BILL ANALYSIS Ó
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 233
S
AUTHOR: Pavley
B
AMENDED: March 31, 2011
HEARING DATE: April 13, 2011
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CONSULTANT:
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Tadeo
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SUBJECT
Emergency services and care
SUMMARY
Expands the definition of a medical professional that can
provide consultation, care, treatment and surgery in an
emergency department setting to include a physician
assistant (PA) practicing in compliance with prescribed
provisions.
CHANGES TO EXISTING LAW
Existing federal law:
Establishes the Emergency Medical Treatment and Active
Labor Act (EMTALA), which governs when and how a patient
may be refused treatment or transferred from one hospital
to another when the patient is in an unstable medical
condition.
EMTALA permits an on-call physician, under hospital
policies, the option to direct a non-physician practitioner
or his or her representative to appear at a hospital and
provide further assessment or stabilizing treatment to an
individual.
Continued---
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Existing state law:
State law contains requirements similar to EMTALA which
require emergency services to be provided to any person
requesting the services or care, or for whom services or
care is requested, for any condition in which the person is
in danger of loss of life, or serious injury or illness, at
any licensed health facility that maintains and operates an
emergency department to provide emergency services to the
public when the health facility has appropriate facilities
and qualified personnel available to provide the services
or care.
Defines "emergency services" as the medical screening,
examination, and evaluation by a physician, or, to the
extent permitted by applicable law, by other appropriate
personnel under the supervision of a physician, to
determine the care, treatment, and surgery by a physician
necessary to relieve or eliminate the emergency medical
condition or active labor, within the capacity of the
facility.
Establishes the Physician Assistant Practice Act
administered by the Physician Assistant Committee
(Committee) of the Medical Board of California (MBC) to
regulate physician assistants.
Provides that a PA may perform those medical services as
set forth by the regulations of MBC when the services are
rendered under the supervision of a licensed physician and
surgeon approved by MBC, except as otherwise provided.
Requires a PA and his or her supervising physician and
surgeon to establish written guidelines for the adequate
supervision of the PA, which may be satisfied by the
adoption of protocols for some or all of the tasks
performed by the PA. Requires the protocol to
meet specified requirements.
Authorizes a PA to administer or provide medication to a
patient, or transmit orally or in writing on a patient's
record or in a drug order, an order to a person who may
lawfully furnish the medication or medical device as
specified.
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Authorizes a PA, pursuant to a Delegation of Services
Agreement (DSA), to order durable medical equipment,
certify unemployment insurance disability, and after
consultation with the supervising physician, approve, sign,
modify, or add to a plan of treatment or plan of care for
individuals receiving home health services or personal care
services. Authorizes physician assistants to conduct
specified medical examinations and sign corresponding
medical certificates for various individuals.
Authorizes a PA to conduct specified medical examinations
and sign corresponding medical certificates for various
individuals.
This bill:
Expands the definition of "emergency services and
care" to clarify that PAs can provide these services by
explicitly including them in the definition.
Expands the definition of "consultation" to clarify that
PAs can provide these services by explicitly including them
in the definition.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
The author states that when it comes to health care access,
California is in a crisis. According to the author,
emergency rooms across the state are overcrowded and
overburdened, and it is important to remove unnecessary
barriers to routine care.
According to the author, SB 233 is prompted by a recent
problem in which recently a PA was prohibited from
providing a consultation in the emergency department (ED)
at Mission Hospital in Orange County. Although these types
of services are explicitly and commonly authorized by
supervising physicians at hospitals, in this case the
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hospital pointed out that existing law does not explicitly
authorize a PA to perform consulting and treatment services
in an ED setting.
The author argues that state law is in conflict with
EMTALA, which permits PAs to provide consults in the ED,
and that SB 233 would make state law consistent with
federal law. The author adds that PAs working in
specialty practice areas provide an essential service to
the ED, as they can expedite the admission or surgical
preparation of the patient, under the supervision of the
physician and surgeon, in order to vacate a bed for an
incoming ED patient. The author contends that as long as
evaluation, consultation and treatment is performed
pursuant to a PA's scope of practice and DSA, and under the
supervision of a physician and surgeon, this type of care
by a PA is routine and should not be unduly restricted by
omissions and lack of clarity in the current definition of
emergency services and care.
Emergency Medical Treatment and Active Labor Law (EMTALA)
EMTALA was
passed as part of the Consolidated Omnibus Budget
Reconciliation Act of 1986, (COBRA). Under EMTALA, a
patient who comes to, or is brought to the ED must be
provided with an appropriate medical screening examination
to determine if an emergency medical condition exists. If
an emergency situation is determined, the hospital is
obligated to either provide treatment until the patient is
stable, or transfer the patient to another hospital in
conformance with the statute's directives.
The purpose of EMTALA is to prevent hospitals from
rejecting patients, refusing to treat them, or transferring
them to charity hospitals or county hospitals because they
are unable to pay or are covered under the Medicare or
Medicaid programs. This purpose, however, does not limit
the coverage of its provisions.
EMTALA applies only to participating hospitals, i.e.,
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hospitals that have entered into provider agreements under
which they will accept payment from the Department of
Health and Human Services, Centers for Medicare and
Medicaid Services (CMS) under the Medicare program for
services provided to beneficiaries of that program. In
practical terms, this means that it applies to virtually
all hospitals in the U.S., with the exception of the
Shriners' Hospital for Crippled Children and many military
hospitals. Its provisions apply to all patients and not
just to Medicare patients.
EMTALA permits an on-call physician, under hospital
policies, the option of sending a representative, i.e.,
directing a non-physician practitioner or his or her
representative to appear at the hospital and provide
further assessment or stabilizing treatment to an
individual. According to EMTALA, this determination should
be based on the individual's medical need and the
capacities of the hospital, and the applicable state's
scope of practice laws, and hospital by-laws and rules and
regulations. There are some instances in which the
non-physician practitioner can provide the specialty
treatment more expeditiously than the physician on-call.
It is important to note, however, that the designated
on-call physician is ultimately responsible for providing
the necessary services to the individual regardless of who
makes the in-person appearance. Furthermore, in the event
that the treating physician disagrees with the on-call
physician's decision to send a representative and requests
the actual appearance of the on-call physician, then the
on-call physician is required by EMTALA to appear in
person.
Physician Assistants (PAs)
PAs are medical practitioners who perform services under
the supervision of a physician and surgeon. The scope of
practice of the PA is described in the Physician Assistant
Practice Act and in regulations promulgated by MBC.
Pursuant to these laws, each PA may perform only those
services he or she is authorized to perform pursuant to a
written delegation of authority by the supervising
physician and surgeon. A supervising physician and surgeon
is required to delineate the services their PAs may render
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in a DSA. The regulations provide that PAs may only
provide those medical services which he or she is competent
to perform and which are consistent with the PA's
education, training, and experience, and which are
delegated in writing by a supervising physician and surgeon
who is responsible for the patients cared for by that PA.
This bill would define DSA consistent with current
regulations.
Current law also authorizes a PA to certify any person as
disabled for purposes of the issuance of disabled placards;
perform medical examination and provide necessary medical
certificates for applicants seeking a license to drive
standard commercial vehicles; perform medical examination
and provide necessary medical certificates for any person
who operates a school bus; and, perform medical examination
and provide necessary medical certificates for any
applicant of a school district or county superintendent of
schools for certificated positions.
Prior legislation
SB 1069 (Pavley and Fletcher), Chapter 512, Statutes of
2010, authorizes a PA, pursuant to a delegation of services
agreement, to order durable medical equipment, certify
unemployment insurance disability, and after consultation
with the supervising physician and surgeon, approve, sign,
modify, or add to a plan of treatment or plan of care for
individuals receiving home health services or personal care
services. Authorizes PAs to conduct specified medical
examinations and sign corresponding medical certificates
for various individuals.
SB 171 (Pavley), Chapter 34, Statutes of 2009, allows PAs
and advanced practice registered nurses to perform a
physical examination and submit directly to the governing
board or county superintendent of schools the medical
certificate of a person wishing to be employed in a
position requiring certification qualifications, or a
former retired employee of a school district, as a
condition of initial employment.
AB 356 (Fletcher), Chapter 434, Statutes of 2009, expands
the existing category of licentiates of the healing arts to
include a licensed PA who practices pursuant to the
Radiologic Technology Act, and authorizes a physician and
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surgeon to delegate procedures using ionizing radiation,
including, but not limited to, fluoroscopy, to a
licensed PA, under specified conditions.
AB 3 (Bass), Chapter 376, Statutes of 2007, creates the
California Team Practice Improvement Act which deletes the
prohibition on the authority of a PA to issue a drug order
for specified classes of controlled substances, but only if
the PA has completed a specified education course, requires
a PA and the supervising physician and surgeon to establish
written supervisory guidelines and protocols, increases the
number of PAs a physician and surgeon may supervise to
four, and specifies that services provided by a PA are
included as covered benefits under the Medi-Cal program.
AB 139 (Bass), Chapter 158, Statutes of 2007, allows a PA
or a licensed advanced practice registered nurse qualified
to perform a medical examination, to conduct medical
examinations on applicants seeking licensure to drive a
school bus, youth activity bus, farm labor vehicle or
paratransit bus.
Arguments in support
The California Academy of Physician Assistants (CAPA), the
sponsor of SB 233, states that existing law allows PAs to
perform a variety of medical services set forth by
regulations adopted by the MBC when rendered under the
supervision of a physician and surgeon. CAPA argues that
SB 233 would clarify an inconsistency in state law by
explicitly authorizing PAs to perform consultative and
treatment services in the hospital ER, providing an
increase in to urgent medical care and a decrease in
patient overcrowding.
COMMENTS
1. This bill could result in limiting emergency services,
care, consultation and surgery to only PAs while other
appropriate medical personnel are also qualified to deliver
these services. As drafted, AB 233 could result in the
unintended consequence of limiting ER services to PAs by
naming them explicitly in law and omitting other medical
professionals, such as nurse practitioners, that are
trained and able to deliver these services within their
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scope of practice.
Suggested amendments would define "emergency services and
care" and "consultation" to include delivery by all
appropriate professional medical personnel, to the extent
permitted by applicable law, hospital policies and medical
staff by-laws, acting within the scope of their licensure
and clinical privileges, under the supervision of a
physician and surgeon.
POSITIONS
Support: California Academy of Physician Assistants
(sponsor)
Oppose: None received.
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