The California Assembly has passed and sent to Gov. Jerry Brown for his expected signature compromise legislation to limit out-of-network medical bills.
The Sacramento Bee reported: “A bill seeking to limit such charges, typically incurred when an insured patient gets treated by a specialist not in his or her network, collapsed last year in the face of fierce opposition from the California Medical Association. The doctors’ lobby warned that measure would backfire and lead to a fewer doctors being available. Organized labor had championed the bill.”
“One year later an amended version, Assembly Bill 72 …. has passed on a bipartisan 70-0 vote. The California Medical Association adopted a neutral stance after amendments gave more options for the level at which out-of-network physicians are reimbursed and fleshed out the process to dispute charges.”
Under the new bill, patients would pay only the rate for an in-network physician as long as the patients went to in-network hospitals. Insurance companies would have to pay physicians the rest. The bill will create an independent process for physicians to challenge payments.
A California bill that would let certified nurse-midwives practice independently is pitting the state’s physicians against its hospitals, even though both sides support the main goal of the legislation.
The California Hospital Association and the California Medical Association, which represents physicians agree that nurse-midwives have the training and qualifications to practice without physician supervision.
But they differ sharply over whether hospitals should be able to employ midwives directly — a dispute the certified nurse-midwives fear could derail the proposed law.
“We are very much caught in the middle,” said Linda Walsh, president of the California Nurse-Midwives Association.
The bill would override an existing law that requires certified nurse-midwives to practice under the supervision of medical doctors. California is one of only six states that requires full supervision. Several other states mandate other forms of collaboration, such as in prescribing medications.
The American College of Nurse-Midwives has been chipping away for decades at state laws that require physician supervision, and it has finally passed the tipping point nationally, said Jesse Bushman, director of federal government affairs for the organization. Nurse-midwives aren’t seeking permission to go off and do whatever they want without consulting anyone, Bushman said. “They’re just asking to be able to do what they are trained to do.”
In states where nurse-midwives can practice independently, there is more access to care, he said, citing a recent report published by the George Washington University’s Jacobs Institute of Women’s Health.
There are more than 11,200 nurse-midwives around the nation, including about 1,200 in California. They provide maternity care, family planning services and other primary care for women.
In 2013, California eliminated the physician supervision requirement for licensed midwives, who require significantly less training than nurse-midwives. Unlike licensed midwives, certified nurse-midwives must become registered nurses and obtain a graduate degree in midwifery. They primarily deliver babies in hospitals, while licensed midwives usually work in homes or birth centers.
Walsh said that her association is trying to make it easier for certified nurse-midwives to practice around the state, especially in areas where there may not be any obstetricians. It can be challenging to find physicians willing to oversee nurse-midwives, because of the responsibility and liability involved, she said.
“We have an access issue in California,” Walsh said. “Yet we have this supervisory language that prevents an increase in access for the people who need it most.”
Lisa Catterall, who works in a hospital-based midwifery practice at Feather River Hospital, in Paradise, Calif., said that getting physician supervision is not easy. For one thing, some nurse-midwives have to pay extra malpractice insurance in addition to paying doctors for their supervision. Even with the supervision, the doctors are not required to be present to oversee the care, added Catterall, who delivers about 100 babies a year and sees patients from throughout the rural region north of Sacramento where her hospital is situated.
The debate between the doctors and the hospitals centers on the state’s prohibition of what’s known as the “corporate practice of medicine.” California does not allow corporations, including hospitals, to hire physicians, though there are several exceptions. The intent of the ban is to avoid undue corporate influence on doctors’ medical judgment and patient care. Under current law, hospitals can hire nurse-midwives, though many don’t.
One of the bill’s co-authors, Assemblywoman Autumn Burke, recently withdrew an amendment that would have mirrored the law applying to doctors by barring hospitals from hiring nurse-midwives. With that provision withdrawn, the California Medical Association now opposes the legislation and the California Hospital Association supports it.
The physicians’ group believes that the healthcare decisions of nurse-midwives employed directly by hospitals could be influenced by their administrators, and it says it will only back the bill if the amendment is reinstated.
Patients should have the same consumer protections whether they see a nurse-midwife or a doctor, said Juan Thomas, a lobbyist with the medical association. “It should be a level playing field,” he said. “We believe very strongly that the corporate practice of medicine bar language provides an important layer of patient protection.”
The California Hospital Association, meanwhile, won’t support the bill if the amendment is reinstated. The association believes hospitals need to retain the freedom to hire nurse-midwives.
A ban on hiring would make it more difficult for nurse-midwives to work in hospitals, forcing them into roundabout contracts that are “unduly cumbersome, unduly burdensome and unnecessary,” said Jackie Garman, a vice president of the hospital association.
In addition, Garman said, some nurse-midwives are already employed by hospitals. “What happens to them?” she asked.
The nonprofit Pacific Business Group on Health recently announced its support of the midwife bill, saying it would help expand women’s choices in pregnancy care and lead to better maternal health. In the spring, the group had sponsored a roundtable with more than 30 organizations from around California to discuss increasing access to nurse-midwives.
“It is really hard to argue with the evidence about the value that midwives offer pregnant women,” said Brynn Rubinstein, the group’s senior manager for transforming maternity care. “They are delivering more patient-friendly care, yielding better outcomes and saving money for purchasers,” she said. “But they are not always easy to find.”
Research shows that patients of certified nurse-midwives have fewer cesarean deliveries and lower epidural rates.
Assemblywoman Burke’s office is continuing to talk to representatives of both the physicians and the hospitals to try and find a solution to the contentious issue of whether hospitals should be allowed to hire nurse-midwives, said Allison Ruff, a senior aide to Burke.
“For both of them, it is an issue they don’t want to compromise on,” she said. “The bill became a pawn in the fight between the hospitals and the physicians. It still is.”
Millions of Californians are newly eligible for a healthcare benefit that could determine the treatment they receive in their final days — and most don’t know it.
Medi-Cal, which covers more than 13 million Californians, and Medicare, with more than 5 million California enrollees, now pay for “advance care planning” discussions with doctors.
Advance care planning isn’t about long-term-care options, such as nursing homes or assisted living.
“If you’re incapacitated, if you need someone to speak for you, who do you want to speak for you? And what would be your medical wishes?” she said.
If, for instance, you have a stroke that leaves you unconscious and unable to communicate, with little hope for improvement, would you want to be kept alive with a feeding tube and or ventilator?
“These decisions may have consequences for the quality of life you have for the rest of your life. They may also have consequences for whether you live or die,” McNeal said.
In other words, they’re important. But many doctors and patients don’t yet realize that talking about these decisions — and possibly putting them into writing — is a covered benefit.
Starting in October, Medi-Cal — the state’s version of the federal Medicaid program for low-income residents — began covering advance care planning discussions between doctors (or other qualified providers) and patients (or a family member), said Tony Cava, spokesman for the state Department of Health Care Services, which administers Medi-Cal.
Any Medi-Cal recipient can use the coverage regardless of age, he said. Doctors can bill for the conversation twice a year per patient — plus an additional 30 minutes for one of the conversations — before they have to seek authorization for more coverage.
Medicare, the federal health insurance program for people 65 and older, and for people younger than 65 who have certain disabilities, started covering the discussions on Jan. 1. Medicare does not limit the number of discussions per patient each year.
Some private insurance plans cover these discussions and some don’t, McNeal said. Check with your plan.
Both Medicare and Medi-Cal will cover the conversations even if patients don’t end up completing an “advance care directive” as a result. That’s a document that formalizes your wishes, which should be shared with your family and doctor.
McNeal believes that anyone over 18 should have this discussion and complete an advance directive.
But don’t expect your doctor to initiate the conversation.
“Many physicians may not be very comfortable having this conversation,” said Richard Thorp, M.D., president of the Paradise Medical Group near Chico, and past president of the California Medical Association, which represents the state’s doctors.
A poll of more than 700 doctors, released in April, found that nearly half of them feel unsure some or much of the time about what to say when discussing end-of-life care with patients. (The poll was commissioned in part by the California Health Care Foundation. California Healthline is an editorially independent publication of the California Health Care Foundation.)
Thorp’s patients are mostly older, so he incorporates advance care planning into their annual Medicare Wellness exams. Medicare reimburses him about $86 for the initial 30-minute discussion, and about $75 for each additional 30 minutes, he said.
“There’s an art to having the discussion,” he said. “There’s an art to recognizing when people are uncomfortable.”
Because many doctors don’t know about this benefit — or may feel uncomfortable broaching the topic — most people should start by having a conversation with family and loved ones, suggested Mark Beach, an AARP spokesman based in Sacramento.
After your discussion, write down your wishes, he said.
“It’s difficult to discuss, but when you’ve done it, it’s a comfort,” Beach said. “Not only will your wishes be followed, but your loved ones will know what to do.”
A variety of forms and templates are available to consumers. Thorp sometimes uses what’s called a “POLST” form, which is a medical order that must be completed and signed by a health care professional.
It is typically for seriously ill or frail patients, McNeal said, whereas an advance care directive is a legal document for people of any age or condition.
McNeal recommends the “Five Wishes” form, which can be personalized and is available online for $5 at www.AgingWithDignity.org. Other options for advance directives can be found at www.CaringInfo.org or through AARP. (A lawyer can help you prepare an advance directive, but you usually don’t need an attorney to get it done.)
After you have filled out your advance care directive, take it to your doctor and tell her you want to talk with her about it, McNeal said. Don’t forget to give your doctor a copy.
“The role of the physician is really to provide information, not to persuade one way or the other,” Beach said.
Thorp explains to his patients what it means to be intubated, fed artificially and kept on life-support.
Most are open to the discussion, he said, and their responses are mixed. Some older or sicker patients tell him they don’t want any extraordinary measures if they’re incapacitated. Others, who are younger and healthier, say they would probably want medical intervention if they might have a chance to thrive afterward.
“Most people don’t want to be kept on life-support indefinitely. They really don’t want that,” Thorp said. “They want to live a productive life.”
The CMA said its change to neutral on the issue was the first by a state medical association.
But CMA’s national parent, the American Medical Association, remains opposed to doctors participating in assisted suicide, that the practice would violate physicians’ roles as a healer, would be difficult to control and would pose “serious societal risks.”
It’s unclear how a California law allowing physician-assisted suicide might affect legal liability and other issues for hospitals employing physicians who help patients kill themselves.
