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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