Nurse practitioner bill, SB 491 (Hernandez), is down but not out

In part because of its own hypocrisy, the nurse practitioner bill has for the present taken an inglorious swan dive. Nonetheless, we believe it'll come to the surface again. But first, let's get to the juicy hypocrisy.

 

Political readers on healthcare will no doubt recall the nurses' efforts this summer to stop schools from allowing teachers and parents to administer insulin injections to diabetic students. The argument the nurses used was that teachers and parents weren't educated and trained to recognize when insulin injections should be given, what harm might occur were such injections not timely given or withheld, and what adverse side-effects might be expected, let alone treated.  It was a "safety" issue, nothing to do with job preservation.

Physicians identified with these arguments because these arguments were the same that the physicians' lobbies were using to fend off passage of SB 491 (Hernandez).  That the nurse practitioner lobby let itself use these arguments on one hand while arguing against them on the other hand turned out to be the very essence of poor political timing. We doubt they'll repeat the mistake when the bill resurfaces which, in due course, we think it will. So the word we issue to the CMA and its allies is CAVE CANEM (beware of the dog, the sign that was found in the Roman rubble of an ancient eruption of Mt. Vesuvius).

 

In essence, relying on the idea that Obamacare will cause a shortage of physicians, emboldened by Senator Hernandez' willingness to take on the traditional physicians' organizations, the nurse practitioners (NPs) sought the right to practice at levels beyond their education and training and to do so without physician supervision. One argument the NPs used was the shortage of sophisticated medical care in rural  areas. What they didn't say was that the NPs would actually populate these areas and stay there. They  didn't promise to accept lower pay, either. In fact, why  should they?  If the NPs are licensed to practice medicine as physicians, shouldn't they then be entitled to equivalent remuneration? That, we say, would be the logical next step for the nursing lobby. But first it was necessary to get SB 491 passed and signed into law. That is why it's inevitable that the NPs will try again sooner or later.

 

The California Medical Association (CMA) successfully argued that quality and safety in medical care was dependent upon proper education and training. Physicians well know that it's hard enough  to make diagnoses and render treatment even with 12 to 15 years of college, medical school, and advanced internship and residency training.

 

The Union of American Physicians and Dentists (UAPD) weighed in heavily on the side of the CMA. The UAPD  and the CMA acknowledged the importance of nurse practitioners but stopped short of allowing their level of education and training to be legislated as equivalent to physicians' level of education and training. Both organizations argued that the right way to fix anticipated physician shortage problems would be to expand post-graduate residency training positions for newly minted physicians and to expand the number of medical schools. The key  is to provide "properly trained individuals," not simply to invoke a "quick fix" by giving higher priority to the number of licensed professionals as opposed to the quality of the education and training of those professionals.   

 

Other organizations that helped to  oppose SB 491 included the California Neurology Society (CNS), California Academy of Family Physicians, Diabetes Coalition of California, California Society of Anesthesiologists, Blind Children's Center, California Academy of Eye Physicians and Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, Latino Physicians of California, Chinese Medical Dental Association, Let's Face it Together, Minority Health Institute, Dream Machine Foundation, Canvasback Missions, Lighthouse Mission, Time for Change Foundation, Here 4 Them, Osteopathic Physicians and Surgeons, etc (if we've left out your organization, just let us know).

 

References

 

See our blog of 6 August 2013 and references

 

The Daily Journal, San Mateo County, "A Slipper (sic) Slope Indeed," Robert L. Weinmann, MD, 8/13/13

Sacramento Bee, "Expanding role of nurses a recipe for malpractice lawsuits," Robert L. Weinmann, MD, 4/24/13 

 

 

SB 491 (Hernandez) Gets Stopped  in  Assembly Committee on Business Professions and Consumer Protection

A united coalition including the California Medical Association (CMA), the Union of American Physicians and Dentists (Local 206 of the American Federation of State, County, and Municipal Employees, AFL-CIO),  the California Society of Physical Medicine and Surgery (CSPM&R),  the California Neurology Society (CNS), and several others helped to convince the committee that allowing healthcare professionals, no matter how well intentioned, to practice beyond their levels of education and training was unwise and a recipe for disaster. Accordingly,  SB 491 failed today to clear the Assembly Committee on Business Professions and Consumer Protection. The name of the game was consumer protection.

In one of our previous blogs we pointed out that nurses and/or nurse practitioners (NPs), once enfranchised to practice medicine without physician supervision, already well disciplined and organized into a proper union would be well poised to negotiate for equal pay. It was not expected that the newly enfranchised nurses would rush to the hinterlands of California where medical back-up in the form of well trained physicians and surgeons would be lacking or that the nurses would rush to places where resources and money were scarce.

One should not expect the nurses to quit this quest. A new campaign should be expected as soon as the old wounds have healed and their  regenerative powers have been regained.

References and a footnote

"SB 491 (Hernandez) clears committee," www.politicsofhealthcare.com, 5/17/13

"If the work is equal, shouldn't the pay be equal?" www.politicsofhealthcare.com, 4/26/13

"No, no, no on SB 491, 492,  493," www.politicsofhealthcare.com, 4/18/13

Footnote: notice that in this instance an AFL-CIO union was on the same side as the CMA  and other traditional physician organizations -- editor.



 

"Equal Work with Unequal Pay" Revisited

In a recent communique sent privately, I was asked about the meaning of  "equal work with unequal pay" from an earlier blog about pending legislation in California re SB 491, 492, and 493 where nurse practitioners, optometrists, and pharmacists would be equated with physicians. The writer asks "in what sense is the work of a nurse practitioner ever quite the same as the work of a board-certified neurologist?" The writer said "I personally would not be willing to pay a nurse practitioner as much as I would cheerfully pay my neurologist. How about you?"

I agree with the challenger that nurse practitioner education and training is not comparable to the training of a physician, much less  to a physician who  has also done additional specialty training. I agree with the writer.  I would not expect to pay the same for the lesser trained practitioner.

But since that wasn't the point of my editorial I'll take another whack at it. My point is that if SB 491 et al pass in California, the decision as to who gets paid and at what rate will pass into new and untested hands. Unless the nurses' union is asleep at the switch, once SB 491 passes, it can be expected that the nurses' union will lobby to make sure that the newly minted nurse-physicians get paid the same as graduate physicians. The argument will be a legal one, namely, that the legislature, having designated nurses as equivlalent to physicians, is now obligated to see that they get equivalent pay.

In this case I asked my challenger to explain why a certain physicians and surgeons organization wasn't lobbying against SB 491. I was told that the group was "focused on other things." My response is that if the Hernandez series,  SB 491, 492, and 493 get signed into law it won't be long before there are no "other things" on which to focus.

Physicians' groups should oppose SB 491 et al in the interest of making sure that optimal medical care remains the goal, not watered down versions thereof.  So far we know that the California Medical Association, the Union of American Physicians and Dentists, and the California Neurology Society have taken up the campaign and so have many individual physicians.

SB 494 REDUCES PHYSICIANS' ABILITY TO PROVIDE OPTIMAL CARE AND COUNSELING

LEGISLATION ALERT

SB 494 DILUTES ACCESS TO QUALITY  HEALTH CARE

SB 494 was introduced by Senator Monning and enjoys having Senator Ed Hernandez as the principal co-author. Their bill was heard in Sacramento this morning.

SB 494 would increase the number of health plan enrollees or insureds to primary care physicians. The original bill was introduced on 2/21/13 and was amended on 4/03/13 to allow "the assignment of up to 2,000 enrollees or insureds to each full-time equivalent primary care physician and would authorize the assignment of an additional 1,750 enrollees or insureds" to each primary care physician if that physician supervises one or more nonphysician medical practitioners.

The bill threatens that "willful violation ... would be a crime."

Senator Hernandez has also proposed enlarging the scope of practice for nurses, optometrists, and pharmacists (SBs 491, 492, 493). Diluting the quality of health care, Hernandez evidently feels, will improve access to health care generally. SB 494 is a companion bill that will make it impossible to do anything else but reduce the quality of physician-time spent with patients. Physicians will be penalized for having assistants by having their workloads increased. That maneuver by itself will chop down the amount of time physicians can spend counseling patients. If this bill is signed into law, patients will yearn for the day then they were allowed a whole ten or fifteen minutes with their doctors.

SB 494 is intended to bully physicians because it makes willful violation a crime. Physicians may not be in charge of whether or not they have assistants since assistants may be hired by HMOs, Accountable Care organizations, Foundations, hospitals, and managed care plans generally. This proposed legislation damages physicians' chances to provide optimal diagnostic and counseling efforts. 

At the hearing today, no testimony was offered by physicians' organizations.  

IF THE WORK IS EQUAL, SHOULDN'T THE PAY BE EQUAL?

Senate Bills 491, 492, and 493 (Hernandez) would allow RNs with advanced training, optometrists, and pharmacists to practice medical care without the pesky obligation of going to medical school, doing internships, or submitting to residency programs under the supervision of faculty. Indeed, most surgery would remain out ot bounds (not all surgery, mind you!).  The nurses, optometrists, and pharmacists would be allowed to undertake primary care. The RNs with advanced training would be qualified as Nurse Practitioners.  Proponents argue that this largesse will reduce medical costs because lower-cost workers would take over some of the tasks done by physicians. Just where to draw the line is one of the problems. For instance, how does one "draw the line" when the differential diagnosis of, say, "numbness" is the chief complaint?  Should an evaluation  for multiple sclerosis be considered? The patient who is misdirected to the lower level diagnostician will find out the hard way.

The San Jose Mercury News, in an editorial on April 12, 2013, said "these bills ... would allow nurse practitioners to establish indpendent practices and deliver limited care without a doctor's oversight." It has also been argued that the lesser-level practitioner would be paid less. Herein lies a problem: if the NP, optometrist, or pharmacist is delivering medical care equal to or on a par with physicians, shouldn't the lesser level practitioners be paid at the same level?

The Affordable Care Act is supposed to expand access to care, not to water it down.

Recently, we learned that the Union of American Physicians and Dentists negotiated a raise for physicians by showing that a  group of nurses was being paid more than their physician counterparts. The opportunities in Hernandez's  legislation make it worthwhile for physicians, nurses, optometrists, and pharmacists to organize into collective bargaining units lest the Hernandez package be used to create equal work with unequal pay. 

If the Hernandez  package is passed,  the nurses' unions would be asleep at the switch if they did not seek equal pay for equal work.

A BONANZA OF MALPRACTICE LITIGATION IS IN THE OFFING

STATE SENATE BILLS 491, 492, AND 493 ARE BILATERAL TRIPLE MALPRACTICE BONANZAS FOR TRIAL LAWYERS -- ON BOTH SIDES.

Senator Ed Hernandez's bills to promote expanded scope of practice for nurses, optometrists, and pharmacists,  scheduled for hearing on April 22nd, got pulled from committee just hours before the hearing.

In our previous post on this topic we pointed out, as did others, that these bills lower the level of education and training for healthcare professionals especially with reference to  differential diagnosis and selection of diagnostic and treatment modalities. If it is determined that a lower level of education and training is acceptable, then the same level of reduced education and training should also be acceptable for physicians. Since these bills allow reduced levels of required education for the same or similar services, we should expect increasing levels of malpractice litigation should any of these bills get voted into law -- a boon to  both plaintiffs' and defense bars, a veritable bonanza of malpractice litigation.

Late notice: we're advised that the Hernandez bills will be brought up in committee on April 29th.