Friday, April 26, 2013


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.


  1. Medscape Medical News
    New Bill Would Clarify Who Is a Medical Doctor and Who Isn't
    Marcia Frellick
    Apr 24, 2013
    Sponsors of a bill recently introduced in the House of Representatives aim to eliminate consumers' confusion over who is considered a medical doctor.

    Rep. Larry Bucshon, MD, (R-In.) and Rep. David Scott, (D-Ga.) are cosponsors of the bill, called the "Truth in Healthcare Marketing Act of 2013," (HR 1427), which was introduced on April 9 and referred to the Energy & Commerce committee.

    The bill would make it illegal for any healthcare professional to make false or deceptive claims in advertisements and marketing materials regarding their training, degree, license, or clinical expertise. Anyone marketing a health provider's services also must clearly state the license the provider holds.

    The bill charges the Federal Trade Commission with identifying specific acts and practices that make deceptive claims and instances when harm or injury resulted from them. Violations would be treated the same as other unfair or deceptive acts under guidelines already established under the Federal Trade Commission Act.

    Fully Informed

    Matt Sturm, deputy director of government relations for the American Psychiatric Association (APA), told Medscape Medical News in an email that this bill is necessary to make sure health professionals, including physicians, are fully informing consumers of their credentials.

    He noted that amid the myriad credentialed providers in mental health services are many who work in collaboration with psychiatrists and other physicians. Credential acronyms may not be readily understood, and providers may add professional association acronyms as well.

    "There is clear data that patients are confused about the level of training for health professionals. We simply think proper display of credentials in marketing and advertising, making licensure misrepresentation clearly illegal, and beefing up enforcement makes logical sense. If you were looking for mental health treatment for yourself or a family member, services that are potentially sensitive and need to be carefully managed, wouldn't you like to know a provider's qualifications?" Sturm said.

    The APA and the American Medical Association (AMA) are among several major players in organized medicine who support the bill. In an April 17 letter to the bill's sponsors, they and 13 other organizations applauded the measure and wrote, "Patients…are understandably confused by the increasing ambiguity of healthcare provider-related advertisements and marketing. Because of this uncertainty, patient-centered care and decision-making have been compromised."

    Confusion is Common
    Confusion is Common

    The bill references 2 surveys, completed on behalf of the AMA, that demonstrate patient confusion. Global Strategy Group conducted a telephone survey in August 2008 and Baselice & Associates conducted a telephone survey in November 2010. Both polled 850 adults nationwide and had margins of error of +/-3.4%.

    Only 46% of the respondents in 2008 and 51% in 2010 agreed with this statement: "It is easy to identify who is a licensed [medical doctor] and who is not by reading what services they offer, their title and other licensing credentials in advertising or other marketing materials."

    Respondents were also asked whether certain professionals listed were medical doctors. The answers showed widespread confusion. Asked whether chiropractors were medical doctors, 38% in the 2008 survey said yes; 53% said no; and 9% were uncertain. Regarding psychologists, 49% said yes; 44% said no; and 8% were uncertain.

    In a press release announcing the legislation, Rep. Bucshon said, "It is imperative that healthcare consumers have adequate information, including the education and training level of the healthcare professionals treating them, so that they are able to make wise healthcare choices. Ultimately, this bill will protect patient autonomy and decision-making and improve our healthcare system."

  2. Thank you, Dr. Rao, this item is important information. One can predict that there'll be efforts at protectionism when the AMA defends and supports only contingent organizations or when specialty groups compete among themselves for subspecialty recognition. -- RLW, Editor

  3. "Expanding role of nurses a recipe for malpractice lawsuits," letter to THE SACRAMENTO BEE, 24 April 2013, states that "over the last several years, progressively strict legislation has been passed to increase the required education and training of physicians. Sen. Ed Hernandez would reverse this trend by enacting Senate Bills 491, 492, and 493.

    Since each of these bills allow lesser levels of education and training for nurses, optometrists, and pharmacists than is required for physicians, these bills will be a bonanza for malpractice litigation, both for plaintiffs and defense lawyers. The next step would be to allow all of us to practice law despite not having law degrees."

  4. In its news release on 4/29/13 the California Medical Association (CMA), acknowledging that the Hernandez bills passed out of committee, stated that "while the bills are now significantly amended, there are still very problematic issues."

    In its news release on 4/13/13 the Union of American Physicians and Dentists (UAPD) stated that "UAPD believes that these healthcare providers do not have the training and experience to safely do all that is authorized by these bills."

    It's of interest that the CMA and the UAPD are so far on the same side. The trouble is that it isn't education or training that'll do in the anticipated expanded scope of practice. It's the hypocrisy of the proponents who hint that anybody who does the same job as the physician will accept doing so at a lower pay level.

    The practical bombshell in the Hernandez legislation is the tacit expectation that equal work will be done for unequal pay.

    The California Neurology Society is also opposed to the Hernandez bills and will take up this issue in a luncheon address by this writer on May 4th in San Francisco. Stay tuned.

  5. Not only that!

    The California Society of Industrial Medicine and Surgery {CSIMS) disclosed its opposition to SB 491, 492, and 493 at the same time that it also disclosed opposition to AB 1000 (Wieckowski) because it would allow direct access to physical therapy without a diagnosis.

    THE SACRAMENTO BEE editorial of 4/22/13 recommended "the three bills should be held in that committee so responsible amendments can be aired." Nonetheless, after the author accepted enough amendments to assuage consciences, the bills were voted out of the Business and Professions Committee. The next step is The Appropriations Committee, Mike Gatto, Chair.

    Feel like writing? The Appropriations Committee address is Room 2114, State Capitol, Sacramento, CA, 95814.