Money Stacked Against Scope Of Practice Bill
Expanding the scope of practice of non-physician medical professionals has been a controversial topic in California and elsewhere. Backers say it would allow many more patients access to hard-to-obtain primary care services. Those who object say it would take patients away from the best-qualified individuals to treat patients: physicians.
Both sides agree that millions of dollars are at stake over the issue, whether it represents savings from improving access to care, or taking away potential practice revenue from doctors.
However, a decision to expand the clinical duties of nurse practitioners – considered by many healthcare experts to be among the most critical components in effectively providing more primary care – may have been sunk by just several thousand dollars changing hands and a handful of key lawmakers choosing to remain on the sidelines.
On Tuesday, such a bill failed to get out of the Assembly Business, Professions and Consumer Protection Committee, even though the yes votes doubled up the noes. However, the 6-3 margin was two votes short of the absolute majority required to move a bill out of the 14-member committee.
The vote was a bitter blow for nurse practitioners, who currently make basic patient diagnoses, prescribe medicines and make referrals under the close supervision of physicians. Their primary lobby, the California Association for Nurse Practitioners, has seen a variety of scope of practice bills fail in the Legislature over the years.
“This is clearly a David versus Goliath struggle and it showed in the vote tally,” said Jeff Wagner, a CANP spokesman, in an email. The committee did vote unanimously for a future reconsideration of the bill, a vote that will take place next week.
Negotiations are underway with its author, Sen. Ed Hernandez, a San Gabriel Valley Democrat, to make revisions.
“We don’t have a lot of time to get this done,” said Assemblyman Curt Hagman, R-Chino Hills.
Five lawmakers – four Democrats and Hagman – abstained from voting. And all received considerably more campaign funding from groups opposed to the bill than those who support it, according to campaign finance records.
“It's a longtime tradition in the Legislature to abstain when someone wants to vote no – it gets the same result without upsetting anyone.” said Bob Stern, former president of the Center for Governmental Studies. He added that the rule requiring a majority of the entire committee to vote in favor of the bill makes the option particularly palatable for lawmakers trying to juggle the desires of competing interest groups.
Jessica Levinson, a professor at Loyola Law School in Los Angeles who focuses on election issues, agreed.
“I think abstention is increasingly an option that legislators use to defeat bills. It allows a legislator to say that they did not vote against a particularly proposal, while at the same time their inaction can have the same result as a ‘no’ vote,” she wrote in an email. “This can be a useful tool when, for a variety of reasons, legislators do not want a ‘no’ vote on their record.
Stern, who has been scrutinizing Sacramento since the 1970s, observed that the Business, Professions and Consumer Protection Committee has been a longtime “graveyard” for troublesome legislation that, if allowed to live, could ironically haunt lawmakers at a future time.
SB 291's major opponents included the California Medical Association (CMA), which has long resisted expanding the scope of practice for nurses, the Consumer Attorneys of California, the California Association of Eye Physicians and Surgeons, the California Association of Anesthesiologists, the American College of Emergency Physicians, and the AFSCME labor union. Its supporters included the California Association of Physician Groups (CAPG), the California Hospital Association and the United Nurses Association of California.
In some cases, the opposition provided campaign contributions by a 2-1 margin or greater. Assemblywoman Nora Campos, D-San Jose, one of the abstaining voters, received $11,000 in the last campaign cycle from SB 491's opponents, and nothing from its supporters, records show.
Hagman received $8,900 from its opponents and just $2,800 from its supporters.
“I'm surprised it was that little,” Hagman said of the sums dryly, adding that he doesn't keep track of who is supporting or opposing bills.
Hagman said his primary concern was about the ability of nurses to prescribe drugs outside of a physician's supervision. For example, he did not want an independently practicing nurse practitioner who specializes in primary care have the ability to prescribe powerful painkillers and other drugs that are outside of the services they deliver. He also wanted California laws that bar the corporate practice of medicine among physicians to also apply to independent nurse practitioners.
The prescribing concern was echoed by Ben Golumbek, spokesperson for Raul Bocanegra, a Democrat who represents the northern San Fernando Valley and another abstainer. Bocanegra received far more contributions than any lawmaker who abstained from voting – $23,400 from supporters and $27,400 from those opposed, including $15,600 from the CMA.
The three Republicans who voted against the bill also received considerably more campaign contributions from the bill's opponents than its supporters, records show.
Assemblyman Richard Gordon, D-Menlo Park said he had concerns about the pathways available for nurse practitioners to practice without physician supervision. He support one pathway, which would allow nurses to practice within a medical group or similar setting.
“I am a real believer in medical teams and people working together collaboratively,” he said.
Gordon objected to another pathway, which would permit nurse practitioners to practice in virtually any setting after three years of physician supervision.
Gordon received $7,800 in the last campaign cycle from the CAPG, the state's primary lobby for group practices. But he received more than double that amount – $16,400 – from groups opposed to the bill.
“I vote simply on the issue,” Gordon said. “What happens on the campaign side is a separate operation.”
Stern noted that the CMA's objections was likely the real deal-breaker for the bill.
“The CMA is just a really powerful force, and if they object to something, it usually dies,” he said of the lobbying group that represents many of California's 90,000 medical doctors.
In a written objection to the bill, the CMA contended that “allowing nurse practitioner practice without standardized protocols and physician supervision reduces patient safety and quality of care. Patients are best served by a physician-led team that can provide high quality and cost-effective care. Current law requires that nurse practitioner practice include the development and use of standardized protocols and physician review and approval of patient treatment plans. These requirements are in place to ensure that patient care includes the involvement and oversight of a physician who is substantially more qualified and experienced to oversee patient care, both in depth and in years of education and training, than a nurse practitioner practicing alone.”
By contrast, the CMA did not raise anyobjections to SB 493, which expanded the scope of practice for pharmacists.
That bill sailed out of the committee on a 14-0 vote a short time after SB 491 was voted down, and moved to the Assembly Health Committee for a future hearing.
Gordon said the bill was emblematic of the collaborative approach to providing healthcare services absent from SB 491.
If signed into law, it would allow specially certified pharmacists to dispense contraceptives, anti-smoking products and related medications, provide vaccinations and provide drug counseling and disease management services without the supervision of a physician.
Although it does not designate specific practice settings for pharmacists with an expanded scope of duties, it requires at least a year of supervision under a medical group, hospital or other form of healthcare delivery before autonomy is granted.
As for SB 491, Stern said it would have to be revised and lift the objections of the CMA and other heavyweight lobbies in order to regain traction in the Legislature.
Gordon said he had spoken to Sen. Hernandez regarding changing how nurse practitioners are overseen in an expanded scope of practice, but would not yet commit to changing his position if his requested changes are made to the bill.
“It depends on what he is willing to do to get my vote,” he said.
