The Massachusetts Medical Society (MMS) is a professional association of over 25,000 physicians, residents, and medical students across all clinical disciplines, organizations, and practice settings. The Medical Society is committed to advocating on behalf of patients, for a better health care system, and on behalf of physicians, to help them provide the best care possible. The Medical Society supports the provision of health care services by a physician-led team of health care professionals who work collaboratively with each other and the patient and family to accomplish shared goals within and across settings to achieve coordinated, high-quality, patient-centered care. For that reason, the Medical Society supports H.1862, An Act to Promote Team Based Health Care, which we believe will promote integrated, coordinated care that utilizes all health care professionals in their most appropriate capacities and ensures physicians are readily available to collaborate when needed in order to promote access to the highest quality and safety of care for all patients.
Physician-led team based care empowers health care professionals to perform the full range of medical interventions that she or he is trained to perform, maximizing the full educational capacity of each team member to effectively provide quality patient care. The extensive medical education, required medical residencies, and frequent post-residency fellowships that physicians undertake provide them with unique expertise and qualifications to manage health care teams, especially those overseeing the care of the sickest and most complex patients. Surveys indicate that patients prefer health care teams led by physicians as patients age or when care becomes complex. Data indicate that physicians have lower rates of utilization for unnecessary tests and higher quality referrals to specialists, both of which contribute positively to containing overall costs of care.
The Medical Society believes that the physician-led health care team model allows for ample access to care for patients while offering the added security of physician relationships with advanced practice nurses in circumstances where consultation or collaboration is indicated. Patients in Massachusetts present with a wide range of acuity—some with common urgent care type needs and others with far more complex comorbidities, undiagnosed conditions, or other complications. While the training of nurse practitioners and certified registered nurse anesthetists is undoubtedly sufficient for certain populations of patients, there are others for whom the extensive training of a physician is better suited. The Medical Society believes it is sensible, for the protection of patients in the Commonwealth, for the legislature to ensure that established relationships are available for purposes of physician consultation on these most difficult cases. H.1862 would act in patients’ best interests by promoting such a care model, as it provides appropriate health care for patients across all acuity levels while utilizing members of the health care team in an efficient and effective manner.
Based on the considerations mentioned above, the Medical Society would also like to be recorded in opposition to S.1278, An Act Relative to the Advanced Nursing Practice. As a result of 2014 Board of Registration in Nursing regulations regarding advanced practice nursing, nurse practitioners are no longer required to work under the supervision of physicians. The only remaining oversight requirement is that nurse practitioners maintain prescribing guidelines that are mutually developed with a physician for the purpose of prescribing medications. There is no longer a requirement that the physician be on site or perform regular chart reviews for patients seen by nurse practitioners. Given the heightened attention to opioid prescribing over the past few years, the Medical Society sees value in continuing the existing requirements for NPs, which
grant them wide latitude to treat patients in need, while still ensuring that a formalized relationship exists with a physician for instances when additional consultation is warranted.
The Medical Society is concerned that this proposal, aimed at promoting cost containment in health care, could instead promote a two-tiered medical system whereby patients seeing physicians would be protected by a panoply of laws and regulations assuring the quality of care provided, whereas none of the same protections would apply to care provided by non-physician providers. The legislature, in fulfilling its duty to protect patients of the Commonwealth, has diligently established a thoughtful, patient-focused framework of policies and statutory requirements that apply to physicians in light of their ability to independently provide medical care.
Conversely, S.1278 would authorize new independent practice for NPs and CRNAs without requiring any of the same patient protections that apply to physicians. Specifically, the Medical Society points to the statutory requirement that all physician complete a two- or three-year medical residency, to the continuing medical education requirement of 100 hours per license cycle, and to the online public physician profile as important means by which the legislature has acted in the name of patient protection and transparency. Care provided by independent non-physician practitioners would not be subject to these same protections.
The Board of Registration in Medicine also provides important protections to patients cared for by physicians through its unparalleled practice requirements, thoroughness in its licensure process, and the unmatched sophistication and resources of its investigatory unit. The most important patient safety protection that can be provided to patients is to ensure that all care meets the same high standard, regardless of whether it is provided by a physician, APRN, podiatrist, optometrist, or any other non-physician provider. Accordingly, licensure boards would need similar expertise and resources to understand and uphold the medical standard of care provided by physicians. The Medical Society is concerned that patients seen by non-physicians would not have the same standard of care, protections, or assurances that patients who are seen by physicians experience. For those reasons, the Medical Society opposes S.1278 An Act Relative to the Advanced Nursing Practice; H.1844/S.1225, An Act Relative to Facilitating the Utilization of Psychologists on the Health Care Team; H.1864/S.1222, An Act Relative to the Board of Registration in Naturopathy; H.1869/S.1329, An Act Relative to the Definition of Podiatry; and H.3483/S.1338, An Act Relative to Athletic Training.
Furthermore, the Medical Society supports H.1964, An Act Relative to Defining Surgery. The Medical Society supports H.1964 insofar as it begins an important conversation about where and how to regulate the practice of surgery. While the MMS understands that statute cannot always articulate all boundaries of a given health profession’s practice, there is value in demarcating a bright line in certain instances of medical practice, such as surgery, where a physician’s level of education and training is critical to ensuring the highest levels of patient safety. The Medical Society looks forward to engaging in this discussion that will serve as a means to ensure that patient safety remains a paramount consideration in the practice of medicine and, to that end, that all health care professionals practice within the scope of their training and experience.
The Medical Society also supports H.1861, An Act Relative to Truth in Advertising. This bill would promote transparency to patients by requiring health care providers to clearly state their level of training, education, and licensing. Patients deserve to know by whom they are being seen, particularly when there may no longer be a consulting, collaborating, or team-based relationship between an advanced practice nurse and a physician. Clarity for the patient is important because of the many differing types of ‘doctors.’ The verbal title of ‘Dr. Jones’ could indicate a Medical Doctor or a Doctor of Osteopathic Medicine, while it could also signify a PhD, PsyD, DScPT, or the like. Many patients may incorrectly assume that the title of ‘Dr.’ means physician. This bill does not judge the merits of any doctorate level degree, but instead provides an important patient protection by providing transparency with regard to education, training, and professional title.
In all, the Medical Society hopes that H.1862, An Act to Promote Team Based Care will serve as a model for cooperative, integrated health care, as it serves to the patients’ benefit by assuring access to appropriate health care professionals throughout a spectrum of patient need. The Medical Society further urges due consideration of H.1964 and H.1861, two bills that will strengthen the transparency of healthcare for patients within the Commonwealth as we continue to work through considerations regarding scope of practice.
