Bill H.3614

FILED ON: 1/20/2012

HOUSE . . . . . . . . . . . . . . . No. 3614

The Commonwealth of Massachusetts

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In the Year Two Thousand Twelve

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An Act encouraging nurse practitioner and physician assistant practice of primary care..

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:

SECTION 1. Section 2 of chapter 32A of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by striking out paragraph (i) and inserting in place thereof the following two paragraphs:

(i) “Primary care provider”, a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice.

(j) “Wellness program”, a program designed to measure and improve individual health by identifying risk factors, principally through diagnostic testing and establishing plans to meet specific health goals which include appropriate preventive measures. Risk factors may include but shall not be limited to demographics, family history, behaviors and measured biometrics.

SECTION 2. Section 22 of said chapter 32A, as so appearing, is hereby amended by striking out, in line 48, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 3. Section 2 of chapter 32B of the General Laws, as so appearing, is hereby amended by adding the following paragraph:-

(k) “Primary care provider”, a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice.

SECTION 4. Section 19 of said chapter 32B, as so appearing, is hereby amended by striking out, in line 127, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 5. Section 1 of chapter 111 of the General Laws, as so appearing, is hereby amended by inserting after the definition of “Nuclear reactor” the following definition:-

SECTION 6. Section 4J of said chapter 111, as so appearing, is hereby amended by striking out, in line 15, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 7. Section 25L of said chapter 111, as so appearing, is hereby amended by inserting after the word “providers”, in line 9, the following words:- physician assistants practicing as primary care providers.

SECTION 8. Clause (ii) of subsection (a) of section 25L of said chapter 111, as so appearing, is hereby amended by striking out subclause (5) and inserting in place thereof the following subclause:-

(5) studying the capacity of public and private medical, nursing, and physician assistant schools in the commonwealth to expand the supply of primary care physicians, nurse practitioners practicing as primary care providers, and physician assistants practicing as primary care providers.

SECTION 9. Section 25L of said chapter 111, as so appearing, is hereby amended by striking out subsection (d) and inserting in place thereof the following subsection:-

(d) The center shall annually submit a report, not later than March 1, to the governor; the health care quality and cost council established by section 16K of chapter 6A, the health disparities council established by section 16O of chapter 6A; and the general court, by filing the report with the clerk of the house of representatives, the clerk of the senate, the joint committee on labor and workforce development, the joint committee on health care financing, and the joint committee on public health. The report shall include: (i) data on patient access and regional disparities in access to physicians, by specialty and sub-specialty, nurses, and physician assistants; (ii) data on factors influencing recruitment and retention of physicians, nurses, and physician assistants; (iii) short and long-term projections of physician, nurse, and physician assistant supply and demand; (iv) strategies being employed by the council or other entities to address workforce needs, shortages, recruitment and retention; (v) recommendations for designing, implementing and improving programs or policies to address workforce needs, shortages, recruitment and retention; and (vi) proposals for statutory or regulatory changes to address workforce needs, shortages, recruitment and retention.

SECTION 10. Chapter 111 of the General Laws is hereby amended by striking out section 25MN, as so appearing, and inserting in place thereof the following section:-

(a) There shall be a healthcare workforce advisory council within, but not subject to the control of, the health care workforce center established by section 25L. The council shall advise the center on the capacity of the healthcare workforce to provide timely, effective, culturally competent, quality physician, nursing, and physician assistant services.

(b) The council shall consist of 18 members who shall be appointed by the governor: 1 of whom shall be a representative of the Massachusetts Extended Care Federation; 1 of whom shall be a physician with a primary care specialty designation who practices in a rural area; 1 of whom shall be a physician with a primary care specialty who practices in an urban area; 1 of whom shall be a physician with a medical subspecialty; 1 of whom shall be an advanced practice nurse, authorized under section 80B of said chapter 112, who practices in a rural area; 1 of whom shall be an advanced practice nurse, authorized under said section 80B of said chapter 112, who practices in an urban area; 1 of whom shall be a physician assistant with a primary care specialty, authorized under section 9E of said chapter 112, 1 of whom shall be a representative of the Massachusetts Organization of Nurse Executives; 1 of whom shall be a representative of the Massachusetts Academy of Family Physicians; 1 of whom shall be a representative of the Massachusetts Workforce Board Association; 1 of whom shall be a representative of the Massachusetts League of Community Health Centers, Inc.; 1 of whom shall be a representative of the Massachusetts Medical Society; 1 of whom shall be a representative of the Massachusetts Center for Nursing, Inc.; 1 of whom shall be a representative of the Massachusetts Nurses Association; 1 of whom shall be a representative of the Massachusetts Association of Registered Nurses; 1 of whom shall be a representative of the Massachusetts Association of Physician Assistants; 1 of whom shall be a representative of the Massachusetts Hospital Association, Inc.; and 1 of whom shall be a representative of Health Care For All, Inc. Members of the council shall be appointed for terms of 3 years or until a successor is appointed. Members shall be eligible to be reappointed and shall serve without compensation, but may be reimbursed for actual and necessary expenses reasonably incurred in the performance of their duties. Vacancies of unexpired terms shall be filled within 60 days by the appropriate appointing authority.

The members of the council shall annually elect a chair, vice chair and secretary and may adopt by-laws governing the affairs of the council.

The council shall meet at least bimonthly, at other times as determined by its rules, and when requested by any 8 members.

(c) The council shall advise the center on: (i) trends in access to primary care and physician subspecialties, nursing services, and physician assistant services; (ii) the development and administration of the loan repayment program, established under section 25N, including criteria to identify underserved areas in the commonwealth; (iii) solutions to address identified health care workforces shortages; and (iv) the center's annual report to the general court.

SECTION 11. Paragraph (a) of section 25N of said chapter 111, as so appearing, is hereby amended by striking out clause (i) and inserting in place thereof the following clause:-

(i) are graduates of medical, nursing, or physician assistant schools;

SECTION 12. Paragraph (d) of said section 25N of said chapter 111, as so appearing, is hereby amended by striking out clause (i) and inserting in place thereof the following clause:-

(i) the number of applicants, the number accepted, and the number of participants by race; gender; medical, nursing, or physician assistant specialty; medical, nursing, or physician assistant school; residence prior to medical, nursing, or physician assistant school; and where they plan to practice after program completion;

SECTION 13. Section 67F of said chapter 111, as so appearing, is hereby amended by striking out, in line 15, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 14. Section 67F of said chapter 111, as so appearing, is hereby further amended by striking out, in line 19, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 15. Section 9E of chapter 112 of the General Laws, as so appearing, is hereby amended by striking out the third sentence.

SECTION 16. Said chapter 112, as so appearing, is hereby amended by inserting after section 80H the following section:-

80I. When a provision of law or rule requires a signature, certification, stamp, verification, affidavit or endorsement by a physician, when relating to physical and mental health, that requirement may be fulfilled by a nurse practitioner practicing under section 80B of chapter 112. Nothing in this section shall be construed to expand the scope of practice of nurse practitioners. This section shall not be construed to preclude the development of mutually agreed upon guidelines between the nurse practitioner and supervising physician under section 80E of chapter 112.

SECTION 17. Section 8 of chapter 118E of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by inserting after paragraph (f). the following paragraph:-

(f1/2). “Primary care provider”, a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice.

SECTION 18. Section 17A of said chapter 118E, as so appearing, is hereby amended by striking out, in lines 60 and 62, the word “physician” and inserting in place thereof the following word in each instance:- provider.

SECTION 19. The third paragraph of section 6 of chapter 118G of the General Laws, as so appearing, is hereby amended by striking out clauses (ii) and (iii) and inserting in place thereof the following three clauses:-

(ii) changes in the benefit and cost-sharing design of plans offered by these payers; (iii) changes in measures of plan cost and utilization; provided that this analysis shall facilitate comparison among plans and between public and private payers; and (iv) the type of provider who delivered care.

SECTION 20. The fifth paragraph of section 6 of Chapter 118G of the General Laws, as amended by section 13 of chapter 288 of the acts of 2010, is hereby further amended by striking out clauses (viii) and (ix), and inserting in place thereof the following three clauses:-

(viii) relative prices paid to every hospital, physician group, ambulatory surgical center, freestanding imaging center, mental health facility, rehabilitation facility, skilled nursing facility and home health provider in the payer's network, by type of provider and calculated according to a uniform methodology; (ix) hospital inpatient and outpatient costs, including direct and indirect costs, according to a uniform methodology; and (x) information concerning the type of provider who delivered care.

SECTION 21. Section 1 of chapter 175 of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by inserting after the definition of “Net value of policies” the following definition:-

SECTION 22. Section 47B of said chapter 175, as so appearing, is hereby amended by striking out, in line 64, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 23. Section 47U of said chapter 175, as so appearing, is hereby amended by striking out, in lines 62 and 64, the word “physician” and inserting in place thereof the following word in each instance:- provider.

SECTION 24. Section 8A of chapter 176A of the General Laws, as so appearing, is hereby amended by striking out, in line 58, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 25. Subsection (c) of said section 8A of chapter 176A, as so appearing, is hereby amended by adding the following paragraph:-

For the purposes of this subsection, the term “primary care provider” shall mean a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice.

SECTION 26. Section 8U of said chapter 176A, as so appearing, is hereby amended by striking out, in lines 64 and 66, the word “physician” and inserting in place thereof the following word in each instance:- provider.

SECTION 27. Subsection (c) of said section 8U of chapter 176A, as so appearing, is hereby amended by adding the following paragraph:-

SECTION 28. Section 1 of chapter 176B of the General Laws, as so appearing, is hereby amended by inserting after the definition of “Participating optometrist” the following definition:-

SECTION 29. Section 4A of said chapter 176B, as so appearing, is hereby amended by striking out, in line 60, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 30. Section 4U of said chapter 176B, as so appearing, is hereby amended by striking out, in lines 64 and 66, the word “physician” and inserting in place thereof the following word in each instance:- provider.

SECTION 31. Section 1 of chapter 176G of the General Laws, as so appearing, is hereby amended by inserting after the definition of “Person” the following definition:-

SECTION 32. Section 4M of said chapter 176G, as so appearing, is hereby amended by striking out, in line 54, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 33. Section 5 of said chapter 176G, as so appearing, is hereby amended by striking out, in lines 59 and 61, the word “physician” and inserting in place thereof the following word in each instance:- provider.

SECTION 34. Section 11 of chapter 176J of the General Laws, as appearing in section 73 of chapter 288 of the acts of 2010, is hereby amended by striking out subsection (b) and inserting in place thereof the following subsection:-

(b) A tiered network plan shall only include variations in member cost-sharing between provider tiers which are reasonable in relation to the premium charged and ensure adequate access to covered services. Carriers shall tier providers based on quality performance as measured by the standard quality measure set and by cost performance as measured by health status adjusted total medical expenses and relative prices. Where applicable quality measures are not available, tiering may be based solely on health status adjusted total medical expenses or relative prices or both.

The commissioner shall promulgate regulations requiring the uniform reporting of tiering information, including, but not limited to requiring, at least 90 days before the proposed effective date of any tiered network plan or any modification in the tiering methodology for any existing tiered network plan, the reporting of a detailed description of the methodology used for tiering providers, including: the statistical basis for tiering; a list of providers to be tiered at each member cost-sharing level; a description of how the methodology and resulting tiers will be communicated to each network provider, eligible individuals and small groups; and a description of the appeals process a provider may pursue to challenge the assigned tier level.

SECTION 35. Section 1 of chapter 176O of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by inserting after the definition of “Person” the following definition:-

SECTION 36. Section 7 of said chapter 176O, as so appearing, is hereby amended by striking out, in line 30, the word “physician” and inserting in place thereof the following word:- provider.

SECTION 37. Chapter 176O of the General Laws is hereby amended by striking out section 15, as so appearing, and inserting in place thereof the following section:-

Section 15. (a) A carrier that allows or requires the designation of a primary care provider shall notify an insured at least 30 days before the disenrollment of such insured's primary care provider and shall permit such insured to continue to be covered for health services, consistent with the terms of the evidence of coverage, by such primary care provider for at least 30 days after said physician provider is disenrolled, other than disenrollment for quality-related reasons or for fraud. Such notice shall also include a description of the procedure for choosing an alternative primary care provider.

(b) A carrier shall allow any female insured who is in her second or third trimester of pregnancy and whose provider in connection with her pregnancy is involuntarily disenrolled, other than disenrollment for quality-related reasons or for fraud, to continue treatment with said provider, consistent with the terms of the evidence of coverage, for the period up to and including the insured's first postpartum visit.

(c) A carrier shall allow any insured who is terminally ill and whose provider in connection with said illness is involuntarily disenrolled, other than disenrollment for quality-related reasons or for fraud, to continue treatment with said provider, consistent with the terms of the evidence of coverage, until the insured's death.

(d) A carrier shall provide coverage for health services for up to 30 days from the effective date of coverage to a new insured by a provider who is not a participating provider in the carrier's network if: (1) the insured's employer only offers the insured a choice of carriers in which said provider is not a participating provider, and (2) said provider is providing the insured with an ongoing course of treatment or is the insured's primary care provider. With respect to a insured in her second or third trimester of pregnancy, this provision shall apply to services rendered through the first postpartum visit. With respect to an insured with a terminal illness, this provision shall apply to services rendered until death.

(e) A carrier may condition coverage of continued treatment by a provider under subsections (a) to (d), inclusive, upon the provider's agreeing (1) to accept reimbursement from the carrier at the rates applicable prior to notice of disenrollment as payment in full and not to impose cost sharing with respect to the insured in an amount that would exceed the cost sharing that could have been imposed if the provider had not been disenrolled; (2) to adhere to the quality assurance standards of the carrier and to provide the carrier with necessary medical information related to the care provided; and (3) to adhere to such carrier's policies and procedures, including procedures regarding referrals, obtaining prior authorization and providing services pursuant to a treatment plan, if any, approved by the carrier. Nothing in this subsection shall be construed to require the coverage of benefits that would not have been covered if the provider involved remained a participating provider.

(f) A carrier that requires an insured to designate a primary care provider shall allow such a primary care provider to authorize a standing referral for specialty health care provided by a health care provider participating in such carrier's network when (1) the primary care provider determines that such referrals are appropriate, (2) the provider of specialty health care agrees to a treatment plan for the insured and provides the primary care provider with all necessary clinical and administrative information on a regular basis, and (3) the health care services to be provided are consistent with the terms of the evidence of coverage. Nothing in this section shall be construed to permit a provider of specialty health care who is the subject of a referral to authorize any further referral of an insured to any other provider without the approval of the insured's carrier.

(g) No carrier shall require an insured to obtain a referral or prior authorization from a primary care provider for the following specialty care provided by an obstetrician, gynecologist, certified nurse-midwife or family practitioner participating in such carrier's health care provider network: (1) annual preventive gynecologic health examinations, including any subsequent obstetric or gynecological services determined by such obstetrician, gynecologist, certified nurse-midwife or family practitioner to be medically necessary as a result of such examination; (2) maternity care; and (3) medically necessary evaluations and resultant health care services for acute or emergency gynecological conditions. No carrier shall require higher copayments, coinsurance, deductibles or additional cost sharing arrangements for such services provided to such insureds in the absence of a referral from a primary care provider. Carriers may establish reasonable requirements for participating obstetricians, gynecologists, certified nurse-midwives or family practitioners to communicate with an insured's primary care provider regarding the insured's condition, treatment, and need for follow-up care. Nothing in this section shall be construed to permit an obstetrician, gynecologist, certified nurse-midwife or family practitioner to authorize any further referral of an insured to any other provider without the approval of the insured's carrier.

(h) A carrier shall provide coverage of pediatric specialty care, including mental health care, by persons with recognized expertise in specialty pediatrics to insureds requiring such services.

(i) A carrier, including a dental or vision carrier, shall provide health, dental or vision care providers applying to be participating providers who are denied such status with a written reason or reasons for denial of such application.

(j) No carrier shall make a contract with a health care provider which includes a provision permitting termination without cause. A carrier shall provide a written statement to a provider of the reason or reasons for such provider's involuntary disenrollment.

(k) A carrier, including a dental or vision carrier, shall provide insureds, upon request, interpreter and translation services related to administrative procedures.

SECTION 38. Section 20 of said chapter 176O, as so appearing, is hereby amended by striking out, in lines 19 and 22, the words “care physician” and inserting in place thereof the following word:- care provider.

SECTION 39. The General Laws are hereby amended by inserting after chapter 176R the following chapter:-

Chapter 176S

CONSUMER CHOICE OF PHYSICIAN ASSISTANT SERVICES

Section 1. As used in this chapter, the following words shall have the following meaning unless the context clearly requires otherwise:

“Carrier”, an insurer licensed or otherwise authorized to transact accident or health insurance under chapter 175; a nonprofit hospital service corporation organized under chapter 176A; a nonprofit medical service corporation organized under chapter 176B; a health maintenance organization organized under chapter 176G; an organization entering into a preferred provider arrangement under chapter 176I; a contributory group general or blanket insurance for persons in the service of the commonwealth under chapter 32A; a contributory group general or blanket insurance for persons in the service of counties, cities, towns and districts, and their dependents under chapter 32B; the medical assistance program administered by the division of medical assistance pursuant to chapter 118E and in accordance with Title XIX of the Social Security Act or any successor statute; and any other medical assistance program operated by a governmental unit for persons categorically eligible for such program.

“Commissioner”, the commissioner of insurance.

“Insured”, an enrollee, covered person, insured, member, policyholder or subscriber of a carrier.

“Nondiscriminatory basis”, a carrier shall be deemed to be providing coverage on a non-discriminatory basis if its plan does not contain any annual or lifetime dollar or unit of service limitation imposed on coverage for the care provided by a physician assistant which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the same services by other participating providers.

“Physician assistant”, a person who is a graduate of an approved program for the training of physician assistants who is supervised by a registered physician in accordance with sections 9C to 9H, inclusive, of chapter 112.

“Participating provider”, a provider who, under the terms and conditions of a contract with the carrier or with its contractor or subcontractor, has agreed to provide health care services to an insured with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the carrier.

“Primary care provider”, a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice.Section 2. The commissioner and the group insurance commission shall require that all carriers recognize physician assistants as participating providers subject to section 3 and shall include coverage on a nondiscriminatory basis to their insureds for care provided by physician assistants for the purposes of health maintenance, diagnosis and treatment. Such coverage shall include benefits for primary care, intermediate care and inpatient care, including care provided in a hospital, clinic, professional office, home care setting, long-term care setting, mental health or substance abuse program, or any other setting when rendered by a physician assistant who is a participating provider and is practicing within the scope of his professional license to the extent that such policy or contract currently provides benefits for identical services rendered by a provider of health care licensed by the commonwealth.

Section 3. A participating provider physician assistant practicing within the scope of his license including all regulations requiring collaboration with a physician under section 9E of chapter 112, shall be considered qualified within the carrier's definition of primary care provider to an insured.

Section 4. Notwithstanding any general or special law to the contrary, a carrier that requires the designation of a primary care provider shall provide its insureds with an opportunity to select a participating provider physician assistant as a primary care provider or to change its primary care provider to a participating provider physician assistant at any time during their coverage period.

Section 5. Notwithstanding any general or special law to the contrary, a carrier shall ensure that all participating provider physician assistants are included on any publicly accessible list of participating providers for the carrier.

Section 6. A complaint for noncompliance against a carrier shall be filed with and investigated by the commissioner or the group insurance commission, whichever shall have regulatory authority over the carrier. The commissioner and the group insurance commission shall promulgate regulations to enforce this chapter.

SECTION 40. The commissioner of public health, in consultation with the board of registration in medicine, the board of registration in nursing, the board of registration of physician assistants, and the board of registration in pharmacy, shall create an independent task force to examine the current regulatory structure governing professional relationships between physicians, nurse practitioners, and physician assistants to identify barriers to the coordination of primary care between physicians, nurse practitioners, and physician assistants and the barriers to expanding patient access to primary care through greater utilization of the nurse practitioner and physician assistant workforce, including the administrative simplification of prescribing practices. The task force shall issue a report of its study, including its recommendations and drafts of any legislation, if necessary, with the clerks of the Senate and House of Representatives and the joint committees on public health and health care financing within 1 year of the effective date of this act.

SECTION 41. There shall be a special commission to study and make recommendations on the opportunities and challenges faced by primary care physicians in community care settings. The commission shall consist of: the secretary of health and human services or her designee, who shall serve as chair; the commissioner of health care finance and policy or his designee; 1 member appointed by the speaker of the house of representatives; 1 member appointed by the senate president; 1 representative of the Mass League of Community Health Centers; 1 representative of the Department of Family Medicine at UMass Medical School; 1 representative of the Department of Family Medicine at Boston Medical Center; 1 executive director of a community health center that currently participates in a family medicine residency training program; 1 executive director of a community health center that is the sponsoring organization and holds the credentials for the accredited training program; 1 representative of a health center with an interest in starting a residency program; 1 community health center physician who is a graduate of a community health center residency program; 1 residency director at a community health center; 1 current community health center resident; 1 representative of the Massachusetts Academy of Family Physicians; and 1 representative of the Massachusetts Chapter of the American Academy of Pediatrics.

The Commission’s review shall include but not be limited to the following: (a) an analysis of the adequacy of the workforce in community health centers in the commonwealth; (b) the workforce needs at community health centers across the commonwealth within the context of the broader workforce shortage issues, and an evaluation on how community health centers can fill those slots; (c) the percentage of residents at health centers that eventually choose to practice in the community health center setting; (d) the contribution community health center residency programs have made in diversifying the physician pipeline and training physicians to address the medical needs of diverse populations; (e) opportunities to improve the training of primary care physicians in leadership roles and in practicing in a coordinated, team-based approach to primary care; (f) barriers to increasing the ability to train family physicians in community health centers (g) the contributions the University of Massachusetts Medical School Learning Contract has made in increasing the primary care workforce in the commonwealth and recommendations for its improvement; (h) opportunities to develop mentorship programs for primary care physicians; (i) the sources of funding for community health center residency programs, and a determination on whether increased state investment will provide benefits for the commonwealth; (j) the feasibility and potential benefits of a supplemental Medicaid fee to community health centers engaged in 3-year residency programs; and, (k) the impact of national health reform on Massachusetts community health center residency programs, both new and existing, and an evaluation of any potential opportunities.

The commission shall report its findings, including its recommendations and drafts of any legislation, if necessary, with the clerks of the Senate and House of Representatives and the joint committees on public health and health care financing within 1 year after the effective date of this act.