April 29, 2013
CMA Capitol Insight is a biweekly column by veteran journalist Greg Lucas, reporting on the inner workings of the state Legislature.
Front and Center
Without question, the most visible legislative issue the California Medical Association (CMA) is engaged in this year is working to defeat three bills that would expand the services that pharmacists, optometrists and nurse practitioners can provide. The three bills are supposed to receive their first Senate policy hearing today. Odds are the impact of the Affordable Care Act and its adding of more than 4 million Californians to the ranks of the insured – more than 1 million to Medi-Cal – starting in roughly eight months, will directly affect more lives in more profound ways than the three bills by Sen. Ed Hernandez, a West Covina Democrat. But what elevates the significance of his legislation is that it centers on the fundamental question of who is best suited to make the most medically sound decisions about a patient’s care. Remembering that fundamental question will be hard given the white noise surrounding these measures. Media interest invariably increases if an issue can be oversimplified into being merely a ”power play” or a “turf fight.” Hernandez’s practice-expanding measures and CMA’s opposition to them have already been labeled as such. Doctors want to wall out other health care providers from grabbing a piece of their action, the storyline goes. Like most things in life and politics, it’s not that simple.
As already noted, these three bills are authored by Ed Hernandez, himself an optometrist. Not surprisingly, supporters of the bills include the California Pharmacists Association, California Association for Nurse Practitioners and the California Optometric Association. Blue Shield is also a backer. CMA opposes all three bills. Some of CMA’s allies vary from bill to bill – as do some of Hernandez’s supporters – but the California Academy of Eye Physicians & Surgeons and the California Society of Anesthesiologists also oppose all three measures. It would make for a more riveting story if the issue were profound enough to unite the strangest of bedfellows on one side or the other. But that’s not the case. Ophthalmologists have fought attempts by optometrists to expand the services optometrists can offer since the dawn of both professions numerous decades ago. News would be if ophthalmologists weren’t opposed to Hernandez’s bills.
What Problems Are Supposedly Being Solved?
In theory, legislation is introduced to solve some problem. (Lots of space could be devoted to the number of times this isn’t true, but sticking to the issue at hand…) According to Hernandez and supporters of his bills, the measures are needed because of the Affordable Care Act’s implementation next year. Says Hernandez – as quoted in the Senate Business & Professions Committee analysis of SB 491, his bill relating to nurse practitioners: “Many newly insured Californians will cause additional pressures on the already strained health care system, particularly in medically underserved areas.” The Optometric Association says the nurse practitioner bill and the one expanding the services optometrists can provide are “necessary to make the promise of the (Affordable Care Act) a reality,” per the same analysis. The analysis goes on to say that Hernandez provided the Business & Professions Committee with various studies showing a shortage of primary care physicians in the state. Among the studies is one by the California Health Care Foundation, “Fewer and More Specialized: A New Assessment of Physician Supply in California.” Using 2008 numbers, the report found that “the number of physicians actively practicing in California is at the very bottom range of, or below, the state's need.” And fewer of those primary care docs can be found in rural areas. In sum, the chief argument offered for Hernandez’s bills is that with the influx of the newly insured in 2014 and insufficient primary care docs to treat them – particularly in rural areas – optometrists, pharmacists and nurse practitioners should be allowed to take up the slack. The regulation by the state and the training required of optometrists, pharmacists and nurse practitioners, while significantly less than that required of physicians, is more than sufficient to equip them for these new tasks – per Hernandez.
An Undelivered Promise
There’s very spirited debate over whether either regulation or training of pharmacists, optometrists and nurse practitioners is sufficient. But it’s parties affected by the legislation who are best judges of the efficacy of broadening the responsibilities and treatment opportunities for nurse practitioners, optometrists and pharmacists. Leaving those issues aside, the bills don’t appear to solve the problem they claim to. There is no requirement in any of the three bills that in return for a broader portfolio of practice, more pharmacists, optometrists and nurses will set up shop in California’s most underserved areas – rural counties and lower income communities. Nor are there incentives to relocate. Conversely, nothing prevents the beneficiaries of these bills from instead opening “medi-spas,” a fact CMA’s legislative advocates enjoy noting. There’s also no requirement to accept any – let alone more – Medi-Cal patients and the woefully inadequate reimbursement that accompanies any services provided them. And given the daily liability concerns that dog the medical profession, aren’t some optometrists, pharmacists and nurse practitioners simply going to stick with the status quo? The less charitable might use the phrase “red herring” to describe the claim that the purpose of these scope of practice bills has anything to do with better management of a glut of newly insured Californians.
Something that Might Expand Options for Care
What in the world of Capitol cliches would be accurately called a “broad-based coalition” backs legislation co-sponsored by CMA that would block imposition of a 10 percent Medi-Cal reimbursement rate reduction approved during the state fiscal year that ended June 30, 2012. A disincentive to provide care to Medi-Cal patients is the already low reimbursement rate, one of the lowest in the country. Not lowering that rate further would certainly increase the potential for more care in 2014 when the Affordable Care Act expands Medi-Cal eligibility. So far the 10 percent cut hasn’t been imposed – it’s tied up in court. But Gov. Jerry Brown banked on the savings from the reimbursement rate cut in the budget he proposed in January for the fiscal year that begins this July 1. The Democratic governor won the last round in court when a three-judge panel from the Ninth Circuit Court of Appeals OK’d imposing the rate reductions. CMA, the chief plaintiff, is seeking what’s called an en banc hearing by the appeals court. En banc means all the judges hear the case. After that, the next step is the U.S. Supreme Court. Imposition of the reimbursement rate cut hits some harder than others. Hospitals with skilled nursing facility beds would see an average reduction of 25 percent for those beds rather than 10 percent because the legislation containing the reimbursement rate cut takes skilled nursing bed services back to reimbursement levels in 2009. A hospital spokeswoman said smaller, rural hospitals, which often have larger percentages of skilled nursing facility beds, will likely close. (These are the same rural areas referenced above in need of higher levels of care, primary or otherwise.) Adding insult to injury, the Brown administration wants doctors, hospitals and others to pay the state the difference between the rates they have been receiving since June 1, 2011, and what they would have been if the rate cut took effect. That “will result in devastating financial hardship,” writes the California Hospital Association in support of SB 640, the bill blocking imposition of the cuts. Gov. Brown says imposing the reimbursement reduction and charging it retroactively to June 1, 2011, saves $488 million.
Good News All Around
Needing that $488 million to balance the budget isn’t a worry. According to the Legislative Analyst, income tax collections for April are $4.5 billion above estimates, leaving more than enough to maintain a balanced budget and not impose the reimbursement. The Democratic governor reveals his revised budget, incorporating actual revenue collections for the past four months rather than estimates made last year, in mid May. That’s when the annual Capitol budget bump-and-grind begins in earnest.
An Artful Exit
William Shakespeare’s birthday was last week. There’s a fairly large contingent that say he’s one of the greatest writers in the English language, if not the greatest. His last play was The Tempest, and for 400 years students of the Bard have wondered if the following musings on the transitory nature of things by Prospero weren’t also Shakespeare’s tip of the hat before exiting stage right into retirement: “The cloud-capped towers, the gorgeous palaces, the solemn temples, the great globe itself. Yea, all which it inherit, shall dissolve and like this insubstantial pageant faded, leave not a rack behind. We are such stuff as dreams are made on and our little life is rounded with a sleep.”