LSL C.S.H.B. 2846 75(R) BILL ANALYSIS PUBLIC HEALTH C.S.H.B. 2846 By: Berlanga 4-17-97 Committee Report (Substituted) BACKGROUND Prescriptive authority for Advanced Practice Nurses (APNs) and Physician Assistants (PAs) was first authorized by the Texas Legislature in 1989. It permitted APNs and PAs to prescribe under the delegated authority of a collaborating physician through the use of jointly developed protocols, but was limited to sites serving medically underserved populations. S.B. 673, passed in 1995, expanded that authority to include the physician's primary practice site and facility based practices and also clarified that protocols did not have to take a "cookbook" approach. An ad hoc committee consisting of 5 physicians, 5 APNs and 5 PAs met during the interim to facilitate implementation of S.B. 673 and to identify any legislation needed to enhance practice and access to health care which was mutually agreeable to all involved parties. C.S.H.B. 2846 is the result of those efforts. PURPOSE CSHB 2846 facilitates collaborative practices between physicians and advanced practice nurses or physician assistants. The substitute bill prohibits an HMO or PPO from discriminating against an advanced practice nurse or physician assistant and prohibits an accident or sickness insurance policy from refusing to pay an APN or PA for covered benefits unless the policy designates those practitioners who will and will not be recognized by the insurer. RULEMAKING AUTHORITY It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency or institution. SECTION BY SECTION ANALYSIS SECTION 1. Amends Section 3.06(d)(5)(D)(ii), Medical Practice Act (Article 4495b, Vernon's Texas Civil Statutes), to change the requirement for physician supervision of an advanced practice nurse (APN) or physician assistant (PA) with delegated prescriptive authority at a site serving a medically underserved population from an on site visit once a week to once every ten business days during which the APN or PA is on site providing care. Amends subparagraph (iii) by replacing the reference to a "registered nurse" with an "advanced practice nurse". SECTION 2. Amends Section 3.06(d)(5)(E), Medical Practice Act (Article 4495b, Vernon's Texas Civil Statutes), by adding Subparagraph (vii) which adds a definition of an "advanced practice nurse". SECTION 3. Amends Section 3.06(d)(6)(G)(iii), Medical Practice Act (Article 4495b, Vernon's Texas Civil Statutes) by expanding the definition of a physician's "primary practice site" at which APNs and PAs may be delegated prescriptive authority to include clinics providing care to students of a school district and their siblings. SECTION 4. Amends Article 20A.14, Section 14 of the Texas Health Maintenance Organization Act by adding a new subsection (i) which prohibits a health maintenance organization from refusing to list on its provider panel an APN or PA in a collaborative practice as defined in Section 3.06(d)(5) or (6), Medical Practice Act, if their collaborating physician is listed and the APN or PA meets the HMO's pre-established quality of care standards. Also, adds a new subsection (j) which prohibits an HMO from refusing to contract with, refusing to reimburse, or otherwise discriminating against an APN or PA because APNs and PAs are not included in Article 21.52 of the Insurance Code. SECTION 5. Amends Subchapter G, Chapter 3, Insurance Code, by adding a new Article 3.703C which defines a Preferred Provider and a Preferred Provider Benefit Plan, and prohibits a Preferred Provider Benefit Plan from refusing to list on its provider panel an APN or PA in a collaborative practice as defined in Section 3.06(d)(5) or (6), Medical Practice Act, if their collaborating physician is listed and the APN or PA meets the PPO's pre-established quality of care standards. Also, prohibits an HMO from refusing to contract with, refusing to reimburse, or otherwise discriminating against an APN or PA because APNs and PAs are not listed in Article 21.52 of the Insurance Code. SECTION 6. Amends Section 2(B), Chapter 397, Acts of the 54th Legislature, Regular Session, 1955 (Article 3.70-2, Insurance Code) by adding definitions of an "Advanced Practice Nurse" and a "Physician Assistant", and adding APNs and PAs to the list of practitioners in this Article which prohibits health insurance benefits from being contingent upon treatment or examination by a particular type of practitioner, unless the policy designates the type of practitioners who will be recognized by the insurer and those who will not be recognized. Makes conforming and nonsubstantive language changes. SECTION 7. Instructional language that the provisions of Sections 4-6 of the bill apply only to an insurance policy or evidence of coverage that is delivered, issued, or renewed on or after January 1, 1998. Any policy or evidence of coverage delivered, issued for delivery, or renewed before January 1, 1998, is governed by current law. SECTION 8. Effective date is September 1, 1997. SECTION 9. Emergency clause. COMPARISON OF ORIGINAL TO SUBSTITUTE SECTION 1 of the substitute clarifies the frequency of site visits by a physician providing medical direction and consultation at a site serving a medically underserved population by tying it to every 10 days that the APN or PA is on site providing care. Also, the Legislative Council recommended a technical correction to delete the term "registered nurse" in subparagraph (iii) and replace it with the term "advanced practice nurse" to be consistent with the language in subparagraph (ii). SECTION 2 of the original bill is deleted from the substitute to address opposition to allowing the Board of Medical Examiners to grant a waiver of the on site physician requirement for sites serving medically underserved populations under certain conditions. The new SECTION 2 adds a definition of an "advanced practice nurse" to Article 4495b, Section 3.06 (d)(5)(E), as a technical correction suggested by the Legislative Council. SECTION 3 clarifies how a clinic must be related to a school district to qualify as a physician's primary practice site. SECTION 4 clarifies that the quality of care standards an APN or PA, in a collaborative practice with a physician, must meet to be listed on a provider panel must be "previously established" by the HMO. The substitute also adds a new subsection (j) to Article 20A.14, Section 14 of the Texas Health Maintenance Organization Act, which prohibits an HMO from discriminating against APNs and PAs because those providers are not listed in Article 21.52 of the Insurance Code. SECTION 5 clarifies that the quality of care standards an APN or PA, in a collaborative practice with a physician, must meet to be listed on a provider panel must be "previously established" by the PPO. The substitute also adds a new Section 3 to Article 3.70-3c, Chapter 3, Insurance Code, which prohibits a Preferred Provider Benefit Plan from discriminating against APNs or PAs because they are not listed in Article 21.52, Insurance Code. SECTION 6 of the substitute is the same as SECTION 6 of the bill, as filed. SECTIONS 7 and 8 of the original bill are deleted in the substitute. These sections addressed concerns raised by APNs and PAs including a concern that managed care organizations are using the fact that APNs and PAs are not listed in Article 21.52, Insurance Code, as a reason to not include them in their provider panels or reimburse them for covered services. A prohibition on this type of discriminatory practice is added in SECTION 4 through a new subsection (j) and in SECTION 5 through a new Section 3. SECTIONS 9 and 10 relating to hospital clinical privileges for APNs and PAs are deleted because agreement could not be reached on the scope of those provisions. SECTION 11 of the original bill becomes SECTION 7 of the substitute with one change. The instructional language is modified by deleting reference to SECTIONS 7 and 8 of the original bill which were deleted in the substitute. SECTIONS 12 and 13 of the original bill become SECTIONS 8 and 9 of the substitute.