Los Angeles Times by Melanie Mason –
September 01, 2013:
An effort to ease a shortage of primary-care doctors in some California communities by letting nurse practitioners operate more independently has flat-lined in the Legislature after a fierce lobbying battle.
A bill by Sen. Ed Hernandez (D-West Covina) would have allowed nurse practitioners, who have more training than registered nurses, to practice without the direct supervision of a physician.
The proposal failed in a committee Friday, under fire from the California Medical Assn., the powerful lobbying arm for the state’s physicians. The organization teamed with some specialists and labor unions to mobilize lobbyists, engage doctors across the state and even dedicate Twitter accounts as it waged its campaign against the bill.
The group supported a separate measure to permit nurse practitioners and some other non-physicians to perform first-trimester abortions, which lawmakers passed and sent to Gov. Jerry Brown last week.
Jockeying over the scope of medical professionals’ practice has intensified this year as California prepares for full implementation of the new national healthcare law, which will bring an influx of newly insured patients.
Still in play, for example, is a Hernandez bill that would authorize pharmacists to do more. It would permit them to administer some vaccines and provide certain types of smoking-cessation medicine and hormonal birth control without a doctor’s oversight. The physicians group is neutral on the measure.
But “the sticking point for the nurse practitioner bill [was] the word ‘independent,'” said Hernandez, who chairs the Senate health committee. “For organized medicine, that’s the … line in the sand.”
The bill’s supporters pointed to a shortage of primary care providers in rural and inner-city areas. A 2009 study by the California HealthCare Foundation, an Oakland-based grant-making and research group, found that only 16 of the state’s 58 counties had enough primary-care doctors. Allowing nurse practitioners to set up their own practices could alleviate those gaps in care, proponents say.
Physicians said the bill made no assurances that independent nurse practitioners would work in underserved areas. And they argued that letting the practitioners, who have fewer years of education and clinical training than doctors, work without oversight would put patients at risk.
“California’s nurse practitioners should be working more closely with physicians, not independently,” said Dr. Paul Phinney, president of the medical association.
Hernandez changed the proposal to authorize nurse practitioners to work autonomously only in certain group settings, such as hospitals or clinics.
Some national groups, such as AARP and the American Assn. of Nurse Practitioners, pulled their support in response, not wanting the revised proposal to become a model for other states. But the California Medical Assn. remained the bill’s biggest obstacle.
Going up against the doctors group “is like taking on labor or the NRA,” Hernandez said.
In the first half of the year, the doctors association spent nearly $1.2 million lobbying on the scope-of-practice bills and others. The group has 10 in-house lobbyists and escalated its Capitol presence in August by adding a lobbying firm to its roster of outside hired guns.
And this year, the group has given more than $500,000 in campaign contributions; lawmakers sitting on committees that oversee health and professional licenses received more than $100,000 of that money.
Beth Haney, who leads the California Assn. of Nurse Practitioners, said that most of the time when she met with lawmakers to argue for the bill, the California Medical Assn. and allied groups had already made their case.
“We were always on defense,” said Haney, whose organization paid $55,000 to a hired lobbyist during the first half of the year. The group, along with other backers of the bill, also hired media consultants and organized email and phone drives.
Phinney said that in his talks with lawmakers, he appealed to their perspectives as patients or parents, explaining how he as a physician is equipped to provide better care than a nurse practitioner could.
“Bringing that kind of example to legislators, making it real to them, is very, very helpful,” Phinney said.
Hernandez said some of his opponents’ alarm over safety issues amounted to scare-mongering.
“It’s fear they put in people’s minds,” he said, “but there’s absolutely no evidence to show” that people’s health would be at risk.
Seventeen states and the District of Columbia allow nurse practitioners to work autonomously.
Catherine Dower, associate director of the Center for Health Professions at UC San Francisco, said data and research from those states “show that the quality of care is the same as, if not better than, doctors’ and that safety is not compromised.”
Hernandez vowed to continue his push next year, saying, “The fight is not over.”
He has an additional scope-of-practice fight already on the horizon: a proposal to expand what optometrists may do. Hernandez introduced it in the spring but shelved it.
The doctors group opposes the measure, which has a personal twist: Hernandez is an optometrist.