With a “tsunami” coming, don’t educate, legislate!

  • Zakowski, Mark, MD
| Apr 07, 2013

The themes discussed at the California Medical Association Council on Legislation (CMA COL) should be a call to arms for many physicians. The CMA COL reviews current and anticipated legislation that affects physicians and patient care, formulating policy recommendations to the CMA Board of Trustees. As our Representative from the CSA, I attended CMA COL on March 21 of this year. Other CSA members included Paul Yost, MD, as an Orange County Medical Association representative, Thelma Korpman MD, as chair of CALPAC, and Rebecca Patchin MD, for CMA District II. Notable speakers included Senator Jerry Hill speaking about his SB598 Biosimilars and Senator Mark DeSaulnier discussing his SB809 controlled substances reporting.

The Tsunami Effect.

When Obamacare (PPACA) is implemented in 2014, there will be an estimated 4 million newly insured people in California. Sacramento legislators are concerned about access to health care for the newly insured. Legislators, hospitals, physicians, nurses and groups of all kinds and sizes are trying to figure out whether the breakfront will give way under the assumed/expected surge of new patients entering our doors. Thus, many mid-level health care providers have already gone to Sacramento asking for scope of practice expansion, with the justification that they will be needed to help take care of the tsunami of new patients arriving next year.

Don’t Educate, Legislate!

The Institute of Medicine report on nursing is often quoted as the new paradigm of letting nurses (and others) “practice to the full extent of their education and training.” A number of bills related to scope of practice, including “spot bills,” have recently been introduced. A spot bill functions to move along through the legislative process, without having final language.

SB491 redefines “optometrist” as “optometric physician,” who may treat any disease with ocular manifestations [e.g. hypertension, diabetes, AIDS]. SB494 allows physician assistants to have expanded scope. SB493 allows advanced practice pharmacists to perform physical assessments, order and interpret tests, and refer patients. SB491 will remove physician supervision of nurse practitioners.

Surely, the house of medicine needs to work together to find ways of taking care of greater number of patients. Mostly likely, physicians will need to work with mid-level health care providers to do so – but as physician extenders, not replacements. A physician’s years of study, training and experience translate into a unique and higher level understanding of diseases, complex medical problems, and interactions across the spectrum of organs, processes and medications. As such, mid-level providers should be under the direction of physicians: skipping the requisite 8 years of education and training will produce mediocre results and put patient safety at risk. Why have a pilot and co-pilot on large aircraft? Safety! Would you ask the navigator to fly the plane?

Real concerns.

Many real patient safety concerns are being addressed this year in Sacramento. The mal-distribution of health care providers – physicians, as well as mid-level providers, occurs more frequently in poor, rural areas compared to wealthier, urban settings. Prescription overdoses have continued to be in the news, with deaths on the rise. SB809 looks to fund the Controlled Substance Utilization Review and Evaluation System (CURES) database so physician and patient prescribing/consuming information can be centralized and outliers identified. The federal expansion of Medicaid (Medi-Cal) will allow those with higher incomes to qualify for coverage, with the federal government first covering all, and then later covering most, of the costs. However, California Medi-Cal payment rates are among the lowest in the country. With the current 7.1 million covered by Medi-Cal and an additional 2.5 million Californians expected to be covered by Healthy Family and ACA expansions, that means ¼ of Californians will soon be covered with a low-reimbursement insurance. This may become a real concern to providing quality care.

On the more positive side, CMA sponsored legislation to help address health care issues in California. SB21/AB27 will increase funding for UC Riverside medical school. SB488 will supplement GME funding in California. SB640/AB900 will restore the 10% Medi-Cal provider rate reductions contained in the 2011-2012 state budget. AB1003 will clarify corporate employment of physical therapists.

What YOU can do.

What can you do? Actively participate in your society. Join CMA if you haven’t already. Contribute to GASPAC and CALPAC. Best of all (and free!) – go talk to your representatives in the California legislature or visit your representative in their local office in your hometown.

CMA/CSA Legislative Day is April 16, in Sacramento. If you are interested in attending on behalf of the CSA, please contact Julie Kahlfeldt at jkahlfeldt@csahq.org or call 650-345-3020 for more information.

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