Testimony: HB 700
Good morning Chairman DeLuca and the members of the House Insurance Committee.
I’m Dr. Mark Piasio, president of the Pennsylvania Medical Society and a practicing orthopedic surgeon from Dubois.
Let me begin by thanking you for asking the Pennsylvania Medical Society to testify today on House Bill 700, which includes parts of Governor Rendell’s Prescription for Pennsylvania.
The number of Pennsylvanians lacking health insurance ranges from 900,000 to 1.5 million depending upon which published report you review. For those without insurance, they often go without the care they need, suffering through symptoms until actual treatment becomes considerably more expensive. Since the uninsured patient needs care, expensive treatment options are carried on the backs of hospitals and physicians, which indirectly get passed along to those with insurance through the form of higher premiums. This is a vicious cycle that will continue until we reform the way health care financing is handled.
And, that’s why it is important that Pennsylvania addresses the rising costs of health insurance through House Bill 700 or other methods. The ultimate goal should be to reduce the number of uninsured while correcting unhealthy lifestyles. Who isn’t for that?
But, we must get this right.
As we all work to collaborate, cogitate, and devise the best reform measures for Pennsylvania, we thank Governor Rendell for putting these issues on the table to get things started. And, we also congratulate Representative DeLuca and Representative Micozzie for your early work on hospital acquired infections before there even was a proposed Prescription for Pennsylvania.
There are many initiatives in House Bill 700 that the Pennsylvania Medical Society stands ready to support.
The provisions in the bill to ban smoking in public places are critical to community health. According to national studies, 53,000 nonsmokers die annually in our country from lung and heart disease due to exposure to passive smoke. About 300,000 children exposed to tobacco smoke have increased frequency of lower respiratory infections. And, tobacco smoke is responsible for one million asthma attacks and 8,000 to 26,000 new cases of asthma and reduction in lung function. It also causes serious middle ear infections among children each year.
According to www.smokefree.net, already 26 states have in place some form of a smoking ban. Pennsylvania, a national leader in safety and reporting, needs to join the ranks. Maryland, for example, just expanded their law.
The Pennsylvania Medical Society also agrees strongly with efforts to reduce the number of hospital-acquired infections. We agree this would save significant health care dollars. And, while some will argue over exactly how much this section will save, the Pennsylvania Medical Society simply suggests that in addition to the actual dollars saved the reduction in morbidity and mortality to a patient is of equal consideration.
For years, the Pennsylvania Medical Society has supported the efforts of the Pennsylvania Health Care Cost Containment Council as well as the Pennsylvania Patient Safety Authority on issues related to quality improvement in health care settings. The work of both of these organizations demonstrates the need to address issues like hospital-acquired infections.
Furthermore, the Pennsylvania Medical Society has placed numerous resources into educating physicians on infection control. At our annual meeting last October, continuing medical education was focused primarily on MRSA, and, we have partnered with the Patient Safety Authority to develop online CME related to hospital-acquired infections.
Addressing health care work force issues is also an important area of this bill. Within House Bill 700 are provisions to establish the Center for Health Care Careers, which would study health care workforce issues and then hopefully find solutions to those problem areas.
Unfortunately, while well intended, there are sections of the bill that could have unintended consequences. For example, we believe there are several problems with the “Cover All Pennsylvanians” insurance product.
First, this product would potentially lower reimbursements to near-Medicaid HMO levels. In certain parts of the state, this may be an undue burden to service areas with a high percentage of Medicaid and CAP patients. If the CAP insurance is similar to Medicaid, it’s possible that CAP could experience similar difficulties in access and quality. Second, will CAP provide incentives for employers to move away from standard insurance products in favor of less costly, state-subsidized products? Third, CAP may promote a tiered and narrow physician network without necessary safeguards and metrics for quality and cost. Thus patients may not be able to see the physician of their choice. Many known cost drivers are not addressed and innovative compensation methodology is lacking.
Also, within the bill is some broad and vague language related to collaboration between health care teams that could have unintended consequences. Section 7303(a) is most troubling.
This section of HB 700 would insert in all regulatory and statutory acts several allied health professions such as certified nurse practitioner, clinical nurse specialist, physician assistant, nurse midwife, and independent dental hygienist wherever the term “physician,” “medical doctor,” “doctor of osteopathy,” and “dentist” appear to define an individual who takes medical histories, performs physical / mental exams, provides acute illness and minor injury care, and chronic disease management.
While the Pennsylvania Medical Society wants to help our colleagues in the allied health fields practice to their fullest extent, this language is so broad that it most assuredly will have unintended consequences that will jeopardize patient care and work against efforts to promote patient safety. This should be deleted or every statute including the word “physician” needs to be reviewed.
Section 7303(c) also is problematic. This section is related to collaborative agreements between physicians and certified registered nurse practitioners and reads, “There shall be no limit to the number of certified registered nurse practitioners with prescriptive authority or physician assistants for whom a physician has responsibility or supervises under a collaborative or written agreement at any time.”
The Pennsylvania Medical Society asks, “Is this really in the best interest of patient safety?” Can one physician supervise an unlimited number of nurse practitioners and physician assistants, provide quality supervision, and be held accountable?
Every collaborative relationship is unique, and should require regulatory oversight as they do now.
The final point that must be made with regard to scope of practice issues relates to the removal of the word “supervision” from current law regarding the administration of anesthesia. We oppose that change very strongly.
Another area of concern that we have with HB 700 is contained in Section 7402(e)(4) that would prohibit any oral orders for medication or treatment unless there is an emergency situation and no alternatives are available. The Pennsylvania Medical Society understands that this is in place in an effort related to patient safety. The unintended consequence of this is that it will cause delays in treatment. For example, let’s assume a physician is in a location where he does not have ready access to a fax machine or other mechanism to provide written orders for urgent care such as his car. But he can provide oral orders by cell phone. In this case, the physician would have to track down a fax or a computer with email access to send in the written order thus delaying treatment and potentially extending discomfort to the patient. Could this delay in treatment develop into an emergency? Possibly! If so, does that get translated into a medical error in which the physician has no control due to state laws, but is vulnerable to a lawsuit? The Pennsylvania Medical Society agrees that every effort should be made to improve patient safety. But we believe in certain situations that mandatory written orders instead of timely oral orders open the doors for other problems. If this section can’t be deleted from HB 700, then some flexibility needs to be written into the bill to allow exceptions for when a physician does not have ready access to a fax machine or other mechanism for transmitting written orders. This section should be deleted from House Bill 700, as we are unaware of any quality data supporting this initiative.
Finally, our last concern with HB 700 relates to an unfunded mandate requiring e-prescribing as a condition of physician licensure.
We support e-health initiatives, but not as a requirement to hold a license in Pennsylvania. A person’s medical school completion and residency training requirements should be the only requirement. And, the Pennsylvania Medical Society believes that this provision could actually hurt efforts to recruit younger physicians to set up practice in our state. Consider the following scenario. A young physician carrying a large debt from medical college searches for a location to set up a practice. When reviewing details on Pennsylvania licensing, they learn that in order to set up their practice here, they must invest in e-prescribing technology. The mandate has no funding. Will they choose Pennsylvania? Or maybe another state? Furthermore, certain parts of the state including rural communities do not yet have the electronic infrastructure in place yet to make this happen.
Simply put, e-prescribing is a practice management tool and should not be a requirement of licensure. Financial incentives to implementation might be a better approach.
Another problem with HB 700 is that it is silent on two key issues. First, it says nothing about the retirement on the unfunded liability of the Mcare Fund. And, second, it does nothing to address the expensive nature of defensive medicine, another well-known cost driver. Although this issue might not be relevant to this bill, it still remains a critical component of any health care reform package.
To conclude, the Pennsylvania Medical Society believes HB 700 is a starting point. We feel we have a good sense for where the Governor wants to go with House Bill 700, but there are some flaws, and unintended consequences could result as the bill is written today. These flaws must be corrected so that Pennsylvania puts its best foot forward as we travel down the path of health care reform.
Thank you.
Last Updated: 10/5/2007