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.
