With federal health law, medical professionals look to expand turf

04/15/2013 12:00 AM

04/15/2013 7:50 AM

They want to take care of you.

Doctors, nurses and a variety of specialized health professionals are duking it out in California's Capitol over who should get your business once federal law requires that everyone have health insurance.

Physician assistants and nurse practitioners are pushing laws allowing them to see more patients for routine medical care.

Optometrists want to diagnose and treat all kinds of ailments related to the eye – even diabetes – not just test vision and prescribe glasses.

Pharmacists want to give more shots and write some prescriptions.

Chiropractors want to do medical exams required for commercial driver's licenses. Physical therapists want to treat injuries without a doctor's referral. Advanced nurses want permission to perform abortions, while midwives want to bill insurance for delivering babies at home.

Turf battles among medical professionals are not new to Sacramento. So-called "scope of practice" fights routinely crop up in the Capitol because state law defines which professions can perform which services.

Over the decades, the Capitol has seen duels between podiatrists and doctors, optometrists and opticians, psychologists and psychiatrists, plastic surgeons and dentists, and even veterinarians and dog groomers.

But 2013 is shaping up as a banner year for such debates in California and nationwide as the industry prepares for the federal health care law to kick in next year. The law requires almost everyone to have health insurance, which means a flood of new customers and billions of dollars for the industry to fight over.

"The expansion of coverage is making people think hard about the workforce and whether we have enough providers to care for the 30 million (more) people (nationwide) who will have insurance over the next few years," said Catherine Dower, associate director of the Center for the Health Professions at the University of California, San Francisco. An additional 3 million to 4 million people in California are expected to have health insurance under the law, Dower said.

Doctors oppose changes

Optometrists, nurse practitioners and other non-doctors argue that they should be allowed to perform broader arrays of services because California doesn't have enough doctors to treat all the soon-to-be- insured patients.

Doctors oppose most of the proposed changes, countering that patient safety is at risk. Non-physician specialists, they say, don't have nearly the training required to diagnose and treat many health conditions without the supervision of a doctor.

The dispute has set off a flurry of legislation and a war among medical trade associations in Sacramento. Doctors are tracking 18 bills they believe are aimed at expanding the scope of practice for non-doctors.

"It's a different environment than in years past where a 'scope' bill here or there would come up," said Molly Weedn, a spokeswoman for the California Medical Association, the lobbying group for the state's doctors. "With the onslaught of all of these this year, people are trying to take advantage of health-reform implementation."

The medical association spent $1.7 million on campaign contributions last year, has a team of eight in-house lobbyists and has contracts with two outside firms – one of whose partners include former Assembly Speaker Fabian Núñez and Adam Mendelsohn, chief of staff to former Gov. Arnold Schwarzenegger.

Going to war with the medical association has created a stream of business for Sacramento's lobbying firms and political public relations shops. At least a half-dozen of the wealthiest lobbying firms in town are involved in scope-of-practice fights.

A handful of trade associations – representing optometrists, pharmacists and nurse practitioners – have banded together to promote three bills that would expand the treatments they could offer patients.

"We have to utilize our health care system a lot more efficiently, and these are people who can very easily do it," said Sen. Ed Hernandez, a West Covina Democrat who is carrying the bills.

Hernandez and his wife are optometrists. They frequently see patients, he said, who exhibit all the signs of diabetes, but must refer them to a doctor for treatment. Hernandez wants optometrists to be able to take care of those patients without sending them to a doctor.

He also wants pharmacists to be able to give shots and prescribe some medications, and nurse practitioners to be allowed to open their own clinics.

"Organized medicine is going to become unglued," he said.

To go up against the doctors' lobby, the associations supporting Hernandez's bill package have launched a social media campaign and hired two well-known Capitol advocates: Andrew Acosta, a Democratic campaign consultant, and Steve Maviglio, a political strategist who also works for Assembly Speaker John A. Pérez.

(Maviglio said there's no conflict in simultaneously working for the trade groups and the speaker because the bills are in the Senate now, and he plans to leave the Assembly before they reach the lower house.)

Even bit players in the medical landscape have publicists and lobbyists making the case that their specialties should eventually be covered by the insurance plans required under federal law.

Practitioners of traumatology – a branch of traditional Chinese medicine – are pushing a bill that would license their specialty, the first step toward being covered by insurance.

Midwives are lobbying for a bill that would allow them to bill Medi-Cal for delivering babies in homes and birthing centers.

Psychologists, who have tried in the past to change the law so they could prescribe psychotropic drugs, are rallying again this year. They don't have a bill, but the National Alliance of Professional Psychology Providers has hired a publicist to help make the case that mental health care should be part of the conversation.

Scope fights go national

California is not the only state grappling with who should be allowed to care for new patients.

Similar fights are playing out nationwide, according to the National Conference of State Legislatures. Last year, the group reports, states handled more than 800 scope-of-practice bills. And in just the first three months of this year, lawmakers in 38 states introduced 178 such bills.

A common theme is how much authority nurse practitioners – who have master's or doctoral degrees – should have in providing primary care, given the shortage of doctors in many rural regions and inner cities.

Many of those bills across the country have been driven by a report from the national Institute of Medicine recommending that the scope of practice for nurse practitioners be expanded and standardized across states, said Dower, the UCSF researcher.

In California, Senate Bill 491 would allow nurse practitioners to open their own practices, without a supervising doctor, and prescribe medical equipment and review tests without a doctor's signature.

"I think this is a reasonable response to a situation that's existed for a long time – the primary care shortage," said Gerald F. Kominski, director of the UCLA Center for Health Policy Research.

Primary care doctors agree that they are in short supply. But they have a different view of the solution: They want California to produce more doctors.

"What you need to do is build the capacity of the system to care for people in safe ways," said Dr. Paul Phinney, a Sacramento pediatrician and president of the California Medical Association.

The association is pushing bills that would create more slots for medical residents in California and send $15 million a year to a new medical school at the University of California, Riverside. It argues that residents, who have graduated from medical school but are completing clinical training, have more education than nurse practitioners.

Call Laurel Rosenhall, Bee Capitol Bureau, (916) 321-1083. Follow her on Twitter @laurelrosenhall.

Editor's Note: This post has been updated from print and online versions to specify that it's the National Alliance of Professional Psychology Providers that has hired a publicist.


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