Quality, Patient Safety, and the Future of Integrated Healthcare Teams
On May 29, 2007, Mark A. Piasio, MD, president of the Pennsylvania Medical Society, presented the following testimony to the Pennsylvania House of Representatives' Professional Licensure Committee.
Chairman Sturla, minority chairman Adolph, and members of the House Professional Licensure Committee. Thank you for holding this hearing and inviting the Pennsylvania Medical Society to testify. The purpose of today’s hearing is to discuss House Bills 1253 and 1254, both of which are considered part of Governor Rendell’s Prescription for Pennsylvania. HB 1253 relates to certified registered nurse practitioners, while HB 1254 concerns clinical nurse specialists. Both bills are somewhat similar in language.
In recent weeks, I’ve been traveling across the state speaking with legislators, media outlets, and physicians about the Governor’s healthcare reform plan. There are certainly components of his Prescription for Pennsylvania that the Pennsylvania Medical Society lauds and supports, as well as parts that we believe raise a cause for concern.
For example, the Pennsylvania Medical Society believes that efforts to improve a person’s health through lifestyle changes would eventually pay big dividends towards the health of Pennsylvanians. The smoking ban is one good example, as well as obesity initiatives targeted at school age children though not explicitly in HB 700.
We also support using physician extenders to the fullest extent of their training and education with physician collaboration and oversight so that important patient safety measures are kept in place, and possibly enhanced. In addition, projects dealing with hospital-acquired infections are noteworthy. We applaud efforts to find a reasonable funding source to insure the uninsured, with a responsible phase-in timeframe.
In my discussions with various groups around the state, I see many nodding their heads in agreement with those proposals. The Pennsylvania Medical Society believes that those areas of the Governor’s Prescription for Pennsylvania offer a path that we should follow.
However, as I sit down with various groups to discuss removing the limit on how many physician extenders one physician can oversee, many believe it would fragment healthcare delivery, increase utilization and therefore cost, and not improve quality or patient safety.
That takes us to House Bills 1253 and 1254.
HB 1253 would allow one physician to have an unlimited number of collaborative agreements with CRNPs.
I personally have worked with CRNPs and believe that when trained appropriately, they are a valuable asset to the health care team. I’ve seen them in action, worked side by side, and within their scope of practice, in an integrated healthcare delivery model, they do a wonderful job.
But, allowing one physician the opportunity to be responsible for an unlimited number of allied health professionals confounds one as a solution to cost and quality, central to any reform measures. First, it is not humanly possible for one person to be personally responsible for an unlimited number of individuals in a clinical setting and to keep patient care safe. For comparison sake, when I trained a certified nurse practitioner in school, hired her, and provided appropriate clinical training for her to do her job, I noticed that in order to ensure patient safety, my workload increased significantly as I reviewed many more patient charts. We worked as a team, and provided access to orthopedic services in a rural community that I could not meet alone. For every physician extender being supervised, the physician will experience an increase in workload, if she wants to provide accurate, safe, cost-effective care.
By removing the cap, the odds of a medical mistake will increase. With greater supervisory responsibility, it’s more likely that something will be missed. One of the reasons for collaborative agreements is to help catch a medical situation that goes beyond an allied health professional extent of training and education. It happens, and we can’t ignore this. It’s reasonable to believe that a physician can catch these situations if the physician’s workload is at an appropriate level. Removing the cap on the number of physician assistants a physician can supervise has the potential to increase a physician’s workload beyond the level the physician can manage safely.
Second, House Bills 1253 opens the door for corrupt, profit-making medicine in the name of convenience and in exchange for quality.
One could certainly foresee the unintended consequence of profiteering companies proliferating dime store clinics, hiring a physician who might be licensed in Pennsylvania but not physically available, and then dispatching multiple physician extenders to work in those retail clinics. Ultimately, the patient may never have direct access to a physician’s expertise, especially in complex medical scenarios. This would create fragmentation in the patient’s care, potentially leaving the patient in the dark searching for a local physician to pick up where the system failed. Not to mention the increased cost associated with redundant services, especially if paid at the same rate. Without close collaboration, will the increased access be worth the cost? Is this the care you envision for your family?
I once felt that no limit on supervision might help with access, especially compared to independent practice without a medical degree. However, I think we have already had this discussion and agreed that 2-4 was a safe and productive limit.
The Pennsylvania Medical Society strongly supports the use of physician extenders including physician assistants and nurse practitioners to the fullest of their education and training through a collaborative agreement that creates a patient safety net to catch those instances that go beyond the extender’s scope. But, as HB 1253 is currently written, we believe there could be safety issues; thus, the Pennsylvania Medical Society has problems with the language.
Some language already in both HB 1253 and 1254 that we view positively is the language that would require both CRNPs and CNSs to carry medical liability coverage that’s equal to that of a physician. Currently, physicians are required to carry $1 million worth of medical liability coverage in the event of malpractice. While we hope that this insurance is never used, we’re glad to know that both CRNPs and CNSs would have such coverage in the event a patient is harmed and is due compensation.
The Pennsylvania Medical Society wants to stress that while some want to turn scope of practice issues into a turf war, we do not view it as such. This is simply about giving patients what they need most … that is a dedicated health care team that opens the door to safe access with each professional playing an integrated role to ensure the best possible outcome at the best possible cost.
If physician extenders such as CRNPs are allowed to practice independently, health care likely will be further fragmented for the patient. Thus, the Pennsylvania Medical Society feels strongly that independent practice for CRNPs would break up good teams and do more harm than good for patient care.
With some changes and clarifications to the current bills, we believe we could avoid potentially dangerous patient care situations and move forward in support. The intent of these bills is good. We look forward to supporting them if the patient safety piece is clear.
Thank you.
Last Updated: 8/1/2008