By Rich EhisenThere has long been friction in the relationship between doctors and other health care providers, with the former ferociously guarding their turf against incursion from the latter. But with the Affordable Care Act soon to bring 33 million new patients into the system, many states are pondering whether it is time to allow nurses, physician assistants, optometrists and even dentists to offer patients services they could previously only get from their primary care physician. According to State Net, as of March 25, 33 states this year have collectively introduced over 140 bills that address medical "scope of practice" issues - the standards that determine which medical providers can offer which services. Those regulations also determine how and what those providers are paid. The bulk of the bills deal with licensing and other issues surrounding advanced practice nursing, the use of physician assistants and the ability to write prescriptions. The push by nurses and other medical providers to be allowed to do more is not new. Many of these groups have been working to expand their professional boundaries for years. But that drive has ramped up significantly since the passage and subsequent U.S. Supreme Court validation of the Affordable Care Act. According to the National Conference of State Legislatures, between January, 2011 and December, 2012 states, U.S. territories and the District of Columbia have combined to introduce 1,795 "scope" bills, with 349 becoming law. Although NCSL does not have official data previous to 2011, NCSL Health Program Policy Associate Kara Hinkley says "there has been increased legislative interest in this issue, even from 2012 to 2013." That increase is due mainly to concern over how a medical system that many already see as over-burdened will accommodate tens of millions of newly-insured patients. According to the Association of American Medical Colleges, the nation's supply of primary care physicians was 9,000 less than demand in 2010. By 2020, that shortfall will grow to approximately 45,000; by 2025 it will reach 66,000. When estimates for specialists are considered, the total doctor shortage will climb to over 90,000 within the decade and to over 130,000 by 2025. That impact would likely be felt the most in low-income and rural areas, which often already have limited access to primary care doctors. Efforts are underway in many states to get more qualified doctors into the pipeline, with incentives both to get promising students to choose medical school as well as to get more doctors to choose primary care, particularly in underserved areas, for their practice. But getting someone from first year med school to full licensure and practice is at best a many-year process. It is also one that leaves virtually every new doctor with a mountain of loan debt, making more lucrative specialty fields far more enticing. To some, the answer is in measures like Nevada's SB 69, which would make the Silver State the 17th to allow nurse practitioners with advanced degrees the ability to work without the usual mandated doctor oversight. Under that proposal, nurses with a master's degree or higher could treat patients much as a primary care doctor would, including ordering and interpreting tests and prescribing medications. The measure is now in the Nevada Senate Health and Human Services Committee. Similar bills are pending in at least 10 others. Those proposals have drawn vigorous support from nurses groups like the American Association of Nurse Practitioners. "We have a ready-made, no-added-cost workforce in place that could be providing care at a much higher level if we modernize our state laws," AANP Director of Health Policy and State Issues Taynin Kopanos recently told the Washington Post. "The question for states is, are you going to fully deploy this resource or not?" California Senator Ed Hernandez (D) echoed those sentiments last month in introducing a trio of bills that would significantly broaden the scope of practice for Golden State nurse practitioners, optometrists and pharmacists. At a press conference, Hernandez said helping the uninsured obtain health coverage was only part of the ACA's promise. "We are working hard at the state level to ensure every Californian has access to affordable, quality health coverage, but what good is a health insurance card if you can't get into see a health care provider when you need one?" he said. "We need to make better use of the trained healthcare workforce we already have if we are ever going to meet demand," he said. But to Dr. Ruth Haskins, a licensed obstetrician and gynecologist practicing in Folsom, California, it isn't nearly as simple as that. She says midwives, nurse practitioners and physician assistants are already "essentially practicing medicine" and should be able to "maximize what they have been trained to do," particularly as patient rolls grow significantly in the coming years. Taking doctors out of the loop, however, would have unintended consequences. "Right now, when a problem develops or a patient's care becomes more complex, the paraprofessional has someone they can rely on," she says. "The patient always is ultimately in the hands of a doctor when things get scary. My hope is that whatever system we adopt that puts the maximum use of our paraprofessionals into action, there is always still a very well-trained physician who can handle those complexities when they arise." Hernandez's bills also drew sharp criticism from the California Medical Association. CMA spokesperson Molly Weedn said the measures are so broadly written they could endanger public health. SB 492, for instance, would allow optometrists to treat virtually any condition related to the eye, which theoretically could mean anything from Botox injections to surgery for migraines that affect vision. SB 493 would allow pharmacists to prescribe medications without consulting patients' doctors first, while SB 491 would allow nurse practitioners to set up an independent office without any collaborative relationship with a doctor and without making any distinction between the many types and specialties of nurse practitioners, i.e. surgical, pediatric, primary care etc. But Hernandez defended the measures, saying they are merely a starting point for what will surely be an active debate over the next few months. In a statement, Hernandez also noted the success similar efforts have had elsewhere, saying "There's no reason these licensed professionals can't perform additional services like they do in other states, which have reported no decline in patient safety whatsoever." Sentiment seems to be growing in that favor. The National Governors Association and the National Academy of Sciences' Institute of Medicine have both endorsed the concept of granting nurse practitioners more leeway to practice independently. And last year, Florida Gov. Rick Scott (R) signed legislation that allows Sunshine State pharmacists to administer shingles vaccinations. The Florida Medical Association vigorously objected to the proposal at first but eventually agreed after the measure was amended to require patients to first obtain a prescription from their doctor before getting the actual shot from a pharmacist. Donald Balasa, Executive Director of the Chicago-based American Association of Medical Assistants, sees the debate broadening even more in the future. As nurse practitioners and physician assistants obtain more responsibility, they also need to be able to delegate some tasks to medical assistants, the scope of which is also still in flux. He says the demands of the Affordable Care Act, however, will eventually likely push the envelope for all medical professionals. "With such an influx of patients, it doesn't seem realistic to not have nurse practitioners, physician assistants and medical assistants all working at the top of their license," he says. Or even beyond the top if some lawmakers get their way.
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