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.
