Scope of Practice, Rural Health Capture Interest at State Legislative Conference

November 12, 2013 02:37 pm Nancy Kuehl Broomfield, Colo. –

By its very nature, all health care is local, which is why what happens at the state level in health care can be particularly important. Those who gathered for the 2013 AAFP State Legislative Conference here on Nov. 1-2 had an opportunity to share information from their states with AAFP members from other states in an attempt to expand that local knowledge nationwide.

James Taylor, M.D., from the Louisiana AFP, tells colleagues at the 2013 State Legislative Conference about his chapter's continuing efforts to stave off scope-of-practice challenges.

Members who attended the conference exchanged information on a variety of topics( that affect most, if not all, AAFP chapters. Popular topics included scope-of-practice issues, health care exchanges and rural health care.

Scope of Practice

During the past few years, physicians in many states have faced challenges from other health care professionals seeking to extend their scope of practice into primary care. According to Kentucky AFP President Ron Waldridge II, M.D., of Shelbyville, his state dealt with this issue( when a long-term collaborative agreement on prescriptive authority for nurse practitioners (NPs) was threatened by a bill designed to give NPs independent prescribing authority.

By the time the Kentucky AFP found out about the bill, it was well on its way to being passed, but the chapter has a well-connected lobbyist with whom it works. That lobbyist was able to get Kentucky AFP staff members in front of a key senator, and, in the end, the bill went down by one vote. However, Kentucky FPs realized they needed to work with the NPs to ensure that patients received the most comprehensive and cohesive care possible.

story highlights
  • Attendees at the recent State Legislative Conference in Broomfield, Colo., spent two days swapping information on the challenges family physicians were facing in individual states.
  • Changes in scope-of-practice laws was a popular topic, and several speakers offered their experiences in this area.
  • In addition, with the launch of the insurance marketplaces called for by the Patient Protection and Affordable Care Act, attendees were eager to hear about other's experiences.

"With the patient-centered medical home sweeping the nation, why would we in Kentucky want to separate out into separate silos of care?" Waldridge asked. What the chapter did was work out a compromise agreement with the NPs. The agreement included an opt-in model that allows tracking of NPs who want to practice independently. In addition, NPs would need to practice collaboratively for four to six years before they could practice independently.

Scope-of-practice issues also were a problem for the Louisiana AFP, winner of an AAFP Leadership in State Government Advocacy Award for its efforts to block expansion of scope of practice by NPs and subspecialists. According to James Taylor, M.D., of Zachary, during the past three legislative sessions, physicians in the state have faced three scope-of-practice bills( one from NPs, one from pharmacists and one from optometrists.

The bill allowing pharmacists to give vaccinations passed, spurring the Louisiana AFP to reach out more aggressively to its state legislators. The chapter set up a series of legislative breakfasts to talk with lawmakers about what family medicine is and how it is the foundation of health care. In addition, the chapter developed a legislative and advocacy training seminar for its members and then provided a day of health screenings for legislators and the community.

The Louisiana AFP also supported a bill that would have brought NPs under the authority of the Louisiana State Board of Medical Examiners and strengthened rules governing physicians supervising NPs.

That bill was withdrawn, however, after NPs in the state reached out to the Louisiana AFP to craft a memorandum of understanding that called on both parties to negotiate in good faith. Conversations between FPs and NPs are continuing, said Taylor.

Medical Marketplace

With the launch of the health care marketplaces called for in the Patient Protection and Affordable Care Act in October, health care exchanges -- and the subsequent problems with the exchanges -- commanded a lot of attention at the conference.

Virginia attorney Hunter Jamerson, of Macaulay and Burtch, P.C., gave a presentation( on his state initially declining to expand Medicaid and instead creating a Medicaid Innovation and Reform Commission composed of six members of the Virginia House of Representatives, six members of the Senate and two cabinet secretaries.

The result was a health care reform initiative that was attached to Virginia's 2013 appropriations legislation. The initiative revamps the existing Medicaid program in Virginia using a three-phase approach. All of the reforms outlined in the initiative need to be completed or have a plan in place for completion before the state's Medicaid program can seek permission to expand.

The reform initiative calls for

  • a demonstration pilot for handling Medicare/Medicaid dual-eligible beneficiaries,
  • enhanced program integrity,
  • a new eligibility and enrollment system,
  • quality payments and incentives,
  • cost-sharing and wellness programs, and
  • limited provider networks and patient-centered medical homes.

Art Kaufman, M.D., tells colleagues about the rural outreach program the University of New Mexico established in that state.

Lindy Hinman, chief operating officer of Connect for Health Colorado, presented on Colorado's approach( to the Affordable Care Act. The state was well on its way to setting up its own health exchange system before the health care reform law's deadlines. Connect for Health Colorado, the state's exchange marketplace, follows many of the guidelines set out in the Affordable Care Act. The exchange is governed by a board of directors, and it offers a competitive marketplace for individuals and small employers.

According to Hinman, consumer benefits from the Colorado exchange program include that it

  • makes comparing and buying health insurance more convenient and competitive,
  • provides an array of choices,
  • helps create transparency so consumers can make an informed decision, and
  • offers a network of trained facilitators to help consumers navigate the process.

Benefits for health care professionals are that

  • there is no impact on agreements between insurers and health care professionals,
  • new insurance carriers are entering the market in Colorado, and
  • Medicaid expansion leads to more demand for health care services.

Rural Practice

For many of the conference attendees, the difficulty of attracting family physicians to rural parts of their respective states was an engrossing topic. Arthur Kaufman, M.D., vice chancellor for community health sciences and distinguished professor of family and community medicine at the University of New Mexico (UNM) in Albuquerque, shared his university's attempts( to broaden the use of the resources offered by the UNM Health Sciences Center to more rural areas of New Mexico.

"Quality may not be enough," said Kaufman, pointing out that although Native Americans in his state rank highest in receiving recommended preventive services, they also have the highest rates of death from diabetes. It is an issue of resources, said Kaufman, noting that the discordance can be traced to years of health care neglect in these rural areas.

In response, New Mexico looked at the example offered by agricultural extension offices, and it created health extension offices across the state to link community priorities with medical resources from UNM. The Health Extension Rural Office (HERO) program places full-time agents in rural communities across the state, links community health priorities with UNM resources and monitors the effectiveness of university programs in addressing community health needs.

The program helps create social outcomes and collegiality, said Kaufman. And the medical residencies are particularly important. Many residents who train in rural areas will return to these areas after graduating, said Kaufman. "It's the residency that becomes critical." He pointed to a local county with a severe need for family physicians as an example. The HERO program worked with resources in the community to bring in rotating residents, and two of those residents eventually settled in the area to practice.

Lisa Miller, M.P.H., senior program officer for the Bingham Program in Augusta, Maine, outlined the solutions Maine found to ensure its rural areas were covered. Although health care in Maine was already above national averages in several areas, the state is focusing on shoring up its primary care system. Miller said the state has more than 100 practices that are recognized as patient-centered medical homes. In addition, the state has 14 federally qualified rural health centers participating in a CMS payment reform initiative. Maine's state Medicaid program also received a $33 million federal grant to strengthen primary care delivery and reform payment systems.

Miller had some words of encouragement for conference attendees regarding advocacy activities at the state and federal levels. "Never doubt the power you have as a practicing physician on a legislator," said Miller. However, she also pointed out that legislators "have little patience for licensing battles." When framing something as a patient safety issue, having data to support that claim is essential, and if it is on a state level, presenting state data is key, said Miller.