BILL ANALYSIS                                                                                                                                                                                                    






                                 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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