On July 20, 2007 Pennsylvania Governor Ed Rendell signed into law at the University of Pennsylvania School of Nursing several bills included in his comprehensive health reform plan, “Prescription for Pennsylvania.” Rendell’s plan is noteworthy among recent state health reform initiatives in focusing not just on covering the 7 percent of Pennsylvanians who are uninsured, but also on improving access for all state residents by controlling costs. The bills signed on the 20th enact one important element in Prescription for Pennsylvania’s broad cost-control arsenal: expanding the role of nurses and other nonphysician care providers in treating patients.
Pennsylvania is not at the forefront of providing access to an interdisciplinary healthcare workforce. Indeed, it is a conservative state that had fallen behind other states in removing barriers to practice by qualified nonphysicians. But Pennsylvania represents the first state to make workforce policy changes integral to a larger reform package. Workforce initiatives have been largely ignored in debates about health reform, despite substantial evidence of nurse and physician shortages.
That the considerable initial opposition to Governor Rendell’s proposed legislation from medical interests was ultimately overcome, and in a conservative state like Pennsylvania, suggests that a tipping point may be occurring. It may now be politically possible to more fully exploit the rich and varied health care workforce in the U.S. as an element in overall health care reforms.
The July 20th bills “expand access to health care providers by eliminating barriers to practice to the fullest extent permitted by the provider’s scope of practice and expanding the scope of practice in certain cases.” The general rule written into law “allows Certified Registered Nurse Practitioners, Clinical Nurse Specialists, Physician Assistants, Nurse Midwives, and Independent Dental Hygienist Practitioners to take medical histories, perform physical or mental examinations and to provide acute illness or minor injury care or management of chronic illness in the same manner as physicians and dentists, so long as those activities fall within their specialty certification and scope of practice.”
The legislation also removes implicit barriers to the full participation of qualified nonphysicians in care by prohibiting the imposition of overly restrictive collaborative or written agreements by organizations or physicians that would constrain nonphysicians’ ability to provide timely and high quality services and referrals for their patients. Additionally, the legislation requires the inclusion of nonphysicians in provider networks, which would increase consumers’ access to lower-cost providers.
The July 20th legislation:
— Lifts limitations on how many NPs and PAs a physician may supervise under a collaborative or written agreement at a time;
— Prohibits unreasonable restrictions in collaborative or written agreements;
— Requires the establishment of a complaint review and mediation process by the state to resolve continuing barriers to nonphysician practice;
— Gives NPs additional authority to order various types of services and equipment and to perform and sign various types of evaluations and assessments. NPs may now order home care, hospice care, and durable medical equipment, make physical therapy and dietician referrals, perform and sign the initial assessment of methadone treatment evaluations, perform disability assessments, and issue home schooling certificates;
— Gives nurse midwives prescriptive authority;
— Establishes the “Independent Hygiene Practitioner” as an identified provider who can perform the functions of a dental hygienist at specified sites without the supervision of a dentist;
— Expands the places where pharmacists are permitted to manage drug therapy;
— Gives nurse anesthetists greater autonomy to practice in collaboration with, not under the supervision of, an anesthesiologist;
— Requires insurers to include in all provider networks: NPs, PAs, clinical nurse specialists working in primary care, nurse midwives, and the following types of practices if geographically available — urgent care, convenient care, nurse managed care, and federally qualified health centers; and
— Requires insurers to provide financial incentives for primary care providers to offer extended evening and weekend hours,which permit patients to “walk in” or receive a same-day appointment.
The Pennsylvania plan contains other measures to contain healthcare spending. It aims to reduce hospitalization for chronic diseases through provider incentives to encourage healthy lifestyles and attention to medications. It attempts to reduce hospital- acquired infections by requiring hospitals to adopt evidence-based practices. The plan also bans smoking in public places.
As have other state health reform initiatives, Governor Rendell has proposed to cover the 900,000 Pennsylvanians without health insurance. He believes that this goal will be more likely achieved if overall healthcare costs are controlled through provisions like those recently enacted. And in the meantime, access to affordable care should improve for all residents in the state because of his healthcare workforce reforms.
Pennsylvania’s health reform is worth watching. It is broad in its objectives and implementation strategies yet incremental in political and budgetary terms. Most importantly, it significantly alters the nature of the debate about health reform strategies by focusing on the health care workforce as a resource for achieving the objectives of improved access and quality at affordable costs.