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PENNSYLVANIA: Workforce Policy Solutions To Health Care Reform

September 5th, 2007

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.

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7 Responses to “PENNSYLVANIA: Workforce Policy Solutions To Health Care Reform”

  1. acavale Says:

    Let’s first delink the two ideas of social justice and healthcare. Just like a banker or laywer or accountant, physicians, dentists and all healthcare providers have their rights to set their own fees for the services they provide. If we want free services, let them make their own choices as to how they chose to provide their services for free. Forcing them to involuntarily provide services for free will only push them away from such services.

    And what is “unjustifiable profits”? Who defines profit as unjustifiable? It is an illusion that socialists cling to – one that inevitably leads to disappointment. Instead of that let’s say higher profits may actually spur an incentive to provide voluntary charity care…how is that for a revolutionary idea?

    Let’s not forget that a vast majority of physicians, dentitsts, nurses, etc. are practicing only because of their love of their profession and have tremendous altruistic tendencies. When honest hard work can only mean 14-hour workdays, 26 weekends of work yearly, and constant threat of litigation, noboody has any intention of providing any more free service time. By the way, if someone believes something like “the American social system” exists, then I have a bridge to sell them…

  2. Neil Gardner Says:

    What are we calling “the health care system”? Aren’t we all components of this system? And why is practicing any profession for profit suddenly an ugly thing? You get what you pay for

    We are all equally important componentsof our healthcare system, or at least we should be. Many are so entrenched in the current system they are incapable or in denial of visualizing any other way/model/paradigm to provide care, thus dooming many to poor or no care while letting unjustifiable profits go to many others.

    Until the blinders come off, not much changes. If you believe the American system is the best social system that can be had for providing healthcare to America, well let us just say that I do not! We can do much much better, and IMO, the first step is to define the overall mission of the healthcare system.

  3. acavale Says:

    What are we calling “the health care system”? Aren’t we all components of this system? And why is practicing any profession for profit suddenly an ugly thing? You get what you pay for – if Medicaid pays pennies on a dollar for a service, why would any logical professional voluntarily provide service at such a rate, especially since Medicaid patients have historically high no-show rates and complicated disease? Is any American willing to work more for less pay, knowing full well that it is going to get worse? Only the NY times can come up with such an outrageous article-probably why its circulation is dwindling…I am still waiting for the day when the Governor announces that he gets his care from a PA or NP and he authorizes Paralegals to function like Attorneys.

  4. Neil Gardner Says:

    Interesting related article in the NYTimes about workforce tampering and related issues, at least for dentistry. see:

    It is a disfunctional health care system that fails to meet its obvious (to many anyway) social mission, and it is proper and indeed necessary for society to make changes to any failing necessary social system such as we have now in our healthcare system in many many respects!

  5. Brenda Turner Says:

    Thank you for blogging about Health Care! The growing number of uninsured, now at over 47 million, the high cost of insurance and the release of the 2008 presidential candidates health care plans have brought the topic of health care reform to national headlines and prime time news.

    But what about the individual stories of American citizens facing a health care crises today? How do they navigate the broken health care system? At Outrageous we talk about the issues concerning individuals and small businesses. In addition to reporting on pending legislation and the record profits of pharmaceutical and insurance companies, we address the real life stories — emergency room care, mental health issues, drug abuse, obesity, preexisting conditions and children’s health. By letting our voices be heard-together we can find common sense solutions to reduce health care costs and increase access to quality health care for all.

    Outrageous Times is our monthly grass roots newspaper, dedicated to health care reform now and is distributed to over 20,000 readers in Mercer County, WV and Tazewell County, VA. The web site is a both a local and national health care resource. We would like to invite you and your readers to submit your stories, experiences, observations and opinions to Comments posted on are often reprinted in the Outrageous Times.

    Thanks in advance for your contributing your knowledge to


    Brenda Turner


    Outrageous Times

  6. acavale Says:

    As a physician who has successfully worked in a collaborative relationship with a non-physician provider for any years, I can appreciate some of the values of this legislation. But this blog would have served a bigger purpose if there was more discussion of practical issues rather than of ideological issues. It is irrelevant whether organised medicine is ooposed to this or not. The question is “at what cost are we allowing our population to access care delivered by less educated and possibly less well-trained individuals?”. I will be convinced of the value of this proposal when the Governor himself signs up to get his Primary Care from a CRNP/PA. If care from a non-physician provider is good for the average Pennsylvanian, it surely must be good enough for the Governor. I haven’t seen him do that yet.

    The second, probably most important in PA, issue left unaddressed by this legislation, is if CRNPs, PAs, etc start independent practice, how will the government keep their Medical Liability insurance costs at the same low (currently 1/10th of independently practicing physicians) level. Anybody who cares to discuss the factual reasons for rise in some of the health care costs must accept that the fear of frivilous law suits is a major cause. It woule be interesting to see how non-physician providers react when flooded with similar litigation. Will they also start to practice defensive medicine or will the government bail them out? If it does, then physicians will also have a legitimate case to ask for such reprieve, since the playing field for medical practice has been “leveled” by the Governor. This legislation conveniently skirts this issue.

    Thirdly, in my opinion, this legislation will most certainly mean the acceleration of the process of Primary Care Physicians either retiring or moving away or becoming hospitalists, which will clearly hurt access to health care, albeit saving some money.

    By the way, I would love to see the day when the Governor proposes to give full authority to Paralegals to perform full functions of lawyers, independent of supervision. If you can trust your life to PAs and NPs, you could certainly trust your legal woes to Paralegals. It would be interesting to see the reaction from the Bar Association to that legislation. It would ceratinly improve legal access to poor Pennsylvanians.

  7. Neil Gardner Says:

    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.

    I applaud the author for this observation and information. I would go so far as to suggest, no decry, that this country WILL NEVER be able to adequately care for all its citizens at a reasonable cost under the old paradigm controlled and enforced by organized medicine and organized dentistry. Expanded types of providers with expanded scopes of practice is the only practical answer to the healthcare riddle. Good for Rendell for realizing this, but the obstacles put up by organized dentistry and medicine will be formidable. Look at the challenge and lawsuit put up by the Amer. Dental Association against the Alaskan Tribes when they tried to use New Zealand type dental therapists to provide care over the nonexistent care provided by the current system. Lucky for the tribes, the judiciary system seems to see them as independent political entities, but they are entities that seem more interested in results rather than the status quo, unlike many states.

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