By Jonathan Z. Cohen*
November 19, 2008
Editors' Note: As promised, this report is the first in a series of healthcare reform updates from our volunteer reporters in various states. The first update from each state will generally consist of a summary of what's happened on the healthcare reform front to date in that state. Once the new legislative sessions start, our reporters will send bulletins as developments occur. There's no significance to the order in which we present state reports. We generally publish them as we receive them.
Over the past two years, a great deal of healthcare legislation has been passed in Pennsylvania. Most, if not all, of this legislation has come under the umbrella of Governor Ed Rendell's "Prescription for Pennsylvania," which his administration describes as a "comprehensive health care reform initiative to address the access, affordability and quality of health care in the commonwealth." However, the bedrock of the program, legislation to greatly decrease the number of uninsured Pennsylvanians, languished in the Senate in 2008. Below is a summary of the most important developments in Pennsylvania health law that occurred in 2007 and 2008.
On May 21, 2007, Governor Rendell issued two executive orders relating to healthcare. One order established the Governor's Chronic Care Management, Reimbursement and Cost Reduction Commission. The other established the Office of Health Equity and the Office of Health Equity Advisory Committee. The Chronic Care order recognized the grave threat posed by chronic diseases to Pennsylvania residents and the high rate of hospitalizations caused by chronic diseases in this state. The purpose of the Commission "is to design the informational, technological and reimbursement infrastructure needed to implement and support widespread dissemination, adaptation and implementation of the components for chronic care in relevant health care sites throughout Pennsylvania, which result in quality outcomes and cost effective treatments for patients with chronic diseases."
The Health Equity order recognized that racial and ethnic minorities in Pennsylvania suffer disproportionately high incidence and mortality rates for heart disease, stroke, cancer, diabetes, infant mortality, and HIV/AIDS. The specific responsibilities of the Office of Health Equity and the Office of Health Equity Advisory Committee are somewhat vague, but they include increasing public awareness of health disparities, identifying sources of federal and private funding to support programs addressing health disparities, and recommending actions to the Secretary of Health that are "data-driven, evidence-based, and culturally aware."
On July 20, 2007, Governor Rendell signed six separate acts expanding the scope of practice of healthcare workers, permitting larger numbers of healthcare workers to work under physicians and clarifying education and licensure requirements:
- Act 46 permitted a medical doctor to supervise up to four physician assistants, and it authorizes application for a waiver of this number from the State Board of Medicine. Previously, Pennsylvania law allowed medical doctors to supervise only two physician assistants.
- Act 47 allowed doctors of osteopathic medicine to supervise four physician assistants under a collaborative agreement. Previously, Pennsylvania law allowed doctors of osteopathic medicine to supervise only two physician assistants.
- Act 48 expanded the scope of practice for Certified Registered Nurse Practitioners (CRNPs). For example, the newly permitted responsibilities of CRNPs include: ordering home health and hospice care, ordering durable medical equipment, making referrals for physical therapy and dietitian services, and making referrals for respiratory or occupational therapy. Act 48 also requires CRNPs to carry the same amount of malpractice insurance as physicians that perform comparable services.
- Act 49 clarified the licensing and education requirements for Clinical Nurse Specialists (CNSs). The "practice of clinical nurse specialist" can now be described as the "provision of direct and indirect nursing at the advanced level." Those desiring to be certified as a CNS must: (1) be a licensed registered nurse; (2) complete at least a masters level program in accredited nursing or CNS; (3) achieve a national certification as a CNS; and (4) satisfy all other requirements of the State Board of Nursing.
- Act 50 permitted certified nurse midwives to prescribe, dispense, and order certain drugs, medical devices, immunizing agents, and laboratory tests. However, these workers must undergo pharmacological training and must act under a collaborative agreement with a physician.
- Act 51 clarified the scope of practice for licensed dental hygienists and certified public health dental hygiene practitioners. Licensed dental hygienists may now perform radiological treatments under the supervision of a dentist. Public health dental hygiene practitioners may perform certain intra-oral procedures and radiological treatments in approved settings without the supervision of a dentist. This act also sets out certification requirements for public health dental hygiene practitioners.
These six pieces of legislation permit healthcare professionals to take full advantage of their education and to treat more patients in a shorter period of time. Physicians and dentists are relieved of a substantial amount of responsibility.
Also on July 20, 2007, Governor Rendell signed an act that amends the Medical Care Availability and Reduction of Error (Mcare) Act to require the surveillance and reporting of healthcare-associated infections (HAIs). This is a response to the startling number of Pennsylvanians who have died from HAIs in recent years. Important provisions of the act include: (1) healthcare facilities must formulate and execute an internal infection control plan that includes a system for determining which patients have become infected with Methicillin-resistant Staphylococcus aureus (MRSA) or other drug-resistant organisms and an infection control intervention protocol; (2) HAIs are deemed "serious events" that must be reported to the Pennsylvania Patient Safety Authority; and (3) the state will offer quality improvement payments to facilities that demonstrate a 10% reduction in infections.
On March 26, 2008, the Pennsylvania Health Information Exchange (PHIX) Governance Structure was established by executive order. This order recognized that a secure statewide information exchange would improve access to electronic health information and thereby reduce medical errors, redundant tests and procedures, and overall healthcare costs. The purpose of the PHIX Governance Structure is to develop and implement this information exchange.
On June 10, 2008, the Senate passed the Pennsylvania Clean Indoor Air Act, which bans smoking in the workplace and most other public places. This legislation took effect on September 11, 2008. Exceptions to the smoking ban include: 25% of the rooms in a hotel or motel, cigar bars and tobacco shops, private clubs, bars with at least 80% of their income deriving from alcohol sales, restaurant bars that maintain a separate entrance and ventilation system for smoking and non-smoking areas, and 25% to 50% of a casino floor. While some anti-smoking special interest groups have complained that the act contains too many exceptions, one senator who supported the bill responded that the ban still covers 90% to 95% of all places of employment and other public places.
On July 9, 2008, Governor Rendell signed the Pennsylvania Autism Insurance Act into law. This act requires many private health insurance companies to cover diagnostic assessment and treatment of autism spectrum disorders. This coverage includes prescription drugs and blood level tests, psychiatric or psychological services, applied behavioral analysis, and speech and language therapy. Autistic persons under age 21 will be entitled to insurance for their disorder if they are enrolled in an employer group insurance policy with more than 50 employees, are on Medical Assistance, or are covered under the state's Children's Health Insurance Program or adultBasic program. Private insurers are obliged to pay up to $36,000 of the costs of autism treatment or diagnosis for each policyholder. If such costs run over $36,000 per year, the state must pay the remainder.
As mentioned above, over the past two years Governor Rendell has attempted to push through legislation that would expand coverage for the uninsured. This proposal, called "Cover All Pennsylvanians," initially called for health insurance for approximately 431,000 uninsured persons. However, the administration has confronted the need to compromise with the Republican-controlled Senate; each offer and counter offer made since the initial proposal in January 2007 has brought the number of covered individuals down and promised fewer benefits. As recently as November 11, 2008, Governor Rendell was negotiating with the Senate to pass some health insurance expansion. However, the downturn in the economy has led Senate Republicans to question the wisdom of adding new spending programs. It appears that no action will be taken on health insurance until the next legislative session.
*We would like to thank Jonathan Z. Cohen, Esquire (Post & Schell PC, Philadelphia, PA) for writing this email alert.