, on a preliminary basis, a veterinarian-client-patient relationship (VCPR).

As of yesterday, no VTSs have yet been certified in the state.

The measures in Colorado and Florida would not, however, expand the veterinary technician role. Rather, they would create a new position.

Both measures say the VPA may perform duties and actions — including diagnosis and prognosis, which have long been the exclusive domain of veterinarians — under certain circumstances. First, the tasks must be within the scope of the VPA's experience and advanced education. VPAs would be required to have a Master of Veterinary Clinical Care.

Currently, only Lincoln Memorial University College of Veterinary Medicine in Tennessee offers such a degree. Colorado State University College of Veterinary and Biomedical Sciences is on track to start a second such program next year.

Unlike veterinary schools and technician training programs, a process or organization for assessing the quality of the education in these programs does not yet exist.

In addition, a VPA's tasks must be assigned by and under the supervision of a licensed veterinarian.

The Colorado initiative does not specifically prohibit any particular practice of veterinary medicine. ASPCA's O'Neill said the measure puts veterinarians in control of what their VPAs can do, and that's as it should be.

The Florida bill, however, has some guardrails. It specifically prohibits VPAs from prescribing or administering prescription drugs and certain controlled substances and from performing surgeries, except for spaying and castrations on cats and dogs, and dental operations.

The measures also differ in the degree of supervision required.

Florida's Veterinary Workforce Innovation Act uses the term "responsible supervision," which gives veterinarians latitude in how they supervise VPAs, according to O'Neill.

" 'Responsible' could mean that the veterinarian might not be actually in the office," he explained. "It would be up to the veterinarian to decide whether or not their practitioner has the skills … to perform a specific procedure or whatnot without the veterinarian actually in the office."

Colorado's proposed initiative requires that the veterinarian be readily available on the premises where the patient is being treated by the VPA.

Florida's bill does not create a state registration or license for the VPA. There would be no credentialing body, exam or title protection. Florida is one of a handful of states that also does not provide a state license or registration for veterinary technicians.

Educating potential VPAs

In contrast, Colorado's measure calls for approving a nationally recognized VPA credentialing organization that may make rules for credentialing, including an exam requirement.

If the initiative becomes law, it would be a misdemeanor in the state to practice as a VPA without an active registration.

New strategy in Colorado

Steele in Colorado said the Dumb Friends League's subsidized hospital is perennially overwhelmed and must turn patients away due to a lack of staff, which she described as "heartbreaking." Forty percent of veterinarian positions and several technician positions are funded but not filled, she said.

She says the AVMA has contributed to the problem, saying the organization is creating an access crunch by denying shortages, and describing the fight against the VPA proposal as "protectionism."

"Protectionism is going to be our downfall," she said, "because veterinarians are so burned out. They're leaving the field. They're committing suicide. We tell them, which is the AVMA message, that you just need to be more efficient. It's not a way to help them do better. It's not a way for us to see more patients. It's not a way for them to have a sustainable, thriving career."

Steele helmed an effort last year to introduce a multi-pronged measure in the Legislature. That bill would have established state credentials for VPAs and VTSs and relaxed requirements for an in-person exam to establish a VCPR.

Simultaneously, Rep. Karen McCormick, the only veterinarian in the Colorado General Assembly and chair of the House agriculture committee, proposed two countermeasures. One bill would have codified in statute Board of Veterinary Medicine rules requiring an in-person exam to establish a VCPR, and the other would have created a commission to study veterinary workforce issues.

By all accounts, McCormick and Steele were asked to forge a compromise. When they could not, the Speaker of the House would not allow any of their bills to be introduced.

"The Speaker was not going to introduce two competing bills by two different members of the Democratic caucus without an agreement on which parts of each bill would move forward in a consensus bill," McCormick said. "This actually happens quite often."

Steele described the Speaker's decision as "unheard of."

McCormick said she first heard rumblings about a midlevel position in 2021 during a review of the state's practice act. At the time, advocates for the midlevel position lobbied to have the new role added.

The lawmaker said she received the idea with an open mind and held 13 Zoom meetings in the summer of 2022 with a variety of experts to better understand the situation.

"I learned about … the many obstacles, barriers and concerns regarding a VPA that had not been considered if we were to create this brand new professional in the midlevel space," she said. "It also became clear that the 'why' behind this idea did not hold up to scrutiny when we began to see that the VTS is truly capable of doing just about every single thing that they were proposing the VPA would do."

Frustrated by the experience of being locked out of the Legislature, the Vet Care Coalition, a collaborative of veterinarians, veterinary technicians, animal welfare advocates and pet owners — with support from the Dumb Friends League and the ASPCA — changed tack by moving to put the VPA to a public vote.

If the ballot initiative goes all the way, lawmakers would have no input.

"The preference is always, as a legislator, to be able to have a say, and the ballot process basically provides an avenue where that conversation doesn't happen the same way," O'Neill said.

Leaving the door open to the possibility of a new bill, he added: "I think Colorado legislators probably need to consider: 'Would we rather have a conversation about this within the Legislature and have some control over it, or allow a ballot initiative to go forward and not engage in these conversations?' "

McCormick, who has never heard of a veterinary issue being put to a public vote, said already there have been years of conversations. "During negotiations last year the threat to bring a ballot initiative was brought to me in an effort to convince those of us fighting for animal health and welfare to give in," she said. "I take my oath to animal health and public safety too seriously for that."

She said the ballot initiative will be a David-and-Goliath fight. "Big money is going to come into our state and get behind these ballot initiatives," she said, referring to what she believes is the primary force behind creating a VPA — money. She believes large corporate groups want to lower costs by creating veterinary care teams with fewer veterinarians in favor of lower-paid VPAs.

Even if the initiative passes, she said, that is not the end of the line.

McCormick is referring to the fact that since the ballot initiative asks for changes in Colorado statutes, if it succeeds, the Legislature will be called on to craft the language in a bill to actually change the law. "The thoughtful deliberative process could still be involved at that stage," she said.

Meanwhile, McCormick already has moved two veterinary bills through the House and Senate this year: HB24-1047 defines a scope of practice for veterinary technicians and veterinary technician specialists, and HB24-1048 is a telemedicine bill that among other things states that an in-person exam is required to establish a VCPR.

Veterinarians express reticence

In December, VIN News published an article examining the history and legacy of nurse practitioners and physician assistants in light of the push to reshape veterinary teams along similar lines. Nearly all 30 veterinarian readers who responded to the story on a message board of the Veterinary Information Network, an online community for the profession and parent of VIN News, expressed opposition to the idea.

Like McCormick, many said creating a midlevel role was a push by corporate-owned practices looking to decrease costs and increase profits at the expense of veterinarians, patients, clients and staff. They said adding a new position wouldn't fix current veterinarian shortages and might exacerbate problems by drawing skilled, experienced technicians away from those jobs. Others said the priority instead should be improving conditions and opportunities for veterinary technicians.

Dr. Jose Pla, who co-owns four small animal practices, stood out as a lone voice advocating for the change. He said opposition to midlevel practitioners is based on the false premise that veterinarians should provide the best care or nothing at all.

He said many pets are not obtaining any veterinary care or getting the full care recommended by their veterinarians — and the only way to reverse these trends is with lower-cost, more easily accessed care.

"Increasing the number of veterinarians will not make a substantial impact because cost is a greater limiting factor than availability of appointments," Pla wrote. "For most of us, we simply don't take into account the number of pets that never get veterinary care. We don't see them, therefore, they don't affect our daily work lives.

"I would argue that we would improve the quality of life of millions of pets if we placed most components of wellness care in the hands of paraprofessionals under the supervision of veterinarians."

Dr. Joe Waldman, a practitioner in Alberta, Canada, challenged the idea that creating a lower tier of medicine would close the care gap.

"I've worked in communities where primary vaccines and spay/neuter were subsidized for people of low income and while they are useful for a small [number] of patients and pet owners, they do not correct the problems of deficient veterinary care," he wrote.

"The reason that some people do not seek out veterinary care is more complicated than cost. Unless there is good evidence that a midlevel practitioner will improve total levels of care, it should not be blindly accepted without [an] understanding of what the possible risks might be."

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