HB1868/SB716, HB1965, HB1853/SB1235
Scope of Practice, Urgent Care, Step Therapy

Joint Committee on Health Care Financing 

The Massachusetts Health & Hospital Association (MHA), on behalf of its member hospitals, health systems, physician organizations and allied healthcare providers, appreciates this opportunity to offer comment on bills regarding advanced practice nurse scope of practice and the licensure of urgent care centers.

With regards to HB1868/SB716, MHA supports the expansion of scope of practice for all advanced practice registered nurses (APRNs) – nurse practitioners, certified registered nurse anesthetists, psychiatric clinical nurse specialists, and certified nurse midwives. The various bills that have been filed on this issue allow certain APRNs to have pathways to independent practice authority. MHA is supportive of proposals to require additional post-graduate training prior to full practice authority or independent practice, including some sort of orientation, mentorship, or preceptorship, as well as allowing advanced practice nurses the ability to supervise the process of their fellow nurses toward independent practice authority.

APRNs should also be held to the same standards of transparency, accountability, and professional responsibility under which physicians practice. This includes: Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE); public reporting to the Department of Public Health (DPH) or Board of Registration in Nursing; quality reporting tied to the practitioner; public reporting of medical malpractice awards or settlements; mandated medical malpractice liability policy limits; public reporting of any arrangements between practitioner and the pharmaceutical industry; continuing education requirements; and peer review. Just like physicians, APRNs currently must carry professional liability insurance in order to practice.

APRNs are guided by specialty-related national and local standards of care, their education and training, as well as by specific regulations governing their scope of practice. Consistent with The Joint Commission recommendations, OPPE is appropriate for all clinicians, including APRNs. There may be gaps in organizational structures supporting OPPE and, where there is appropriate movement towards full practice authority, steps should be taken to ensure that structure and accountability is the same for all licensed independent providers. At the institutional level, scope of practice should be determined by education, training, and experience for APRNs just as is done for physicians. It should be expected and verified that an individual’s practice is within his/her education, training, and experience, and that he/she functions within professional boundaries with ongoing professional evaluations.

MHA supports HB1965, which would increase state oversight of new, non-affiliated urgent care provider entries into the Massachusetts market. Currently, certain clinics delivering office-based urgent care are able to treat patients without undergoing DPH licensure processes. Many of these facilities are not affiliated with an existing hospital or hospital system, do not utilize interoperable electronic health records, do not accept reimbursement from Medicaid, and largely operate outside the tenets of Chapter 224. While Massachusetts hospitals and hospital systems have established urgent care clinics as a cost-effective way of delivering immediate care while minimizing non- emergent use of hospital EDs, urgent care centers that are not affiliated with an existing provider system appear to be based on a business model of drawing commercial patients away from integrated health systems. We appreciate that HB1965 would create two separate licensing pathways for “institutional urgent care centers,” or those owned by or affiliated with a hospital or hospital system, and “freestanding urgent care centers,” those facilities that have been too long operating without proper oversight from state regulators.

MHA supports HB1853/SB1235, An Act relative to fail first and patient safety. Step therapy is a practice used by insurers that requires patients with certain diagnoses to try lower-cost medications before the insurer allows more expensive treatments, despite a physician’s recommendation. As a result, more expensive effective drugs can only be prescribed if the cheaper drugs prove ineffective. When a patient changes insurers, or a drug they are currently taking is moved to a non-preferred status, the patient may be put through the step therapy process again.

This legislation, which 25 other states have already adopted, would allow a physician to override the step therapy process when patients are stable on a prescribed medication or if: 1) the physician expects the treatment to be ineffective based on the known relevant medical characteristics of the patient and the known characteristics of the drug regimen; 2) the patient comorbidities will cause, or will likely cause, an adverse reaction by, or physical harm to, the patient; 3) the treatment is not in the best interest of the patient, based on medical necessity; or 4) the patient requires an expedited process of no more than 24 hours in cases of emergency. The legislation also requires health insurers to maintain step therapy approval and override request processes electronically and, in circumstances where a patient is changing health insurance plans, the new insurer may not require the person to repeat step therapy that was completed under a prior insurance plan.

A survey of more than 1,400 patients conducted in 2016 by the Arthritis Foundation found that over half of all patients reported having to try two or more different drugs prior to getting the one their doctor had originally ordered. Step therapy was stopped in 39 percent of cases because the drugs were ineffective and 20 percent of the time due to worsening conditions. Nearly a quarter of patients who switched insurance providers were required to repeat the step therapy process with their new carrier. For all of these reasons, MHA supports HB1853/SB1235.

 Thank you for the opportunity to offer testimony on these important matters. If you have any questions regarding this testimony, or require further information,, please contact Michael Sroczynski, MHA's Senior Vice President of Government Advocacy at (781) 262-6055 or msroczynski@mhalink.org