Wednesday, January 16, 2019

2015 Legislative Wrap Up

By Janus L. Norman, CMA Senior Vice President

It is difficult to imagine, but the 2015 legislative year was even more challenging than the 2014 legislative year, which included the diversion of staff resources to defeat Proposition 46. With a third of legislators (40 out of 120) serving freshman terms, the California Medical Association’s (CMA) Government Relations staff spent a considerable amount of time during the first quarter educating new legislators and their staff about the mission and policies of CMA. Through our educational efforts, we successfully stopped the introduction of a number of harmful legislative proposals and shifted focus to the passage of CMA’s sponsored bill package.

School Vaccines
A majority of our resources this year went to the passage of SB 277 (Pan and Allen), our sponsored bill eliminating the personal belief exemption (PBE) for school vaccination requirements. We faced relentlessly vocal opposition from anti-vaccine activists, who were supported by the California Chiropractic Association and the newly founded Public Health Council. As it moved through the Legislature, SB 277 had four hearings in various committees, each of which was flooded by protesters. Our strategy to overcome this deluge was to counteract on the same grassroots level from which we were attacked. CMA engaged with school districts, county boards of supervisors and all levels of local government to strengthen support for the bill. Through these and our more traditional lobbying efforts, we were able to see the bill passed out of the Legislature and sent to the Governor’s desk. Although the Governor had 12 days to pass or veto the measure, he chose to sign SB 277 into law less than 24 hours after he received it. In his signing message, he wrote, “The science is clear that vaccines dramatically protect children against a number of infectious and dangerous diseases. While it’s true that no medical intervention is without risk, the evidence shows that immunization powerfully benefits and protects the community.”

SB 277 also garnered tremendous support in the press and from the physician community at large. All through the year, this bill made state and even national headlines. The New York Times, often regarded as the national “newspaper of record,” even editorialized in support of the bill. After SB 277 became law, Senator Richard Pan, M.D., was lauded by TIME magazine as a “hero of vaccine history,” while the Journal of the American Medical Association pointed to SB 277 as a potential catalyst and model for stricter vaccine requirements across the nation. The New England Journal of Medicine chronicled the entire SB 277 story, describing a sea change in the national politics of vaccination. We continue to regularly field calls from allies across the country who are seeking to learn more about what we accomplished and how we did it.

Unfortunately, our time to celebrate the hard-won victory was not long, as we quickly had to turn our attention to new attacks: a referendum to overturn the new law and a recall effort against Dr. Pan for his authorship of it. Through CMA’s political action committee, CALPAC, we will continue to work to defend Dr. Pan and his important law from this spurious attack.

Scope of Practice
Throughout the year, CMA dedicated a vast amount of resources to the successful defeat of several scope-of-practice expansion attempts that were before the Legislature. These measures were: SB 323 (Hernandez), for nurse practitioners; SB 538 (Block), for naturopathic doctors; and SB 622 (Hernandez), for optometrists. Each of the bills claimed to expand the scope of practice for allied health professionals as a means of ameliorating California’s access to care crisis, but, in reality, posed a danger to patients. Through diligent lobbying and with the engagement of our physician members calling and writing their legislators, CMA convinced lawmakers of that truth. Each bill was successfully killed in either a policy or fiscal committee, sending an unequivocal rejection of scope expansions as an answer to access to care issues. Year after year, these expansions are rejected by the Legislature, demonstrating that the physician voice still holds sway at the Capitol.

Scope of practice fights generally play out similarly, except, this year, for one unique experience. An amicable solution was reached on AB 1306 (Burke), relating to certified nurse midwives (CNMs). Negotiations with the CNMs were productive and in time we were able to reach an agreement, moving CMA to a neutral position. Ultimately, however, this bill, too, died in committee.

Physician Aid-in-Dying
Another fruitful negotiation centered on SB 128 (Wolk and Monning), the physician aid-in-dying bill. This controversial measure demanded a lot of attention from CMA. We began the year with a longstanding House of Delegates-established policy of opposition to this subject. It soon became clear, though, that this was no longer the overwhelming stance of the membership that it once was. CMA’s physician leaders began a conversation with our physician members so that we could update our official policy to reflect the new, nuanced views of our members. CMA became the first medical association in the nation to move from opposition to neutrality on physician aid-in-dying. Having received permission from our Council on Legislation and from our Board of Trustees to engage with the bill’s proponents in hopes of reaching solutions, CMA’s lobbyists, in conjunction with CMA’s Center for Legal Affairs, entered exhaustive negotiations. Although CMA had become neutral on the concept of physician aid-in-dying, there were still concerns to be addressed about the bill’s language. Through countless meetings, a final comprehensive solution was reached and CMA officially became neutral on the bill. The crucial amendments that were secured to reach that agreement included the strongest statutory immunity protections for physicians, voluntary participation protections and mental health evaluations. After SB 128 failed in the Assembly Health Committee, its cause was revived through a bill, ABX2 15 (Eggman), in the special session on health care called by the Governor. This bill ultimately retained our negotiated amendments and our neutrality, and was passed by the Legislature on its last day in session. On October 5, the Governor signed the bill into law.

Workers' Comp
The physician aid-in-dying bill was far from our only instance of exhaustive negotiations this year. CMA also took part in extensive discussions regarding AB 1124 (Perea), a bill that would require the Division of Workers’ Compensation to establish a prescription formulary. After several months of diligent negotiations, we reached an agreement with the author’s office that moved our position to neutral. Through negotiations on this bill, CMA solidified its standing as a full stakeholder in workers’ compensation.

In the final days of the session, while almost all eyes were watching the major political fights, CMA staff went to work with Assemblymember Travis Allen to extend the Controlled Substance Utilization Review and Evaluation System (CURES) registration deadline for all prescribers and furnishers. On Thursday, September 10, CMA and Assemblymember Allen gutted and amended AB 679 to extend the deadline from January 1, 2016, to July 1, 2016. This extension will allow the Department of Justice to roll out its automated registration process and protect doctors from being disciplined by the Medical Board of California during the system roll-out.

In two days, the bill was heard in Senate Business and Professions Committee, on the Senate Floor and on the Assembly Floor. AB 679, as amended on September 10, passed the Legislature without receiving a single “no” vote. The measure also included an urgency clause, meaning the bill goes into effect as soon as it is signed by the Governor.

“Surprise” Billing
Our other focus in the final days was the completion of a year-long fight. AB 533, introduced by the Chair of the Assembly Health Committee, Rob Bonta, initially seemed like a matter of negotiation. We had a good relationship with the author, and we shared his goal of addressing the “surprise billing” problem. Instead, over the course of the year, those negotiations became increasingly hostile until they finally deteriorated to an all-out war.

Going into the last week of the legislative session, AB 533 would have drastically changed the current health care marketplace by allowing a massive transfer of negotiating power to the health plans at the expense of physicians. The bill would have required non-contracted physicians and dentists to accept Medicare rates as payment in full when performing services in a contracted or “in-network” facility. In addition, the bill would have implemented barriers for PPO patients seeking to access their out-of-network benefits. Overnight, the bill became essentially a health plan-sponsored bill, with the strong support of consumer groups and organized labor.

With myriad resources, the health plans spent tens of thousands of dollars hiring contract lobbying firms to lobby in favor of AB 533. The California Federation of Labor, the California Firefighters and most of organized labor, who were misinformed about the full contents of the bill, also lent their political muscle to the passage of bill, for they believed it would protect patients from exorbitant, unexpected bills. Finally, the California Chamber of Commerce and consumer groups, led by Health Access, also spent their political resources in favor of the bill.

In order to defeat AB 533, it was all hands on deck at CMA and we called upon our Legislative Key Contacts, CMA officers and medical executives, asking them to call their legislators on the last night of session to ask them to vote no on AB 533. CMA was also able to call upon the specialty societies and two of our closest allies to stand in opposition: the California Dental Association and the California Podiatric Medical Association.

After countless hours of lobbying and passionate debate in the halls and on the floors of the State Capitol, CMA and our allies defeated the measure on the floor of the State Assembly. This CMA victory was the final act taken by the Legislature in 2015, solidifying this year as one of the most challenging and one of the most successful.

Legislative Alert: Urge your Legislator to OPPOSE Bills to Expand Scope of Nonphysician Practitioners

Urge your assembly members to OPPOSE SB 491, SB 492 and SB 493 today!

These bills would provide nurse practitioners with independent practice, allow optometrists to perform surgical and nonsurgical primary care beyond their scope of practice, and create a new advanced practice pharmacist who can prescribe medication and administer immunizations. Ultimately, these bills will put patients at risk and lower the quality of care provided in our state.

Additional information, including talking points, are provided below.

(Click here to) Take Action!

(Click here if you called) I Made the Call!

Call (877) 362-8455 to be connected with your legislator.

CMA is urging you to call your legislators and ask for NO votes on SB 491, SB 492 and SB 493. These three bills will expand scope of practice and remove necessary supervision by a physician and surgeon, ultimate harming patients while decreasing quality of care.

 SB 491 (Hernandez) – This bill would allow nurse practitioners to open practices without any oversight from a trained medical doctor and prescribe dangerous, addictive drugs without supervision. While an important part of the health care delivery system, nurse practitioners simply do not have adequate training or years of education that physicians do in order to be qualified to practice medicine without physician involvement.

SB 492 (Hernandez) – This bill would allow optometrists to provide primary care service including diagnosing diabetes, high cholesterol and hypertension. Under this bill, optometrists would be able to examine, prevent, diagnose and treat any disease, condition or disorder of the visual system, the human eye and adjacent related structures.

SB 493 (Hernandez) – This bill would allow advanced practice pharmacists to evaluate and manage diseases and health conditions without physician consultation. Additionally, any pharmacist would be able to furnish prescription smoking cessation drugs and devices with known harmful side effects including depression and in some cases, suicide.

All three of these bills will be heard in the Assembly Business, Professions and Consumer Protection Committee soon.

Legislators need to know the true impact these bills would have in their districts.

Your calls are imperative to help us stop these bills and protect patients. We ask that you and your colleagues call, fax or email your legislators TODAY and urge them to vote NO on SB 491, SB 492 and SB 493!

Phone calls and office visits are most effective, but faxes and emails are important too. If you choose to fax or email your legislators, we strongly encourage that you personalize the letter (provided below), which will greatly increase its impact.

If you are logged into the CMA website, your legislators should automatically be displayed. If not, you can click here to locate your legislators by zip code.

Talking Points

  • SB 491, SB 492, and SB 493 harm patient safety plain and simple.
  •  Other health professionals, while hugely important to the health care delivery system and an integral part of medicine, are not trained to diagnose and treat diseases like physicians are.
  •  Rather than further fragment the health care delivery system, we need to be looking at integrated care models that utilize everyone to the best of their abilities.
  •  SB 491, SB 492 and SB 493 will allow NPs, optometrists and pharmacists to practice medicine without being subject to the controls and oversight of the Medical Practice Act. The end result would be that these specific health practitioners would be held to a lower standard of care than physicians providing the same service.
  • If passed, these bills will allow individuals the ability to prescribe dangerous medications such as opioids. The Registered Board of Nursing is simply not equipped to oversee such prescribing and does not have an investigatory arm, as the Medical Board of California does.  
  • In my own experience, under-trained professionals order more tests and imaging studies as well as send patients for more referrals than do physicians.
  • To ensure patient safety, medical care must be administered in coordinated teams led by experienced, fully trained, qualified physicians.  
  • Proponents of this bill are using the guise of health care reform to say that independent practice will expand access to care. That is just not the case.
  • The same economic factors that I face as a physician will impact NPs, optometrists and pharmacists. (Expand on the economic considerations you face each day).
  • The number of physicians in California is unevenly distributed with regards to the general population, but these bills do not solve the problem. The majority of allied health professionals are practicing in the same regions as physicians now. There is no proof that indicates NPs, optometrists and pharmacists will indeed move to rural or under-served areas.
We believe patients are best served when they are provided with meaningful access to safe medical care provided by medical teams led by highly trained and qualified physicians.

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