Call to Order and Roll Call
The 2nd meeting of the Interim Joint Committee on Licensing and Occupations was held on Friday, July 12, 2013, at 10:00 AM, in Room 129 of the Capitol Annex. Senator John Schickel, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator John Schickel, Co-Chair; Representative Dennis Keene, Co-Chair; Senators Tom Buford, Julie Denton, Denise Harper Angel, Jimmy Higdon, Christian McDaniel, Morgan McGarvey, R.J. Palmer II, Dan "Malano" Seum, and Damon Thayer; Representatives Larry Clark, Jeffery Donohue, Joni L. Jenkins, Charles Miller, David Osborne, Darryl T. Owens, Ruth Ann Palumbo, Sal Santoro, Arnold Simpson, Diane St. Onge, and Ken Upchurch.
Guests: Senator Paul Hornbeck; Senator David Givens, Senator Carroll Gibson, Representative Addia Wuchner; Kyle Kiser, MD, Director of ER Services, T.J. Samson Hospital, Glasgow, Molly Gadd, DNP, APRN, Jason Gregg, DNP, APRN, Elizabeth Partin, DNP, APRN, Julianne Z. Ewen, DNP, APRN, President, Kentucky Coalition of Nurse Practitioners and Nurse Midwives (KCNPNM); R. Brent Wright, MD, MMM, Medical Director T.J. Samson Family Medicine Center, Associate Professor U/L Department of Family & Geriatric Medicine, Nancy Swikert, MD, KAFP, Glenn A. Loomis, MD, MSHM, FAAFP, President and Chief Executive Officer, St. Elizabeth Physicians, John R. White, MD, Kentucky Medical Association.
LRC Staff: Tom Hewlett, Bryce Amburgey, Carrie Klaber, Michel Sanderson, and Susan Cunningham.
Approval of minutes
A motion to approve the minutes from the June 14, 2013 meeting was made by Senator Seum and seconded by Senator Thayer. The motion was carried by voice vote.
Kentucky Coalition of Nurse Practitioners and Nurse Midwives
Senator Schickel reminded the committee that in 2010 the topic of collaborative agreements between physicians and Advanced Practice Registered Nurses was identified as one of the issues confronting the General Assembly. Bills filed in previous sessions were unsuccessful in making changes. It is hoped that the two groups can come together with an agreement for the upcoming legislative session. Because the topic was moved from Health and Welfare in 2013 to this committee, Senator Schickel he decided to hear testimony during the interim. If the topic returns to the committee in the 2014 session, the Senate will be prepared for an informed vote on the legislation.
Senator Paul Hornback told members that he had sponsored legislation the past two years regarding advanced practice registered nurses. This is an important issue for health in Kentucky. If access and availability of care can improve health at no cost to the state, it should be done. The issue is the collaborative agreement. Nurses and doctors are all to collaborate in school when they reach a level beyond their knowledge. Because collaborative agreements do not provide oversight, legislation in the past and legislation in the coming session ask that the requirement of a collaborative agreement be removed. Eighteen other states have removed this requirement with no decrease in the quality of health care.
Kyle Kiser, M.D., Director of ER Services at T.J. Samson Hospital in Glasgow, said that elimination of the collaborative agreement on prescriptions for nurse practitioners would help relieve the shortage of primary care access. In his work with nurse practitioners both in the emergency department and the community, he has found the care they provide to be appropriate and their training and judgment in patient care to be appropriate and sound. APRNs can see and counsel patients; however, they cannot write prescriptions without a collaborative agreement with a physician, even though the physician’s presence in the same office is not required. This includes prescriptions for blood pressure medicine, diabetic medicine, or an antibiotic for an ear infection. While the training for APRNs is different than for physicians, it is not inadequate to treat the conditions they have been trained to care for.
Every day more physicians are refusing to take new Medicare/Medicaid patients. The rising cost of overhead and the regulation of medical care and running a business are causing doctors to leave their practices and take employed positions. A study published at Washington University in St. Louis shows that only 25 percent of medical school graduates between 2006 and 2008 chose to enter primary care. Only 5 percent of resident graduates chose to go into a rural area to practice.
The implementation of the Affordable Care Act will add two hundred thousand patients to state funded insurance. APRNs are licensed to provide medical care and will be able to provide more access to care if the collaborative agreement is abolished.
Jason Gregg, APRN, said the physician shortage is not new. Kentucky ranks among the highest in cancer deaths, heart disease, strokes, and high blood pressure. Increasing access to care in underserved areas of the state is a common goal. Sixty-three percent of APRNs practice outside of Jefferson and Fayette counties. APRNs are educated and certified by the American Academy of Nurse Practitioners to work independently to diagnose and treat a wide range of conditions. Their focus is on educating their patients and preventing costly care.
APRNs will not crowd out primary care physicians. States that are the least restrictive of nurse practitioners have a higher proportion of primary care physicians while states that have a higher restriction have a lower number of primary care physicians. All nurse practitioners want to collaborate with other health care providers and should be allowed to practice to the full extent of their education and training.
Molly Gadd, DNP, APRN, said APRNs provide information, guidance and follow-up to patients to prevent possible complications. APRNs are involved in patient-centered team care through referrals and collaboration with other providers. APRNs and nurse midwives re-certify every five years. License renewal requires completion of additional hours in pharmacology education each year. Legislation passed in 1996 allows APRNs to prescribe, therefore the proposal does not ask for an expansion of the scope of practice. There is no requirement for a physician to supervise nurse practitioners or a nurse midwife. The requirement is to have a “prescribing agreement,” which is a piece of paper, signed once, with no other requirements for the physician. This poses a barrier to providing health care in Kentucky. Ms. Gadd provided an example of the Collaborative Agreement for APRN Prescription Authority for Non-Scheduled drugs or CAPA-NS. It is a single sheet of paper that APRNs spend months finding a physician to sign. Some physicians add requirements to the agreement before they will agree to sign a CAPA-NS, and some do not.
Groups that have studied this topic, such as the National Governor’s Association and the Federal Trade Commission, are not medical or nursing associations. They agree that removing the prescribing agreement increases access to health care without increasing costs, and addresses the shortage in the health care field. Other consumer advocacy groups agree with the removal of the collaborative agreement.
In response to a question from Senator Schickel, Julianne Ewen said the piece of paper signed by the nurse practitioner is not motivation to collaborate; rather, collaboration is needed when there is a condition outside the APRN’s scope of practice.
In response to a question from Senator Buford, Ms. Ewen said that fees physicians charge for signing a collaborative agreement vary. A member of the KCNPNM reported that she had to discontinue her collaborative agreement because the fee had increased to an amount that did not allow her to continue her practice.
In response to a question from Senator McDaniel, Ms. Ewen said the APRNs are licensed under the Board of Nursing and that there are two national certification organizations. Concerning the amount of liability a physician might be exposed to by signing a collaborative agreement, Beth Partin added that in other states, when a lawsuit is filed and no physician has been involved in the care of the patient, the physician is excused from the case. Dr. Kiser said if a physician’s name is on a piece of paper there is going to be some liability; however, it is determined on a case by case basis. Ms. Ewen said that there is a competency standard for achieving certification for APRNs.
Senator McDaniel also requested a copy of a contract between a nurse practitioner and a physician.
In response to a question from Representative Jenkins, Ms. Partin said she and another nurse practitioner own their own business. A typical day includes patients with diabetes, hypertension, cholesterol checks, preventive care, and physicals for children. On occasion there are acute problems that require a higher level of care.
In response to a question from Representative St. Onge, Ms. Partin said that all care is provided based upon national standard parameters particular to the condition presented whether the provider is a nurse practitioner or a physician. The collaboration is based on the scope of practice and patient needs. The agreement is only for prescribing.
In response to a question from Representative Owens, Ms. Partin said the only time she met with the physician who signed her collaborative agreement was at the time of the signature of the document. There was no ongoing supervision.
In response to a question from Senator Harper-Angel, Ms. Ewen said if the physician who signs the collaborative agreement retires, moves away, or dies, the APRN must would find another physician to sign another collaborative agreement, or else the APRN must close the practice.
In response to a question from Representative Osborne, Ms. Ewen said that a demonstrated standard of competency in the management of health care is necessary to complete the preceptorship. In the last month, the Kentucky Coalition of Nurse Practitioners and Nurse Midwives has received four complaints regarding the collaborative agreement.
Kentucky Medical Association/Kentucky Academy of Family Physicians
R. Brent Wright, MD, Medical Director, T.J. Samson Family Medicine Center, said across the nation healthcare is moving to a team-based practice rather than independent offices. Team is not a term used to shift the discussion from the collaborative agreement. A team consists of varying combinations of physicians, nurse practitioners, physician assistants, mental health providers, and other professionals to ensure the patient is receiving the right type of care. The result has been higher quality care and cost savings by reducing duplicative or unnecessary services.
The goal of KMA and KAFP is to testify as two physician bodies that have worked together and met with their colleagues to seek solutions. The physicians’ concern is that elimination of the collaborative agreement moves away from the team-based model of care. Working independently has demonstrated a model of healthcare that does not promote health. The collaborative agreement has been in place for 17 years with no major issues, which is proof that it is working.
The Patient Centered Medical Home (PCMH) is a primary care model build around patients and delivered by teams led by the patient’s personal physician. The personal physician coordinates with other health care providers within the PCMH to provide quality and safety. Patients and their family members actively participate in decision making.
Kentucky is ranked as one of the poorest health states and one of the most medicated states. Some non-scheduled drugs have the potential for harmful or even fatal drug interactions. Thirty-four states require a collaborative agreement in some form; twenty-five of those states require a collaborative agreement for treatment, diagnosis, and prescriptive authority. Physicians have met with nurse practitioners to listen to their concerns. Those concerns are charging excessive fees by the physician for a collaborative agreement and loss of their collaborating physician (e.g. physician dies, moves, retires, etc.) putting APRNs in a difficult situation if they cannot find another physician to sign their agreement. Solutions offered are to develop a cap on the amount that can be charged for an agreement, and to form a clearinghouse of physicians willing to work with existing practices to maintain current practices when collaborating physicians have left. There are ongoing discussions regarding rural health clinics and federally qualified health centers to increase access to care. There is an overwhelming concern regarding the need to increase access to healthcare, particularly in rural areas. PCMH demonstrates cost savings, decreased ER utilization, hospitalization, and readmissions.
Health care is changing and physicians are committed to finding lasting solutions for patients, professional organizations, the legislature, and the citizens of Kentucky.
Glenn A. Loomis, MD, MSHM, FAAFP, President and CEO of St. Elizabeth Physicians, said that his group has 285 physicians and 65 nurse practitioners and physician assistants. Twenty-one of the group’s 28 primary care offices have been certified as Patient Center Medical Homes. Medicine has become a highly orchestrated team requiring everyone to do their part. St. Elizabeth Physicians has used the collaborative physician supervision model successfully with the physician and the nurse practitioner working together. This should be a standardized practice. Nurse practitioners should work collaboratively with physicians with a clear standard for that collaboration. There should be close supervision for those early in their career, with clear delineation of the educational experience that must be obtained before autonomy is considered. There should be a clear delineation of specialty services that should never fall outside physician collaboration in order to protect the public.
The issue of finding collaborative physicians in rural areas is being discussed. Large groups are working on telemedicine solutions for collaboration with nurse practitioners and specialty collaboration. Large groups may consider collaboration at a distance with rural practitioners and would do this at a very reasonable rate.
Nancy Swikert, M.M., KAFP, told committee members that doctors want to be part of the solution and have enjoyed working with the nurse practitioners.
In response to a question from Senator McDaniel, Dr. Swikert said there are four doctors in her group who each spend a day supervising nurse practitioners. On her day to supervise, she answers, and at the end of the day she reads the charts and signs off on them. The cost for this is $34 per hour, which is about $8,000 per year. This is built into the system of payment to the nurse practitioner. This makes her responsibility higher and makes her liable if a lawsuit is filed against the nurse practitioner.
In response to a question from Senator Seum, Dr. Loomis said hospitals have wide discretion regarding which doctor can or cannot collaborate with a nurse practitioner.
In response to a question from Representative Owens, Dr. Wright said there should be value in the collaborative agreement and that, ethically, physicians should communicate regularly with nurse practitioners.
In response to a question from Senator Denton, Dr. Wright said the doctors want to review collaborative agreements that charge excessively so they can be dealt with. Discussions about caps for collaborative agreement fees are ongoing.
Senator Thayer commented that he wants a compromise and that he was pleased to hear that both sides were coming together.
In response to Senator McGarvey, Dr. Loomis said there is a nebulous standard for the collaborative agreement that is massaged greatly by different people in different areas. The collaborative agreement in his group would be more detailed than the generic form that the members are seen.
In response to a question from Senator Givens, Dr. Loomis said he employs 135 physicians and 25 APRNs and physician assistants in 28 primary care offices. The PCMH was originally started by the Academy of Pediatrics and ultimately taken by the Academy of Family Physicians and Internists. It has been adopted by a number of large payers. St. Elisabeth is in a pilot project with CMS and most large payers in Northern Kentucky. Most large groups use telemedicine for specialty physicians not within their group.
Senator Carroll Gibson said that his wife’s niece, Dr. Tracey Ragland from LaGrange, has worked with physicians, and that he was confident that the nurses and doctors would be able to work together to resolve their differences.
Senator Schickel said there will be another meeting on this topic. He said he believes that committee expects an agreement between the two groups.
There being no further business, and following a motion and second, the meeting was adjourned at 11:57 AM.