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Wednesday Nov 13, 2013

The Good, the Bad and the Ugly … A Tale of Three Bills

Congratulations to our Louisiana, Ohio and Pennsylvania chapters for winning Leadership in State Government Advocacy Awards at the AAFP's State Legislative Conference, Nov. 1-2 in Broomfield, Colo. Our national and state legislative leaders spent that weekend discussing issues related to scope of practice, the Patient Protection and Affordable Care Act, opioid abuse and rural workforce. This annual event presented a great forum for knowledge sharing and cross pollination of legislative strategies across the states.

If you have spent any time at your state legislature, you know that actions are worth more than words, and that legislators -- despite good intentions -- may craft bills that are good, bad or just plain ugly when it comes to public health and the practice of medicine.

My state legislature is no exception. In California, we just ended the first of a two-year legislative session, which meant that all bills were chartered, killed or pushed onto a second year session for more work. This year, we saw three scope-of-practice expansion bills: one for pharmacists, one for nurse practitioners and one for optometrists.

Here is the low down on each of these bills.

The Good

The first in this triad of bills became law, allowing pharmacists to furnish self-administered hormonal contraceptives, nicotine replacement products, and prescription medications not requiring a diagnosis that are recommended for international travelers. In addition, they will be allowed to order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies in coordination with the patient's primary care physician, including by faxing or entering results in patients' medical records. And finally, they are allowed to initiate and administer routine vaccinations recommended by the CDC's Advisory Committee on Immunization Practices.

Why, you ask, is this expansion good for family physicians? The house of medicine initially opposed the bill. However, after several thoughtful discussions with pharmacists, the bill was amended to bring pharmacists into a patient-centered medical home model, which allows them to become a part of the health care delivery team in their area of expertise. This will result in more coordination between a patient's primary care physician and pharmacist, and it will decrease the barriers our patients may face in obtaining certain treatments.

It is always good when each member of the health care team is participating to the maximum that their training allows.

The Bad

In stark contrast to the pharmacists, the nurse practitioner scope bill exemplified how bills should not be worked through the legislature. After years of working with physician organizations -- including by supporting several prior bills that were passed to allow increased scope of practice for nurse practitioners within a collaborative agreement structure -- nurse practitioners tried to pull a fast one on the legislature this year. Nurse practitioners argued that they can fill in primary care shortage gaps where family physicians cannot or are not willing to do so.

However, physician organizations successfully argued to the legislature that independent nurse practitioners would not improve quality and may adversely affect patient safety. This argument was further augmented by data provided by the California AFP showing that independent nurse practitioners would not improve primary care misdistribution in our state.

To their credit, state legislators heeded our message, and the bill failed to pass out of committee. By focusing on obtaining independence, nurse practitioners sought to further fragment the health care delivery system and to further undermine the cornerstone of health care reform by putting their financial self-interest above coordinated, patient-centered care. The nurse practitioner bill simply highlighted deficiencies in our fragmented health delivery system without providing a workable solution to the primary care workforce shortage.

The Ugly

The last of the three scope bills would have allowed optometrists to diagnose and treat all conditions presenting with ocular manifestations. It would not only allow them to initiate treatment of chronic diseases -- such as diabetes and hypertension -- but also complex conditions such as systemic infections and autoimmune diseases.

Needless to say, the house of medicine was strongly opposed to this bill. Yet, the author, an optometrist himself, would not take on any amendments to his bill. He was able to move this bill out of the committee that he chaired. But facing a high likelihood of defeat on the floor, he pulled the bill for further work next year.

Lessons learned

I had an opportunity last week to participate in a community chronic disease forum hosted by the author of this trio of scope bills. After some careful repartee sitting around a small table, I came to realize that he, like many, if not all, legislators, drafts bills with the best of intentions. In this vein, it would be in our best interest as family physicians to keep close tabs on all our legislators and develop relationships with them. Successful advocacy takes good will and influence to bring about change.

So, what can you do? You can join the thousands of family physicians who have signed up to become key contacts for advocacy. Key contacts receive regular updates from the Academy's government relations staff on issues important to family medicine, and they occasionally are asked to reach out to their legislators by phone or e-mail to tell their stories and let lawmakers know how issues are affecting family physicians and our patients.

For those who aren't able to get directly involved with advocating for family medicine, you can still make a difference by supporting FamMedPAC, the Academy's federal political action committee. FamMedPAC enhances AAFP advocacy efforts by making direct, nonpartisan contributions to candidates for the U.S. House of Representatives and the U.S. Senate. FamMedPAC provides AAFP members with an easy way to get involved in the political process and to support candidates who support family medicine.

With mid-term elections approaching, you'll be helping to improve the delivery of health care in this country, and helping put family physicians on equal footing with the powerful insurance companies and trial lawyers. It's one way to ensure our voice is heard on Capitol Hill.

Jack Chou, M.D., is a member of the AAFP Board of Directors.

Posted at 10:19AM Nov 13, 2013 by Jack Choud, M.D.

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