Amended Mid-Level Provider Bills OK'd

by David Gorn

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The Assembly Committee on Health this week passed two bills that would redefine the role of physician assistants, nurse practitioners and advanced pharmacists in the California health care system.

SB 493 by Sen. Ed Hernandez (D-West Covina) and SB 494 by Sen. Bill Monning (D-Carmel) don't expand scope of practice, the authors of both bills said, in that mid-level practitioners and advanced pharmacists won't have new responsibilities, but they will be able to practice with a little more autonomy. The bills are an effort to address the looming access-to-care issue in California.

"With implementation of the Affordable Care Act in California … there is going to be a capacity issue. There is going to be an access issue" once the Medi-Cal expansion and the Covered California health benefit exchange are fully established, Hernandez said.

"The two particular concerns of mine are the rural areas and the inner city," he said. "The pharmacy profession can play and will play an important role in this expansion mode, and they'll need an expansion of their scope of service to enable them to do so."

Monning said the dearth of providers can be addressed by allowing mid-level practitioners to take on more patients under the supervision of a physician.

"We must consider expanding our workforce to allow more efficient use of our primary care providers," Monning said. "This bill allows a health plan to increase the number of patients assigned to a primary care physician, based on the use of one or more physician assistants or nurse practitioners."

Monning's bill allows an additional 1,000 patients per mid-level provider to the physician-led team.

Both measures were amended. In the case of Monning's SB 494, the change was adding a 2018 sunset date.

Assembly member Richard Pan (D-Sacramento), chair of the committee, said he was voting for the measure but had one lingering concern:

"Expanding the number of people who could be followed by a physician assistant, raising the number for a PA from 1,000 to 2,000" could create an unusual problem, Pan said. "If the physician's practice size stays the same, it could put pressure [on physicians] to reduce the number of PAs in their practice."

Monning said the added amendment addressed that issue, in a way. "Now that sunset date was added," Monning said, "if there are unintended consequences, we can revisit."

Pharmacists must have an advanced degree to qualify for the benefits of SB 493, Hernandez said.

"Pharmacists now are going to be doing a residency program and rotations to increase the number of patients they see," he said. "Pharmacists are vastly underutilized for the amount of training and education they receive.

This bill expands the types of settings in which pharmacists can collaborate with physicians, as they do now under specific settings."

According to Jennifer Abraham, a Kern County internist who spoke at Tuesday's committee hearing, about 90% of prescriptions in California are filled for chronic conditions.

"Medication management is getting more and more complicated," Abraham said, adding that some chronic-condition patients of hers take 8 to 10 medications a day.

"I've always appreciated the expertise of the doctors of pharmacy," she said. "What I need most in my practice is to have my patients have more access to me, and my expertise. What I need is a provider I can trust to delegate education and medication regimens of some of my more chronic disease patients. This will expand patient access."

Both bills passed by 18-0 votes, and both now head to Assembly Appropriations.


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