Senate Rules Committee s1

SENATE RULES COMMITTEE SB 233 Office of Senate Floor Analyses 1020 N Street, Suite 524 (916) 651-1520 Fax: (916) 327-4478

THIRD READING

Bill No: SB 233 Author: Pavley (D) Amended: 5/18/11 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

SUBJECT: Emergency services and care

SOURCE: California Academy of Physician Assistants

DIGEST: This bill revises the definition of “emergency services and care,” “consultation,” and “stabilized” to clarify which medical professionals may provide medical screening, examination, evaluation, and treatment within an emergency department.

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 CONTINUED SB 233 Page 2

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 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.

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8. Authorizes a PA, pursuant to a Delegation of Services Agreement (DSA), 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.

This bill:

1. Clarifies that “emergency services and care” means medical screening, examination, and evaluation by a physician or surgeon and would also specify that other appropriate personnel rendering these services do so pursuant to their scope of practice and licensure.

2. Adds “decision regarding hospitalization or transfer” to the definition of “consultation” and would provide that other appropriate personnel acting pursuant to their scope of practice and licensure under the supervision of a physician and surgeon may provide “consultation”.

3. Permits appropriate personnel, in addition to a physician or surgeon, acting pursuant to the scope of practice and licensure under the supervision of a physician or surgeon, to determine when a patient’s emergency condition has been “stabilized”.

4. States that the bill does not expand the scope of licensure for 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

CONTINUED SB 233 Page 4 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 (CMS) 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 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 Senate Appropriations Committee:

Fiscal Impact (in thousands)

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Major Provisions 2011-12 2012-13 2013-14 Fund DPH oversight no fiscal impact Special*

* Department of Public Health Licensing and Certification Program Fund

SUPPORT: (Verified 5/18/11)

California Academy of Physician Assistants (source) United Nurses Associations of California/Union of Healthcare Professionals

OPPOSITION: (Verified 5/18/11)

American College of Emergency Physicians 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 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.”

CTW:mw 5/18/11 Senate Floor Analyses SUPPORT/OPPOSITION: SEE ABOVE **** END ****

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