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Obamacare fuels turf war

It's doctors vs. other medical providers in a debate about what type care non-doctors may provide. The Legislature and governor should negotiate a truce to the decades-long fight that's only heating up.

April 24, 2013|George Skelton | Capitol Journal
  • Diana Dooley is secretary of California's Health and Human Services Agency, which is preparing for the startup of Obamacare.
Diana Dooley is secretary of California's Health and Human Services… (Hector Amezcua / Sacramento…)

SACRAMENTO — Obamacare is supplying fresh ammunition for one of the oldest turf wars in Sacramento.

It pits doctors — represented by the politically powerful California Medical Assn. — defending their turf against other medical providers. They're nurse practitioners, optometrists and pharmacists.

In political speak, it's about "scope of practice" — the type of medical care non-doctors are allowed to provide. The war has been waged for many decades, at times also involving chiropractors, podiatrists and any number of medical professions trying to encroach on the docs' terrain.

Mostly, the well-heeled docs have held their ground.

But now the nurse practitioners, optometrists and pharmacists are attacking all-out, fighting for a larger chunk of the action to be funded by Obamacare, officially called the Affordable Care Act.

When the act kicks in next January, most Americans will be required to buy health insurance or pay a penalty.

In California, that is expected to swell the insurance rolls by 4 million to 5 million people. (About 7 million currently are uninsured, but that includes illegal immigrants, who won't be eligible for Obamacare.)

There simply won't be enough doctors to care for all the newly insured, contend the turf invaders.

"If we're going to be mandating that everyone have health insurance, it's incumbent on the Legislature to make sure they have access to care," says state Sen. Ed Hernandez (D-West Covina), chairman of the Senate Health Committee. He's also an optometrist.

There seem to be ample primary care physicians in most urban areas. But Hernandez says there are major shortages in rural regions and minority communities. An estimated two-thirds of counties lack enough doctors. Moreover, around a quarter of the physicians are at retirement age.

Hernandez is pushing three bills (SB 491, 492, 493) that would allow, for example, nurse practitioners — more highly trained than RNs — to open their own shops and operate separately from physicians, who now are their supervisors.

"They wouldn't do anything above and beyond what they're now doing," Hernandez says, "But they'd be more accessible in inner cities and rural areas."

Optometrists, however, would be permitted to expand their scope of care for such maladies as diabetes.

Pharmacists could "do direct patient management," Hernandez says. "Prescribe birth control pills, smoking cessation pills…. Pharmacists are the most overly trained and underutilized professionals we have."

"This is all very contentious," the senator adds.

And very political.

It amounts to a full-time employment act for lobbyists.

The California Medical Assn. spent $2.9 million on lobbying during the last legislative session and funneled $1.2 million into campaign contributions during the 2012 elections. It donated $500,000 to Gov. Jerry Brown's tax-increase measure, Proposition 30.

Seventeen states allow nurse practitioners to operate independently, but the CMA is opposed.

"They need supervision," says CMA President Paul Phinney, a Sacramento pediatrician.

"It's the best way for them to practice to the full extent of their training. If my practitioner gets to a point where she's not confident in what she's dealing with, she has me to come to. I help educate her so she can take it from there."

Anyway, Phinney continues, "it's not like nurse practitioners are sitting around waiting to provide care. They're really very busy. This legislation wouldn't expand the work force. It just removes supervision."

As for optometrists, Phinney says, "some would know their limits. But opening the door to allow more [care] threatens patient safety."

And permitting pharmacists to alter prescriptions, he says, "could make someone's ailment a lot worse."

Hernandez' bills are scheduled for their first legislative hearing Monday.

The Brown administration is open to considering expansion of the non-docs' role in medical care.

"We haven't taken any position on the bills," says Diana Dooley, secretary of the state's Health and Human Services Agency, which is preparing for the startup of Obamacare.

"But we have to redesign the healthcare system. We need more managed care. We need to incentivize managing health instead of just treating disease. That underlies affordable healthcare," she says.

"To that end, there will be incentives for physicians to use more health professionals in their practices. There may be a need to consider the scope of services provided by other professionals."

How much might they expand?

"That's the conversation," Dooley replies. "We've got to be concerned about training and quality. And these bills are an opportunity to consider those issues. To the extent they give us more opportunity to manage health, they're worth considering."

One doctors' lobbyist, who didn't want to be identified because he was speaking off the reservation, told me: "Historically, the CMA hasn't wanted to give on anything. And the other groups want everything. Somewhere in the middle is where it's going to land.

"Everyone is trying to find the sweet spot — and flying the flag of ACA [Affordable Care Act] as the rationale for whatever they want to do."

We definitely should be using every medical professional's skills — while not sacrificing patient safety.

The Legislature and governor probably aren't expert enough to discover that fine line — the sweet spot. But they're the people empowered to do it. Hopefully they can negotiate an amiable truce to the turf war and make quality healthcare more accessible in inner cities and the boonies.

george.skelton@latimes.com

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