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RHAT Opposes SB976/HB1211 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. 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.