Tuesday, July 17, 2007

Assistants to be Elevated in PA Healthcare

On July 14, 2007, the Pennsylvania House & Senate both signed a package of five bills for transmission to Governor Rendell. The proposed laws would expand the roles of nurse practitioners, nurse clinicians, & physician assistants in rendering health care in the Commonwealth.

An Associated Press article dated July 13, 2007, under the caption "News from the Pennsylvania General Assembly" summarized these bills (which I identify with links). All these bills, in final forms, were signed by both the House & the Senate over the past weekend:

  • NURSE PRACTITIONERS [House Bill 1253, which, on July 20, 2007, became Act 48 of 2007]: A bill that would expand the scope of duties that could be performed by nurse practitioners passed the Senate unanimously. Under the bill, nurse practitioners would be able to: order medical equipment, home health and hospice care; make therapy and dietitian referrals; issue home bound schooling certifications; perform disability assessments for methadone treatment; and more. Such activities would be allowed only under agreement with a physician and if nurse practitioner has a specialty certification. The bill is an element of Gov. Ed Rendell's "Prescription for Pennsylvania" health care agenda. * * *
  • NURSE CLINICIANS: The Senate unanimously approved a bill that would create a definition for nurse clinicians and set state certification requirements. The bill also is an element of the "Prescription for Pennsylvania" health care agenda. * * *
  • PHYSICIANS' ASSISTANTS: The House sent to Rendell bills that allow doctors to supervise up to four physicians' assistants — up from two — and to let nurse midwives who have sufficient training prescribe specific drugs under certain circumstances. The "scope of practice" measures also are elements of the "Prescription for Pennsylvania" health care agenda. All three bills, which had been amended in the Senate, passed the House unanimously without debate. * * *
The Pennsylvania Medical Society was deeply involved in this package of legislation. In its online update entitled "Compromise Amendment on Patient Access Retains Physician Oversight", dated July 12, 2007, the Society noted:
The state House of Representatives unanimously approved five bills affecting patient access to allied health practitioners and retaining physician oversight through strong collaborative agreements.

The bills address restrictions on certified nurse practitioners (CRNPs), physician assistants (PAs), nurse midwives and clinical nurse specialists (CNSs).

Bills addressing pharmacists, certified registered nurse anesthetists (CRNAs), and dental hygienists are still in committee.

The five-bill package was approved by the Senate Consumer Protection and Professional Licensure Committee and by the Senate Appropriations Committee with only technical changes.

One substantive amendment, agreed to by all parties, was made to require a graduate level degree for nurse midwives who want to prescribe. * * *

For the history of the legislation and the negotiations, and details on the compromise amendments specific to each type of allied health practitioner, read:

Timeline: Patient Access Legislation

The Sturla amendments: Status of Patient Access Bills as of June 20

The amended bills are the result of days of intense negotiations late into the night between the Pennsylvania Medical Society, several nursing organizations, the Office of Health Care Reform, and leadership of the House committee.

Early in June, the Office of Health Care Reform (OHCR) asked the Medical Society to serve as primary negotiator for physicians in meetings arranged by the OHCR with CRNPs, CNSs, nurse midwives , and staff of the House Professional Licensure Committee, chaired by Rep. P. Michael Sturla (D-Lancaster). This group of bills included House Bills 1253, 1254, and 1255, addressing CRNPs, CNSs, and nurse midwives, respectively. * * *
Signature by the Governor on all bills described above is expected, based upon Governor Rendell's prior public comments. See: "Rendell dislikes 2 bills to reduce hospital infections", by Amy Worden, posted by the Philadelphia Inquirer on June 27, 2007.
Rendell applauded the passage of the bills (HB 1251, HB 1252, HB 1253, HB 1254 and HB 1255), saying, "These bills will make it easier for patients to seek appropriate care where and when they need it, and also help to reduce costs."
However, proposed upgrading of certain other allied health care professionals, as originally requested by Governor Rendell, did not occur.

These other medical assistants -- pharmacists (under HB 1250), nurse anesthetists (under HB 1256), & dental hygienists (under HB 1257) -- were
identified by the PA Medical Society in its online posting "House Democrats Propose Scope of Practice Legislative Package" as subject to other bills. All bills were set for separate public hearings in May, 2007. But these other bills remained in the Professional Licensure Committee of the House after initial referral.

For a broader view on Governor Rendell's "Prescription for Pennsylvania" proposal & an explanation as to why some elements -- such as those relating to assisted living and certain allied health care professionals -- were adopted, but others were not, see the editorial published in the Wall Street Journal on July 13, 2007, entitled "Wrong Prescription".

That confrontation [over Rendell's proposal for "universal health care" in Pennsylvania] plus a few others led to a budget standoff in Harrisburg, which ended earlier this week with a compromise -- though not without the political flourish of a government shutdown.

Mr. Rendell wanted to muscle through as much new spending as possible, but his most controversial proposals were kicked down to a legislative session sometime in the fall.

On health care, this isn't a defeat so much as a deferral. The Governor got a few consolation prizes and now says he's focusing on an "incremental" approach. Democrats nationwide seem to be opting for the same strategy, which hopes to avoid major political blowups while still achieving a systematic liberal overhaul piece by piece. * * *
The Wall Street Journal's "Health Blog" had mentioned similar points in a posting by Heather Won Tesoriero, dated July 10, 2007, entitled "Pennsylvania Health-Care Reform Plan Sparks Showdown":

“Everyone’s ox gets gored a little bit in this,” Rendell told the Times.

“If we’re ever going to have accessible health insurance for all Americans, we have to begin by containing costs. If costs continue to spiral out of control, there is no way the government can afford to pay for it.”

Rendell’s reform calls for a ban on public smoking, a reduction in the rate of hospitalization for chronic diseases and an expansion of the role nurses play in treating patients.

Hospitals, doctors and small businesses are pushing back. Hospitals are lobbying against his proposals to regulate spending on construction and new equipment and to cut off payments when patients stay longer because of medical mistakes and preventable infections. Physicians oppose his proposal to give more responsibility to physician assistants and nurse midwives. And small businesses bristle at Rendell’s proposed 3% payroll tax on employers who don’t offer insurance, with the proceeds dedicated to covering the uninsured. * * *

The referenced New York Times article, "A State Finds No Easy Fixes", dated July 10, 2007, offers a candid analysis as to Governor Rendell's prospects for success regarding his full "Prescription for Pennsylvania" proposal. It also offers useful links.

So passage of these five bills did not come easily; and other pending bills might be even more difficult to resolve in the fashion that the Governor originally proposed.

Updated: 07/21/07:

This package of bills were signed into law by Governor Rendell on Friday, July 20, 2007, in Philadelphia, PA, as Acts 46, 47, 48, 49, & 50 [as noted above, in brackets].

For further background, see: Press Release, dated July 20, 2007, entitled "First Pieces of Governor Rendell's 'Prescription for Pennsylvania' Signed into Law":
Governor Edward G. Rendell said Pennsylvania today took its first steps in making health care more accessible and eliminating deadly hospital-acquired infections when he officially signed the first pieces of his Prescription for Pennsylvania health care reform plan into law. * * *

Bills allowing certified registered nurse practitioners, certified nurse midwives and dental hygienists to practice to the full extent of their education and training, and a bill to more aggressively attack and eliminate hospital acquired infections were passed by the General Assembly. * * *

The Governor said now that two large components of Prescription for Pennsylvania have been passed and a third on the improved management of chronic diseases is underway by executive order, he is looking forward to working with the legislature to enact the final pieces of his reform plan. * * *