Testimony in Support of H.2437, H.1138, & H.2470, and in Opposition to H.2451 & S.1257, Before the Special Senate Committee on Public Health

The Massachusetts Medical Society (MMS) wishes to be recorded in support of H.2437, “An act to promote team based care.” The Medical Society 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 often 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. Data indicates that physicians have lower rates of utilization for tests and higher quality referrals to specialists, both of which contribute to overall costs of care. The Medical Society believes that the physician-led health care team model can allow for ample access to care for patients in Massachusetts—without unnecessary or overly burdensome supervision requirements—but all while ensuring that nurse practitioners would have a relationship with a physician for circumstances when consultation or collaboration is required. Patients in Massachusetts present with a wide range of acuity—some with common urgent care type needs, while others with far more complex co-morbidities, undiagnosed conditions, and or other complications. While there are undoubtedly populations of patients for whom the training of a nurse practitioner is imminently sufficient, there are others where the extensive training of a physician, who has completed medical school, a several-year residency, often a fellowship and other post-doctorate training and education, is a better suit. The Medical Society believes that it is prudent for the protection of patients in the Commonwealth that the legislature ensures that there are established relationships for the purposes of consultation and collaboration on these most difficult cases.  

It is for these reasons that the Medical Society respectfully opposes H.2451 & S.1257. As a result of 2014 Board of Registration in Nursing regulations regarding advanced practice nursing, nurse practitioners are no longer required to work under the supervision of physicians. The only remaining requirement is that nurse practitioners maintain guidelines mutually developed with a physician for the purpose of prescribing medications. There is no longer a requirement that the physician be onsite or perform regular chart reviews. Given the heightened attention to opioid prescribing over the past few years, the Medical Society sees value in continuing the existing flexible requirements for nurse practitioners, while emerging data indicate a need to continue to evaluate levels of controlled substances prescribing.

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, H.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 physician’s experience.

The Medical Society supports H.2470, “An act relative to the definition of surgery.” While the MMS understands that statute cannot always articulate all boundaries of a given health profession’s practice, providing a bright line to demarcate the limit of medical practice, in this case surgery, that is reserved only for physicians who have the appropriate education and level of training is an important means by which to ensure that patient safety is paramount and that all health care professionals are practicing within the scope of their training.

Additionally, the Medical Society supports H.1138, “An act relative to truth in advertising.” This bill would promote transparency to patients by requiring health care providers to clearly and honestly state their level of training, education, and licensing. This bill will become particularly important should nurse practitioners gain the ability to provide primary care independently.  Consumers must have the ability to know by whom they are being seen, particularly when there may no longer be a consulting, collaborating, or team based relationship between an advanced practice nurse and a physician.  Written title clarity for the patient is important because of the many differing types of “doctors”.   The verbal title of “Dr. Jones” could be an M.D. or D.O, PhD, PsyD, DScPT, and more. Many patients may assume that a “Dr.” means physician. This bill does not judge the merits of any doctorate level degree, but instead provides an important patient protection by providing transparency of training and professional title.

The Medical Society hopes that H.2437, “An act to promote team based care” will serve as a model for the cooperative, integrated health care. We appreciate the opportunity to share our consideration with H.2451 & S.1257. Lastly, we urge due consideration of H.2470 and H.1138, two bills that will strengthen healthcare for the patients of the Commonwealth as we continue to grapple with scope of practice issues. 

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