Report

Pennsylvania’s Healthcare Should Always be Crisis Ready

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COVID-19 has done its part to highlight the weaknesses of Pennsylvania’s healthcare sector. Primarily, what has been revealed is a lack of flexibility, and regulations that make it difficult to rapidly respond to an evolving crisis. This rigidity has resulted in medical professionals becoming unemployed or furloughed, despite having the necessary training to help. As medical efforts have been focused on COVID-19—which is understandable—these medical professionals were barred from meeting the primary care demands of their communities, which didn’t go away as a result of the pandemic. 

As Pennsylvania learns these lessons from the first wave of COVID-19, lawmakers need to implement changes so that the same errors don’t occur during the next wave, or the next pandemic. We can make great strides in improving the healthcare sector so that physicians have the flexibility to focus on COVID-19 and other urgent cases. This can be done by enabling mid-level health professionals to step in and address basic healthcare needs. 

The Commonwealth Foundation proposes the following three legislative actions in order to improve the healthcare sector to better meet patient demands.

  • Examine which emergency suspensions should be made permanent, with an emphasis on telemedicine and state reciprocity of medical licenses.
  • Expand the scope of practice for mid-level medical practitioners.
  • Expand the scope of practice for pharmacists.

Regulatory Actions
The temporary suspensions of existing regulations by the Pennsylvania Department of State to address COVID-19 should be applauded. Notably, encouraging telemedicine, allowing out-of-state providers to treat patients, and the relaxation of supervision and administrative regulations. These regulations restricted the healthcare sector prior to COVID-19 and would have only made the crisis worse. Additional temporary suspensions are listed below. 

  • Telemedicine 
    • Health care professionals licensed under any of the Department of State's Bureau of Professional and Occupational Affairs (BPOA) licensing boards can provide services to patients via telemedicine during the coronavirus emergency. This also applies to professionals licensed in other states.
  • Out-of-State Licenses 
    • Allow expedited temporary licensure for practitioners in other states to provide services to Pennsylvanians for the duration of the coronavirus emergency. 
  • Mid-wives 
    • Suspend regulations related to collaborative agreement and reactivations of licenses.
  • Physicians 
    • Suspend the limitations on the number of institutions with which a medical doctor can be affiliated and the requirement to report those affiliations to the Board of Medicine for the duration of the disaster declaration. 
  • Nursing License Requirements 
    • Suspend certain administrative requirements for nurses, including temporarily extending license expiration dates and waiving associated fees. 
  • Physicians Assistants 
    • Suspend requirements pertaining to written agreements and supervision and administration of Physician Assistants.  
  • Pharmacies 
    • Suspend regulations regarding remote supervision of staff and allowing for the licensure of out-of-state pharmacies to ship goods into Pennsylvania.
    • Permitted to test for COVID-19.
  • Reactivation for Retires
    • Temporarily waive regulations and costs for reactivation of an inactive license for professions and licensing boards. 
  • Certified Registered Nurse Practitioners
    • Allow Certified Registered Nurse Practitioners to practice to their full capabilities, including the ability to practice outside their specific clinical specialty as well as the ability to prescribe drugs outside of their established formulary. 
  • Psychologists, Social Workers, Therapists and Counselors
    • Enable unlicensed practitioners to provide teletherapy so long as their supervisor complies with regulatory requirements.  
  • Flexible prescriptions
    • Include COVID-19 diagnosis on relevant prescriptions and allow for smaller doses as appropriate within the limited scope of COVID-19 related medications.
  • Certified Registered Nurse Anesthetists
    • Permit Certified Registered Nurse Anesthetists (CRNA) graduates who have completed an approved anesthesia program to practice under supervision without having taken the CRNA exam. 
  • Osteopathic Physicians and Surgeons
    • Allow osteopathic physicians or surgeons from other states or Canada to be issued a “short term camp license” in Pennsylvania.
  • Respiratory Therapists
    • Extend timeframe for applying for a temporary respiratory permit from within 30 days of expected graduation to 90 days.
  •  Graduate Medical Trainees
    • Allow medical residents to advance to their next year of training based on the residency director’s determination.
  •  Perfusionists
    • Extension of all temporary graduate perfusionist licenses. 
  • Military Medical Personnel
    • Allow medical personnel to practice in PA so long as they are employed by the Armed Forces, or an additional qualifying agency. 
  • Hospitals and Ambulatory Surgical Facilities
    • relax the scope of practice requirements and supervision requirements for health care professionals working in those facilities. 

Make Telemedicine and State Reciprocity for Telemedicine Permanent
Regulatory suspensions related to COVID-19 are set to expire after the crisis. These suspensions should be examined and, in many cases, maintained and made permanent to prepare for the next wave. Suspensions that increase the medical labor force, ease licensing barriers, and improve access to care without increasing patient risk are all prime candidates for being made permanent. 

In particular, lawmakers should provide guidelines for telemedicine that clarify insurance compensation in order to encourage wider adoption. Combined with state reciprocity of medical licenses and expanding pharmacists’ ability to test and treat simple illnesses, Pennsylvania can expand access to basic healthcare for residents across the state. 

As a policy paper from the Mercatus Center pointed out, an overwhelmed healthcare sector can increase the deadliness of COVID-19, as the Italian experience has proven. Therefore, the proper policy response is workforce capacity building in order to mitigate the burdens from the growing influx of patients, while allowing preventative and primary care to continue. The following proposals are designed to do just that. 

Independent Practice for Nurse Practitioners 
In 2017, Benjamin J. McMichael found that strict scope of practice laws result in fewer practicing nurse practitioners and physician assistants. Nurse practitioners are specialized high-level nurses who have a master’s degree in their area of practice. In Pennsylvania, nurse practitioners must work under a physician despite having the ability to provide essential care such as ordering tests, interpreting results, and the development of treatment plans. 

In response to COVID-19, Governor Wolf issued a waiver for scope of practice and supervisory requirements within certain facilities. In regard to nurse practitioners, many of the provisions in the waiver should be made permanent through legislation. Thankfully, some state lawmakers have already introduced bills to do just that. Senate Bill 25 and House Bill 100 create a path for nurse practitioners to practice independently after a minimum of 3 years and a minimum of 3,600 hours under the supervision of a physician. This legislation would free up the over 7,000 nurse practitioners in the state to better serve their patients, while also making the state more attractive for other nurse practitioners. 

According to the most recent data from the Association of American Medical Colleges (AAMC), Pennsylvania has 41,041 active physicians with only 12,910 focused on primary care. This means that for every one primary care provider, there are almost 1,000 patients—992 to be exact. With almost 90% of nurse practitioners qualified to practice primary care, empowering them to practice independently would bring the patient burden down to 667 patients per primary care provider. This would represent roughly a one-third reduction of patient burden and expand access to care for all Pennsylvanians. 

Flexibility of Practice for Physician Assistants
Physician assistants have similar educational requirements to nurse practitioners and also must obtain an advanced master’s degree; however, their education is more general. Physician assistants practice under a collaborative agreement with a physician, with practice limits placed at the state level. This means that individual practices do not have complete flexibility to adjust their structure to adequately reflect the ability, training, or knowledge of the physician assistant.

The 5,700 physician assistants in the state represent untapped potential that the medical field could be using in order to better serve their patients. In order to better serve patients and maintain talent, decisions like physician to physician assistant ratios and a doctor’s presence at satellite offices should be determined at the practice level. The goal is not to encourage independent practice, rather to alleviate the supervisory burden of physicians depending on the physician assistants’ abilities. 

In addition, physician assistants should have the freedom to practice as soon as their collaborative agreements are submitted to the licensing board instead of waiting weeks or months for approval. 

These improvements are embodied in House Bill 1997 and House Bill 1998, and are awaiting consideration in the House. Passing these improvements would streamline practice operations and reduce some of the current patient burdens of physicians. 

Expand Pharmacist Services
Pharmacists are advanced medical professionals who undergo an advanced education to gain a doctoral degree and must pass a series of exams before gaining their license to practice. These qualifications put them in a prime position to help assist physicians in meeting the medical needs of their communities. 

A key way to do this is to expand their current abilities in regard to immunizations. In Pennsylvania, under the Pharmacy Act of 1961, pharmacists are able to offer injectable medications, biologicals, and immunizations to anyone 18-years-old or older as well as offer flu vaccinations to anyone 9-years-old or older. Expanding these limitations to enable pharmacists to administer approved injectable medications, biologicals, such as MMR and HPV, and immunizations to anyone 9-years-old or older would empower these medical professionals to better serve their communities. 

House Bill 91, represents the current legislative effort to expand the immunization ability of pharmacists. When Act 8 of 2015 allowed pharmacists to offer flu shots to anyone 9-years-old or older, it created an additional 9,000 access points for flu vaccinations across the state. This bill would build upon this expanded access for flu vaccinations to cover the complete range of approved immunizations. 

Additional Options
Advanced practice registered nurses are divided into specialty sub-categories, one of them being a nurse practitioner and the other being a nurse anesthetist. However, while many states recognize nurse anesthetists as a separate license, Pennsylvania is not one of them. This creates barriers for these medical professionals to expand their focus and fill in gaps during health crises like COVID-19. 

Fortunately, some lawmakers are already working to change this through Senate Bill 325 and House Bill 1064, which officially recognize the expertise of certified registered nurse anesthetists as a specialty. This legal recognition makes it easier for these professionals to be licensed and better utilized during times of crisis. In particular, nurse anesthetists are trained to use ventilators, but cannot provide this service outside of surgery settings without recognition of their specialty. 

Conclusion
Solidifying temporary regulatory suspensions, while empowering other healthcare providers to meet the needs of their community will help Pennsylvania be better prepared for the next wave of COVID-19 or any other health crisis that arises. Intentionally limiting healthcare options and the talents and skills of the health workforce is an idea that doesn’t make sense at any time, especially not at this moment.