Bills on the Hill: Scope of Practice, Telemedicine among Issues Addressed in New Health Care Legislation

Last Updated: Mar 27, 2019

Mike-Siget-ThumbnailBy Michael D. I. Siget, JD, MPA, PAMED’s Legislative & Regulatory Counsel

With the start of a new legislative session, numerous bills have been filed that may affect physicians across the Commonwealth. In Part II of Bills on the Hill, we will focus on telemedicine; any willing providers; tiered providers; CRNPs; POLST; CRNAs; assault against a health care practitioner; and optometrists. 

You can access Part I of Bills on the Hill here to read about immunizations by pharmacists; continuing education for Lyme disease and other tick-borne diseases; informed consent for vaccinations; credentialing; restrictive covenants not to compete for employees of purely public charities; and non-compete clauses in physician contracts.

  1. Telemedicine
    HB 15, introduced by Rep. Harry Readshaw, is similar in scope to SB 780, as amended by the House of Representatives, from the 2017-2018 legislative session. Telemedicine would be defined as the delivery of health care services provided through telemedicine technologies to a patient by a health care provider who is at a different location (but does not include a provider-to-provider consultation). HB 15 would require the state licensure boards to promulgate regulations that would provide for and regulate telemedicine within the scope of practice and standard of care regulated by the board. 

    HB 15 would require medically necessary telemedicine delivered by a participating network provider to provide coverage so long as the policy provides coverage for the same covered service when delivered in person by the same provider. Reimbursement would not be conditioned upon the use of an exclusive or proprietary telemedicine technology or platform.

    HB 15 was referred to the House Insurance Committee on March 5, 2019. 

    PAMED supports this bill.
  2. Harrisburg-Capitol-FountainAny Willing Provider
    HB 602, introduced by Rep. Anthony DeLuca, would require a health care payer to contract with and to accept as a health care benefit plan participant any willing provider of health care services. The bill would also prohibit a health care payer from discriminating against a provider of health care services that agrees to accept the health care payer's standard payment levels and meets and agrees to adhere to quality standards established by the health care payer. 

    HB 602 would apply to fee-for-service, per diem, or other non-risk plans. It would not apply to health care benefit plans regarding products that compensate providers on a capitated basis or under which providers accept significant financial risk in a formal arrangement approved by Federal or State authorities.

    HB 602 was referred to the House Insurance Committee on March 1, 2019. 

    PAMED supports this bill.
  3. Tiered Providers
    HB 891, introduced by Rep. Greg Rothman, would prohibit a managed care plan from paying a health care provider at a lower rate, or place a health care provider in a lower payment tier, due to the health care provider's employment status or affiliation, or lack thereof, with a managed care plan, health care network, health care facility, or other health care provider. This bill seeks to eliminate tiering by managed care plans where they reimburse insurer-owned hospital employers at a higher rate than private practice physicians.

    HB 891 was referred to the House Insurance Committee on March 20, 2019. HB 891 was proffered by PAMED as a result of PAMED’s House of Delegates adoption of Resolution 18-301. You can find details on this resolution as well as all the final resolutions from PAMED’s 2018 HOD meeting here.
  4. CRNPs
    SB 25, introduced by Sen. Camera Bartolotta, would grant independent practice to certified registered nurse practitioners (CRNPs) after they have worked under a collaborative agreement with a physician for a minimum of 3 years and 3,600 hours. The bill would also rename CRNPs as Advanced Practice Registered Nurse-Certified Nurse Practitioners (APRN-CNPs). The bill would also require APRN-CNPs to complete at least 30 hours of continuing education approved by the State Nursing Board, including at least 16 hours in pharmacology for APRN-CNPs who prescribe medical therapeutic or corrective measures.  

    SB 25 also authorizes APRN-CNPs to form professional corporations with other registered nurses and other health care practitioners who are not required to receive a referral or supervision from another health care practitioner. SB 25 would also require APRN-CNPs to maintain medical professional liability coverage for a non-participating provider under MCare by maintaining an individual policy in the APRN-CNPs own name, but they would not be eligible to participate in the MCare Fund.

    SB 25 was referred to the Senate Consumer Protection and Professional Licensure Committee on Feb. 27, 2019. SB 25 was voted out of the Committee on March 27, 2019. PAMED opposes this bill.
  5. POLST
    SB 142, introduced by Sen. Gene Yaw, would codify Pennsylvania Orders for Life Sustaining Treatment (POLST). POLST orders are different from advance directives in that POLST orders convert an individual’s wishes regarding health care into a medical order that is immediately actionable and applicable across all health care settings. In contrast, advance directives often only name a surrogate decision-maker to make health care decisions for the individual or often lack specificity as to the individual’s goals and preferences for a medical condition that subsequently develops because it was not foreseen by the individual.  
    Included in this bill are provisions that:

    • Prohibit insurers from certain actions regarding POLST orders, including requiring an individual to consent to a POLST order or to have a POLST order as a condition for being insured, prohibit insurers from charging an individual a different rate whether the individual consents to a POLST order or has a POLST order, and prohibit an insurer from requiring a health care provider to have a policy to offer a POLST order to any individual.
    • Prohibit health care providers from adopting policies that require individuals to have a POLST order as a condition for treatment or admission to a facility.
    • Ensure that POLST orders are valid anywhere within the Commonwealth, including health care facilities, the individual’s residence, vehicle transits from one health care facility to another and other care settings outside of a health care facility. It would also require a health care facility that transfers an individual to another health care facility to provide a copy of the POLST order to the receiving health care facility.
    • Provide immunity for health care providers and other persons for complying with a POLST order based upon a good faith assumption that the order was valid.

    SB 142 was referred to the Senate Health and Human Services Committee on Jan. 31, 2019. 

    PAMED supports this bill.
  6. CRNAs
    SB 325, introduced by Sen. John Gordner, would amend The Professional Nursing Law by recognizing Certified Registered Nurse Anesthetists (CRNAs). A licensed registered nurse would be certified as a CRNA under this bill after he or she meets specified requirements under the law and set by the Nursing Board. While SB 325 would grant recognition to CRNAs, it would not set scope of practice standards.

    SB 325 was referred to the Senate Consumer Protection and Professional Licensure Committee on Feb. 26, 2019. 

    PAMED opposes this bill.
  7. Assault of a Health Care Practitioner
    SB 351, introduced by Sen. Judy Ward, would add all health care practitioners as defined under the Commonwealth’s Health Care Facilities Act as a protected class in the event of an assault. This bill would raise the penalty for an assault on a health care practitioner, while in the performance of duty where there is bodily injury, from a misdemeanor to a felony. Currently, under the law, physicians are a protected class only when considered emergency medical services personnel while working within the scope of their employment.

    SB 351 was referred to the Senate Judiciary on March 4, 2019. PAMED supports this bill.
  8. Optometric Practice and Licensure Act
    SB 391, introduced by Sen. John Gordner, would amend the Optometric Practice and Licensure Act in several ways, including: 

    • It would remove the Secretary of Health from the approval process for therapeutic drugs that optometrists are authorized to prescribe. The Secretary of Health would be replaced by the State Board of Optometry. The Board would be authorized to approve drugs for use in the practice of optometry after the drugs are approved by the Food and Drug Administration.
    • Allow optometrists to be identified as “Doctor” instead of “Dr.” followed by “Optometrist.”
    • Allow optometrists to remove superficial foreign bodies and the draining of superficial cysts.
    • The practice of optometry would include epinephrine auto-injectors for anaphylaxis.
    • The ordering and interpretation of angiography via noninvasive imaging, including, but not limited to, light wave imaging and other imaging tests.
    • The treatment of glaucoma.
    • Optometrists would be prohibited from performing surgery with a scalpel or scissors, refractive or therapeutic surgery with a laser and surgery with a CryoProbe.
    • While optometrists would be prohibited from prescribing Schedule I and Schedule II controlled substances, optometrists would be allowed to prescribe the use of codeine and hydrocodone combinations (not to exceed a 72-hour supply) which were reclassified from Schedule III to Schedule II prior to the effective date of this bill and any drugs approved by the Board for the treatment of ocular disease.

    SB 391 was referred to the Senate Consumer Protection and Professional Licensure Committee on March 5, 2019. 

    PAMED opposes this bill.
Interested in seeing bills that PAMED is tracking? PAMED has two bill tracker websites, one for high priority legislation and one for all bills. You can find both bill tracker websites here

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  1. James W. Thomas | Mar 28, 2019

    Please ask the Legislators to differentiate between Physicians and Providers and Nurses and Assistants by both quality and pay.

    The Nazi's tried to call the Jewish Physicians "Providers". Here is a very good article called. "If you call me a "Provider I will assume you are a Nazi"

     

    https://thedeductible.com/2019/02/08/if-you-call-me-a-provider-i-will-assume-you-are-a-nazi/

    Lets make sure laws differentiate between the care a Physician provides and the care a Nurse or Physicians Assistant provides  by pay.

     

    Transparency in Quality and Pricing is important and differentiation for real quality is needed not meaningless metrics.

    A physicians Assistant in another State recently placed a dialysis catheter into the carotid artery rather than the Jugular vein.

    Was the patient given an option to have a Physician place the catheter? Did the patient pay less for a cheaper person to do it?

    Do corporations and hospitals and CVS make more money by hiring mid levels to do the job a Physician should?

    Do Legislators go along because they get lots of political donations from such entities as PBM's and GPO's  like CVS and Vizient and others?

    Do all these systems work at the expenses of the poor and sick to make corporations wealthy?

    Should physicians be compensated for taking liability and active oversight like tele-medicine that can be used to supervise nurses and assistants in real-time?

    Why did CMS change payment scales.

     

     

    CVS needs to employ nurses to make the Aetna merger more profitable and Aetna can pay itself by having CVS take over primary care than paying independent physicians. Not having physicians around by telemedicine means more money for CVS and more liability transfer via contract law?

     

    Seen in that light attached are the CMS changes propose for 2019. 

     

    CVS Payment changes needed : Pay lots for low level follow-up care and little for complex care.

      • CVS will be glad for physicians to see the level 5s and nurses at CVS see the level 2’s
    • -Nurse who sees  Four level 2(99212) pts per hour will  earn $2,976, and  last year earned $1440; nurses seeing new patients(99202) will earn  $4320 vs last year $2,432
    •  
    • Physician who sees Two  level 5(99215) pts per hour will earn $ 1,488 and  last year  earned $2,368; physicians seeing complex new patinents (99205) will earn   $2,160 vs  last year $3,376

     

    Physicians pay for seeing more difficult level 5 patients will fall substantially while Nurses seeing low level patients will increase dramatically, almost double. More money for CVS and hosptials who employ them and CMS proposed changes play right into this scheme!

     

    These  changes may be devastating to primary care physicians. 

     

    We know that in CVS current proposed scheme, supervisory physicians don’t see the patient nor contribute in real time positively toward patient care yet take money and liability via Contract law will be sued preferentially by attorney’s and jury’s will be sympathetic. Cases will settle as indefensible by the physician. 

     

    Patients would be paying more for a lower standard of care. Note that additional legislation is proposed that allows CVS to be paid with money from HAS’s ie Cash!

    HR 5138 and 6199 and more.

     

     

     

    Suggested fix is  to pass the tele-medicine bill and allow physicians to oversee in real-time all Physicians Assistants and Nurse Practitioners. After the Nurse or Phys Asst. sees the patient , ideally, the doctor reviews the electronic record and finishes he diagnosis. This would allow all Americans to access physicians and not just their assistants or nurse practitioners. 

     

     

      

    Convenience will force patients to use these CVS Aetna Minute clinics preferentially over more knowledgeable independent Physicians. Note that that US HR 5138(HYPERLINK "https://www.govtrack.us/congress/bills/115/hr5138/text/ih"https://www.govtrack.us/congress/bills/115/hr5138/text/ih) in the US Congress, would have incentivize use of the Minute Clinics over Physicians’ offices, for the bill preferentially allows patients to pay such Assistants and or Nurse Practitioners who work in CVS Minute Clinics with their Health Savings Accounts (HSA’s) while not allowing Direct Primary Care Physicians or Physicians in their offices similar ability to be paid with HSA’s. This would have further push primary care toward CVS/Aetna Minute clinics.  Although support for this particular bill has waned similar bills limit patients use of HAS's for care provided by Physicians and free market pricing systems and push patients toward care provide by clinics associated with outpatient pharmacies.  

     

     

    This is the future of the full-on Corporate Practice of Primary Care in by insurance companies and middlemen PBM. We must speak up against the corporate practice of medicine which places profit over patient care and transparency. 

    It appears that funding via CMS as well as the legalized kickbacks offered to the PBM’s and GPO's favors the finances of the PBM’s/GPO's   in their quest to assume control of  health care and rake in corporate profits on the backs of the unsuspecting elderly and poor of the United States who will soon walk into CVS and be cared for by those with a fraction of training of a physician,  while having their insurance company reimburse CVS  more money  for a low level visit while decreasing pay to those who see the complicated high complexity chronic patients in their private offices.  

    The time is now to call out CVS and their lobbyists; the true architects of the PBM/GPO  kickbacks, the mergers of the health insurance companies and vertical integration and now the increased remuneration for basic low-level office visits and the preferential payments of CVS with cash from patients directly from their Health Savings Accounts. 

     CVS will rake in the cash while  Physicians will be bankrupted and have to take all the liability.

     

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