Testimony in Opposition to H.3829 an Act Promoting Affordable Health Care Options before the Committee on Health Care Financing

The Massachusetts Medical Society (MMS) wishes to be recorded in opposition to H.3829, An Act Promoting Affordable Health Care Options.  This bill would increase the scope of practice provisions for Nurse Practitioners, Certified Registered Nurse Anesthetists, Psychiatric Nurses, Optometrists, and Podiatrists without any corresponding increase to policies aimed at ensuring professional quality of care and patient safety.  The MMS thanks Governor Baker for his interest in health care cost containment, his stated reason for putting forth this legislation.  However, we believe this bill would not accomplish that goal and could jeopardize the high quality of health care provided to citizens of the Commonwealth through the current statutory framework. 

The MMS believes that the physician led team-based care model promotes integrated, coordinated care that utilizes all appropriate health care professionals while ensuring that physicians are available for consultation or collaboration when necessary to promote the highest quality and safety of care for patients. Physicians’ extensive medical education, required medical residencies, and, in many cases, post-residency fellowships, provide them with unique expertise and qualifications to manage care for the sickest, most complex patients. Surveys indicate that patients prefer health care teams led by physicians when care becomes complex and as patients age. The MMS supports H.2437, An Act to Promote Team Based Health Care, as a model for cooperative, integrated health care.

The MMS shares the Governor’s commitment to finding solutions to the growing costs of health care in Massachusetts. We disagree, however, that this legislation is an effective means to address costs. While nurse practitioners and other advanced practice nurses may be reimbursed at slightly lower rates, studies have shown that their increased utilization, referral patterns, and hospitalization rates often offset savings that might have resulted from the reduced price. Additionally, many claims of cost savings from changes in scope of practice laws put forward by the optometry community have been widely accepted as significantly inflated.

The MMS is concerned that this proposal, aimed at promoting cost containment in health care, could instead promote a two-tiered medical system whereby patients seeing physicians would be assured of a panoply of laws and regulations assuring the quality of care provided, whereas none of the same protections would apply to care provided by non-physician providers. The legislature, in fulfilling its duty to protect patients of the Commonwealth, has over many years established a thoughtful, patient-focused framework of policies and statutory requirements that apply to physicians in light of their ability to independently provide medical care. Conversely, House bill 3829 would authorize new independent practice for several different health care practitioners without requiring any of the same patient protections that apply to physicians. Specifically, the Medical Society points to the statutory requirement that all physician complete a two or three year medical residency, to the 100 credit/hour per license cycle continuing medical education requirement, and to the online physician profile as important means by which the legislature has acted in the name of patient protection and transparency. Care provided by independent non-physician practitioners would not be subject to these same protections.

Additionally, the Board of Registration in Medicine, with its unparalleled requirements and thoroughness in the licensure process, and through the unmatched sophistication and resources of its investigatory unit, also provides important protections to patients cared for by independently practicing physicians. The most important patient safety protection that can be provided to patients is to ensure that all care meets the same high standard, regardless of whether it is provided by a physician, APRN, podiatrist, optometrist, etc. Therefore, licensure boards would need similar expertise and resources to understand and uphold the medical standard of care provided by physicians. The Board of Registration in Nursing, for example, currently has seven vacancies, and only has three members trained to understand the medical standard of care. The Medical Society is concerned that patients seen by non-physicians would not have the same standard of care, protections, or assurances patients seen by physicians experience. 

The Medical Society also opposes Section 29 of this bill, which would double the mandated rate differential between providers offered in a tiered insurance plan. The promise of tiered plan design—to drive down health care costs while improving quality-has never been fully realized. Several studies have found that tiering fails to impact patient behavior in prompting them to seek lower cost providers, and a study published in 2016 found that “the current methods for profiling physicians on quality may produce misleading results.”[i]. In addition, misclassification of physicians and other providers, due to imperfect attribution methodologies, has been a consistent problem since the initiation of these plans, as tiering methodologies remain shrouded in opacity. A 2015 report from the Office of the Attorney General alludes to these issues, noting the tension between the findings of their study of tiering and the Ch. 288 mandate to tier providers based on standardized and transparent cost and quality measures. Before the legislature focuses on doubling the cost-sharing differential in tiered insurance plans, it should first ensure that the issues of methodology and attribution are sufficiently addressed, and that prevailing research supports tiering as an effective means to promote value-based care. 

In conclusion, we hope these comments convey a willingness and desire to engage in further discussion of strategies to further cost containment and increased access to care, while also promoting patient safety and quality for patients of the Commonwealth.


[i] Adams JL & Paddock SM. 2016. Misclassification risk of tier-based physician quality performance systems. Health Services Research.

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