BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                      



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          |SENATE RULES COMMITTEE            |                   SB 233|
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                              UNFINISHED BUSINESS


          Bill No:  SB 233
          Author:   Pavley (D)
          Amended:  8/25/11
          Vote:     21

           
           SENATE HEALTH COMMITTEE  :  9-0, 4/27/11
          AYES:  Hernandez, Strickland, Alquist, Anderson, Blakeslee, 
            De León, DeSaulnier, Rubio, Wolk

           SENATE APPROPRIATIONS COMMITTEE  : Senate Rule 28.8

           SENATE FLOOR  :  37-0, 5/31/11
          AYES:  Alquist, Anderson, Blakeslee, Calderon, Cannella, 
            Correa, De León, DeSaulnier, Dutton, Emmerson, Evans, 
            Fuller, Gaines, Hancock, Harman, Hernandez, Huff, Kehoe, 
            La Malfa, Leno, Lieu, Liu, Lowenthal, Negrete McLeod, 
            Padilla, Pavley, Price, Rubio, Runner, Simitian, 
            Steinberg, Strickland, Walters, Wolk, Wright, Wyland, Yee
          NO VOTE RECORDED:  Berryhill, Corbett, Vargas

           ASSEMBLY FLOOR  :  76-1, 8/30/11 - See last page for vote


           SUBJECT  :    Emergency services and care

           SOURCE  :     California Academy of Physician Assistants


           DIGEST  :    This bill clarifies existing law to explicitly 
          permit appropriate 
          licensed personnel to perform consultations and treatment 
          in an emergency department if within their existing scope 
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          of practice.

           Assembly Amendments  authorize the treating physician and 
          surgeon to request to communicate directly with the 
          consulting physician and surgeon, and require the 
          consulting physician and surgeon to examine and treat the 
          patient in person when it is determined to be medically 
          necessary, as specified, and make conforming changes.

           ANALYSIS  :    

          Existing federal law:

          1. 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.

          2. Permits, under the EMTALA, an on-call physician, under 
             hospital policies, the option to direct a non-physician 
             practitioner or his/her representative to appear at a 
             hospital and provide further assessment or stabilizing 
             treatment to an individual.

          Existing state law:

          1. 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.

          2. 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 

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             emergency medical condition or active labor, within the 
             capacity of the facility. 

          3. Establishes the Physician Assistant Practice Act 
             administered by the Physician Assistant Committee 
             (Committee) of the Medical Board of California (MBC) to 
             regulate physician assistants.

          4. Provides that a physician assistant (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. 

          5. Requires a PA and his/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.  

          6. Requires the protocol to meet specified requirements.

          7. 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.

          8. 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, approve, 
             sign, modify, or add to a plan of treatment or plan of 
             care for individuals receiving home health services or 
             personal care services.  

          9. Authorizes PAs to conduct specified medical examinations 
             and sign corresponding medical certificates for various 
             individuals. 

          10.Authorizes a PA to conduct specified medical 
             examinations and sign corresponding medical certificates 
             for various individuals. 


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          This bill:

          1. Revises the existing definition of "emergency services 
             and care" to mean medical screening, examination, and 
             evaluation by a physician or surgeon, or, to the extent 
             permitted by applicable law, other appropriate licensed 
             personnel under the supervision of a physician and 
             surgeon, to determine if an emergency medical condition 
             or active labor exists. 

          2. Clarifies that, upon a determination that an emergency 
             medical condition or active labor exists, "emergency 
             services and care" also includes the care, treatment, 
             and surgery, if within the scope of the appropriate 
             licensed personnel's license and clinical privileges, 
             necessary to relieve or eliminate the emergency medical 
             condition, within the capability of the facility. 

          3. Includes the rendering of a decision regarding 
             hospitalization or transfer by telephone or other means 
             of communication in the existing definition of 
             "consultation" and authorizes other appropriate licensed 
             personnel acting within their scope of licensure to 
             provide consultation. 

          4. Requires the request for consultation to be made by the 
             treating physician and surgeon, or by other appropriate 
             licensed personnel acting within their scope of 
             licensure, provided that it is made with the 
             contemporaneous approval of the treating physician and 
             surgeon. 

          5. Permits the treating physician and surgeon to request to 
             communicate directly with the consulting physician and 
             surgeon, and requires, when determined to be medically 
             necessary, jointly by the treating physician and surgeon 
             and the consulting physician and surgeon, the consulting 
             physician and surgeon to examine and treat the patient 
             in person. 

          6. States that the consulting physician and surgeon is 
             ultimately responsible for providing the necessary 
             consultation to the patient, regardless of who makes the 
             in-person appearance. 

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          7. Authorizes, in addition to a physician or surgeon, other 
             appropriate licensed personnel acting within their scope 
             of licensure to determine when a patient's emergency 
             condition has been stabilized. 

          8. Prohibits this bill from being construed to expand the 
             scope of licensure for licensed personnel providing 
             services in the emergency department. 

           Background  

          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 emergency 
          department 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., 
          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 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 United States, 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/her 

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          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.

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes   
          Local:  Yes

          According to the Assembly Appropriations Committee, 
          negligible direct state fiscal impact.  This bill clarifies 
          state law and conforms state law to existing federal law 
          and current practice, and is not likely to significantly 
          change the delivery of emergency medical care. 

           SUPPORT  :   (Verified  8/22/11)

          California Academy of Physician Assistants (source)
          Medical Board of California
          United Nurses Associations of California/Union of 
          Healthcare Professionals

           OPPOSITION  :    (Verified  8/22/11)

          American College of Emergency Physicians, California 
          Chapter
          California Nurses Association

           ARGUMENTS IN SUPPORT  :    The California Academy of 
          Physician Assistants (CAPA), the bill's sponsor, states 
          that existing law allows PAs to perform a variety of 

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          medical services set forth by regulations adopted by the 
          MBC when rendered under the supervision of a physician and 
          surgeon.  CAPA argues that this bill clarifies an 
          inconsistency in state law by explicitly authorizing PAs to 
          perform consultative and treatment services in the hospital 
          emergency room, providing an increase in to urgent medical 
          care and a decrease in patient overcrowding. 

           ARGUMENTS IN OPPOSITION  :    The California Nurses 
          Association writes:  "As currently written, the law is 
          clear that physicians may provide emergency consults, care, 
          treatment and surgery.  As such, SB 233 was initially 
          introduced in order to provide a simple clarification that 
          PAs may also perform such care under physician supervision. 
           However, in taking the bill beyond PAs, the proposed 
          amendments raise questions about potential expansions of 
          scope of practice and whether or not other practitioner 
          types are lawfully able to provide these services."  
           

           ASSEMBLY FLOOR  :  76-1, 8/30/11
          AYES:  Achadjian, Alejo, Allen, Ammiano, Atkins, Beall, 
            Bill Berryhill, Block, Blumenfield, Bonilla, Bradford, 
            Brownley, Buchanan, Butler, Charles Calderon, Campos, 
            Carter, Cedillo, Chesbro, Conway, Cook, Davis, Dickinson, 
            Eng, Feuer, Fletcher, Fong, Fuentes, Beth Gaines, 
            Galgiani, Garrick, Gatto, Gordon, Grove, Hagman, 
            Halderman, Hall, Harkey, Hayashi, Roger Hernández, Hill, 
            Huber, Hueso, Huffman, Jeffries, Jones, Knight, Lara, 
            Logue, Bonnie Lowenthal, Ma, Mansoor, Mendoza, Miller, 
            Mitchell, Monning, Morrell, Nestande, Nielsen, Norby, 
            Olsen, Pan, Perea, V. Manuel Pérez, Portantino, Silva, 
            Skinner, Smyth, Solorio, Torres, Valadao, Wagner, 
            Wieckowski, Williams, Yamada, John A. Pérez
          NOES:  Donnelly
          NO VOTE RECORDED: Furutani, Gorell, Swanson


          CTW:mw  8/30/11   Senate Floor Analyses 

                         SUPPORT/OPPOSITION:  SEE ABOVE

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