Even before the start of the second year of the 109th Tennessee General Assembly, the Tennessee Medical Association has several key legislative priorities it will be working on. The ultimate goal of the organization’s 2016 Legislative priorities is to help create a better, safer healthcare environment for Tennessee doctors and patients. Three of the five main initiatives the TMA has on its agenda are bills already in the pipeline that should pave the way for a healthcare future that is patient-centered and physician-led, holds insurance companies more accountable when changing fee schedules and payment policies as well as preserves Tennessee’s favorable medical malpractice climate.
The Tennessee Healthcare Improvement Act (SB00521/HB0861) calls for physician-led coordination and collaboration. The bill creates a blueprint for the future delivery of healthcare by implementing a team-based care model with doctors as the team leaders in patient care coordination. The legislation calls for collaboration between physicians and advanced practice nurses to ensure patients receive care from the appropriate providers. Under present law, an advanced practice nurse is a registered nurse with a master’s degree or higher in a nursing specialty and national specialty certification as a nurse practitioner, nurse anesthetist, nurse midwife or clinical nurse specialist. Under this bill, an advanced practice nurse will instead be certified as an advance practice registered nurse (APRN).
“Having the proper collaboration from a physician in diagnosing and treating a patient ensures the highest quality of care and patient safety,” said John Hale, MD, TMA president. “We want to knock down silos among providers, increase care collaboration and create a model that supports the best possible outcomes for patients. The Healthcare Improvement Act will allow advanced practice nurses to use the full extent of their training, but makes sure that a physician is involved in the care of every patient. It is in the best interest of all Tennesseans.”
This bill requires every APRN to practice as part of a patient care team. Each member of the patient care team provides healthcare services within the scope of that team member’s practice area.
The bill would change the relationship between physicians and advanced practice nurses from one of supervision to one of collaboration. The goal is to ensure patients receive care from appropriate providers with proper oversight. This is a very different approach to the Nurse Independent Practice/Full Practice Authority Bill, which is designed to give nurses the ability to diagnose and treat patients and prescribe drugs without a physician supervisor to review charts or provide consultation. The bill was taken off notice in order for involved parties to discuss compromises during the summer.
Representative Steve McDaniel (R-Parkers Crossroads) says he wants to see each side get together to make things work and hopes he can further that process. “I think that a collaborative effort between Advanced Practice Registered Nurses and Primary Care Physicians is something that needs to be looked at. I am not sure how well the current system is working so I am interested in seeing it work better,” he said. “I represent four rural counties where healthcare is not as available as in urban and suburban areas and where it is harder to attract physicians. So we need to find a way to utilize nurse practitioners to best serve the underserved.”
Reimbursements
The Healthcare Provider Stability Act (SB0937/HB0963), if passed, would make Tennessee the first state in the country to limit how often payment policies can be changed. The bill changes the way the insurance companies negotiate contracts with doctors and hospitals. The central issue is that physicians rely on insurance companies to refer patients through provider networks. Under the current guidelines, insurers can change the terms of agreements with providers in the middle of multiyear contracts. If a physician does not agree to the change, health plans will drop them from the network forcing patients to find a new provider or pay higher “out-of-network” fees.
“It’s impossible for a physician to make sure the business side of a practice runs smoothly when health plans can cut reimbursement mid-contract with no recourse for the physician,” said Hale.
The goal of the bill is to achieve much needed predictability in reimbursement for healthcare providers by limiting arbitrary reimbursement changes in the middle of a contract period. By requiring notice of changes to fee schedules and payment policies, the bill would make it easier for providers to see, understand and deal with contract changes as they are made.
As amended, this bill establishes limits on a payer’s ability to make changes to a fee schedule to 1 time in a 12-month period. It limits changes to payment policies and other administrative changes to only 2 times per year by a third-party payer. It also provides for transparency of all payment policies and methodologies on a payer’s website.
“I think that insurance companies should not be allowed to unilaterally change the terms of their contracts midstream,” said Tennessee State Senator Brian Kelsey (R-Germantown). “Doctors should have confidence in the fairness of their negotiations with insurance companies.”
Insurance companies oppose the bill claiming it will affect patient care and could increase the cost for plan members, since renegotiating contracts annually would be costly. The bill is currently in the Senate Finance Committee and the House Finance Subcommittee. The administration added a $5 million fiscal note to the bill at the end of the previous session.
Damage Caps
An amendment to the Tennessee constitution clarifying that the General Assembly can cap noneconomic damages in cases including medical liability is the third major initiative for TMA. The Tennessee Civil Justice Act of 2011 places a cap of $750,000 on non-economic damages such as pain and emotional suffering and a $500,000 cap on punitive damages in medical malpractice and personal injury cases. The cap on noneconomic damages is currently being threatened by lawsuits, including one in Chattanooga in which the judge ruled the cap unconstitutional. Groups with opposing views to the cap include trial lawyers through the Tennessee Association for Justice and the New York-based Center for Justice and Democracy.
The joint resolution is expected to be introduced in the 2016 session. The proposed amendment would be required to pass two separate General Assemblies before it would be placed on the ballot for a vote in 2018. “The General Assembly needs to act now to prevent us from going backwards on the issue of a noneconomic damages cap,” said Hale. “The cap fosters growth in Tennessee’s healthcare industry by cutting back on frivolous lawsuits and the costs that come with them. I’m confident Tennessee voters will support it if given the chance to have their voices heard.”
Other Issues
Another issue on TMA’s agenda is proposed legislation that would set parameters for in-office dispensing of medications in order to ensure that unscrupulous doctors are not able to abuse this ability. The other top issue is a bill to establish penalties when insurance companies don’t comply with regulations already in place for workers’ compensation silent PPOs.
“TMA’s legislative priorities are about making improvements for Tennessee physicians and the patients they serve,” said Hale. “We are looking out for the future of Tennessee healthcare, working to make sure it evolves in ways that allow doctors to provide the best care possible to their patients. The issues on our 2016 agenda reflect our mission as an organization.”
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