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RHAT Opposes SB976/HB1211
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THERE IS A PRESCRIPTION SUBSTANCE ABUSE PROBLEM IN TENNESSEE! SB976/HB1211 is not
what is needed to combat the issue.
Nurse Practitioners, Clinical Nurse Specialists, Nurse Anesthetists, Certified Nurse Midwives, and
PAs work in many settings including primary care, hospitals, mental health agencies and
hospitals, urgent care, medical specialty clinics, long term care, schools, and the Department of
Health clinics. These health care providers are delivering health care to millions of patients
across Tennessee. The current laws in Tennessee address the scope of practice and prescribing
through the rules and regulations implemented by the Boards of Nursing and Medicine.
Legislative action last year, the Tennessee Prescription Safety Act has been successfully
implemented and already has demonstrated effectiveness. David Reagan of the Tennessee
Department of Health was pleased to report the overall increase in prescribing narcotics in
Tennessee was very small in comparison to the previous years. I congratulate the legislators and
the Boards of Nursing and Medicine who promulgated the rules and regulations for the
Prescription Safety Act.
Tennessee Code Annotated, Title 53, Chapter 10, Part 3; Title 53, Chapter 11, Part 3; Title 53,
Chapter 11, Part 4 and Title 63, Chapter 1, Part 3 (Tennessee Prescription Safety Act) clearly
already requires health care providers to access the controlled substance database prior to
prescribing these medications for a new patient and annually for ongoing prescriptions for
established patients (Section 20 [TCA Section 53-10-310]).
SB976/HB1211 has noted no fiscal impact on the state. However, this is not true. For patients
enrolled in TennCare, increased frequency of office visits to refill prescriptions that are approved
and evidence-based for management of long term consequences of chronic disease will
increase. Instead of a quarterly visit (4 times a year), TennCare will be paying for monthly visits
(12 times a year) for patients who are receiving the appropriate care and medication
management.
Delays in care delivery in all settings will occur. In primary care and specialty care, fewer patients
will be seen due to the requirement for direct physician contact prior to prescribing scheduled
II-IV medications. In acute and long term care, pain management is a critical component of
patient satisfaction not to mention the relationship between healing, recovery and decreased
hospital length of stay due to appropriate pain management. RNs working in those settings are
the ones judged for their responsiveness to patients' pain. Their scores not only reflect on
nursing but if this bill is enacted, will be linked directly to lack of timeliness and responsiveness
of the advance practice nurses and PAs providing the care in collaboration with their physician
colleagues.
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The human cost of this bill has not been addressed. The need to address the prescription abuse
in Tennessee is akin to saying all gun holders are criminals. Not all patients who require
scheduled II-IV are criminals, but this bill treats them in that light. In the outpatient setting,
fewer patients will be seen due to the requirement for NPs and PAs to have direct
communication with their supervising MD. While we are working diligently to control the costs
of TennCare and private health insurance through decreased emergency room utilization,
patients will return to the ERs due to lack of access to services at primary care clinics and health
departments who predominately serve the uninsured and TennCare population. For the
supervising physicians patient flow in their practice will be disrupted as he/she speaks
individually to APNs prior to prescribing resulting in decrease of the physician ability to provide
access to care, decreased patient satisfaction due to limited access to provider time, and
increased practice costs due to decreased revenue generation. Lastly, school children who have
a confirmed diagnosis (by psychology and/or psychiatry) will be required to miss school in order
to have an office visit for prescription renewal. A lost day of school does create lost funding for
the schools.
For insured patients, most insurances (including TennCare carriers) require chronic medications
to be filled for 90 days for stable chronic medical management. This is a cost saving measure for
the insurers and patients.
The APNs in Tennessee already have prescription oversight by physicians (Rules of The
Tennessee Board of Nursing) Chapter 1000-4. These regulations specifically provide rules for
treatment of pain (1000-4-.08).
The Tennessee Board of Nursing rule 1000-4-.09 specially outlines the physician supervisee
requirements.
Formulary process and agreement between the APN and physician supervisor is already a
requirement for APNs to prescribe.
According to TDOH David Reagan only 52 prescribers
(http://www.knoxnews.com/news/2013/mar/04/painkiller-prescriptions-in-tennessee-onthe/?comments_id=2566857 ) are an issue in Tennessee. We need to address the issue at the
individual level versus through this legislation.
Stop SB976/HB1211 this year. Give the legislation put in place last year time to demonstrate the
difference. Let TDOH use the data to address issues at the individual provider level versus
treating all health care providers and patients as the problem.
ETSU College of Nursing has 10 clinics where primary care is provided by nurse practitioners. The
patients we serve are predominately uninsured (70% at Johnson City Community Health Center)
and TennCare (53% across all clinics). In Hancock County, our nurse practitioners are the only
primary health care providers for the county and in Johnson County 5 of the 8 practice sites
have NPs and PAs providing primary care to the citizens of the county. Over 30,000 individuals
receive health care in our clinics. As we strive to provide health care for those who do not have
access, any further regulations to limit how we care for patients will only serve to further
impede access to health care, prevention, and management of chronic illness that will ultimately
result in increased costs to the state from avoidable emergency, hospital, and long term care
admissions. Lastly and most importantly, we have no recourse for referrals of our patient
population to specialty providers, mental health services, and/or substance abuse programs
when identified as a need.