The 112th Tennessee General Assembly convened in mid-January. As the state and nation continue to navigate COVID-19, legislators are looking at issues and fallout pertaining to the pandemic In addition, hundreds of bills have been filed that intersect with the broad topic of healthcare. While many will never make it out of committee, the major provider and facility organizations - Tennessee Hospital Association, Tennessee Medical Association and Tennessee Nurses Association - will keep watch for those impacting their membership while also pursuing action on their own legislative priorities.
Hospitals are a year into caring for the sickest COVID-19 patients with dedicated but exhausted staff. The Tennessee Hospital Association's 2021 legislative agenda focuses on bringing relief to hospitals struggling to stay staffed and stay competitive while serving all comers. Joe Burchfield, senior vice president of Government Affairs for THA, outlines three top priorities for the year.
Nurse Graduate Licensure: THA looks to codify a current executive order that allows nursing graduates who haven't yet taken the National Council Licensure Examination (NCLEX) to begin practice under the supervision of a licensed registered nurse while they await testing and licensure. Burchfield noted new graduates have a gap of up to three months between finishing their studies and being able to sit for the exam and complete the licensure process.
"The nurse graduate executive order helped close a fundamental gap in the workforce pipeline that existed before the pandemic but was exacerbated as staffing needs became a critical issue in 2020," Burchfield explained. "By enabling immediate practice with proper supervision from experienced nurses, nurse graduates are able to complete the orientation and training process at the hospital and are better prepared for full practice upon licensure. Allowing the licensure and onboarding processes to occur concurrently benefits everyone."
CON: While the pandemic pushed back action on CON reform, or possible repeal, last year, Burchfield said THA expects it to be a priority for lawmakers in 2021. Adding to the overall discussion, the Health Services and Development Agency, which oversees the CON program, is up for sunset in 2021. Although THA understands the desire for CON reform and recognizes support exists among legislators to take action, the association believes parts of the program are essential to keep hospitals in business. The CON program assess community need and growth to avoid oversaturation in a market and ensure orderly development.
"Certificate of need requirements help level the playing field between hospitals that are subject to federal regulations, requiring them to treat all individuals regardless of their insurance status or ability to pay, and other non-hospital providers - like imaging centers and ambulatory surgery centers - that are not subject to the same requirements," said Burchfield.
"The unique role of hospitals in the healthcare system has never been more apparent than in the current pandemic, as hospitals played the central role in response to the surge in the most seriously ill COVID-19 patients," he continued. "One of the most significant ways hospitals are able to maintain overall operations and preparedness for any emergency is through the critical revenue generated through outpatient procedures. Unregulated growth of non-hospital providers whose business model is to focus on the most lucrative patients and procedures undermines a hospital's ability to sustain the money-losing but essential services they provide to the community."
Hospital Assessment: The annual hospital assessment is once again part of THA's legislative agenda for 2021. The voluntary assessment, which began in 2010, generates $602 million in state dollars and totals $1.7 billion for the TennCare program when adding the federal match.
"The impetus for the hospital assessment in 2010 was the Great Recession and a series of cuts proposed to the TennCare program in order to balance an austere budget. The items funded since that time have avoided a number of benefit limits for TennCare enrollees and a hefty provider rate reduction," Burchfield said. He noted 49 states and the District of Columbia have some type of assessment program in place, so Tennessee is not unique in this funding mechanism.
Burchfield added the new TennCare III waiver has no impact on the assessment, which will continue to fund the same items in the budget and in the same manner. Not every hospital is required to pay the assessment, though. Exclusions exist for public hospitals, critical access hospitals, state-owned mental health hospitals, St Jude Children's Research Hospital and rehabilitation hospitals.
While at the ready to weigh in on any number of bills impacting physicians, the Tennessee Medical Association is heavily focused on three key issues in 2021 - graduate medical education funding, balance billing and scope of practice. Julie Griffin, vice president of Legislative Affairs for TMA, shared insights on the organization's stance on each of these top priorities.
Graduate Medical Education Funding: Last summer, the Centers for Medicare and Medicaid Services ruled Tennessee must scrap its long-standing formula to fund graduate medical education slots through TennCare and develop a new plan. Griffin said a key concern is the ruling puts millions of dollars and all of the state's residency program at risk, including additional GME funding TMA worked to get added to Governor Lee's 2019 budget.
She said limited funding and slots are already an issue in Tennessee. Despite putting money towards attracting and educating medical students with outstanding programs available statewide, far too many leave to finish their training. "Over 60 percent of residents end up staying in the state where they actually do their residency," said Griffin. "We are now an exporter of students." She said increasing funding and training options in Tennessee should mean many of those young physicians opt to build a life and a practice in the state. "The economic benefit of having a physician in a community is broader than just the care delivery," she noted, adding that benefit is even greater in rural areas.
TMA's priority will be to have a seat at the table in determining the new formula for resident funding and to preserve the additional slots gained in 2019. Griffin said her understanding from discussions with TennCare officials is that CMS wants a more streamlined process to ensure the state monies and the federal match flow directly to the creation of residency slots. "We are very concerned about what we're going to do to ensure those dollars are secure," she noted. However, Griffin added, Oklahoma went through a similar process a few years ago and ultimately did wind up receiving their full GME match after reworking their funding formula.
Balance Billing: Everyone agrees patients shouldn't be surprised with thousands of dollars in unexpected healthcare costs. TMA is leading a coalition of hospital-based physician specialty organizations to address narrow networks from health insurers that they believe is at the root of the problem.
A federal bill passed last year, and there is currently a similar measure gaining momentum at the state level. Griffin said the reason to have a state law on top of the federal act is to ensure there is no gap in patients who are covered under the law. Although there are differing views, Griffin said the concern is the federal language is specific to self-funded ERISA plans and doesn't apply to commercial markets. Additionally, the state plan puts a mechanism in place for the uninsured to start in the negotiation process for pricing.
State-wide listening sessions are being hosted with SB001/HB002 sponsors, Sen. Bo Watson and Rep. Robin Smith. Based on a successful model used in Georgia, their bill would only require patients to pay according to their in-network responsibility if they receive a surprise medical bill and would allow out-of-network physicians to pursue fair payment from health insurance companies through an independent arbitration process if the initial payment was unsatisfactory.
"We want to take the patient out of the middle and make the decision between provider, payer and arbitrator," said Griffin.
Scope of Practice: An ongoing contentious issue, a three-year moratorium on any scope-of-practice legislation redefining supervisory parameters for advanced practice nurses expired in 2019. The pandemic allowed the issue to simmer for another year, but in 2021, both advanced practice nurses and physician assistants look to make a push for independent practice.
TMA has steadfastly promoted physician-led, team-based healthcare delivery as the best model for patient safety and quality of care. "There are things with the current system that absolutely do need to change," Griffin said of some areas of common ground. "We are always willing to sit down and find ways to reduce barriers to an advance practice nurse or PA who is trying to extend care to patients," she continued. "However, we do not think the best care for patients is to sever a required relationship with a provider who absolutely has more education and training than the extender seeing the patient."
"Our 2021 legislative agenda reflects TNA's mission is to protect and promote the professional nurse" said Kathleen Murphy, director of Government Affairs for the Tennessee Nurses Association. The statewide organization continues to focus on legislation addressing scope of practice issues in a quest for more independence for advanced practice registered nurses (APRNs). Other agenda items for 2021 include increased funding for school nurses and enhanced attention to workplace safety.
Scope of Practice: "We are supporting SB176/HB184 which will allow advanced practice registered nurses to continue prescribing and caring for their patients without the economic burden of a contract agreement," said Murphy. "Along that similar line, we are also supporting APRN's ability to prescribe home health orders in SB478/HB743." She said the two pieces of legislation go toward addressing access issues for Tennesseans. "These bills allow patients to choose who their provider is and do not force patients to establish new relationships with a provider they have never seen before to meet an administrative requirement," she stated.
Murphy added, "Nurses have always been prepared to step up when needed. As we have seen this year more than ever, nurses answer no matter what the call is." She noted nurses have worked tirelessly, often at the risk of their own health and wellbeing, during the pandemic. "We look forward to working with the legislature to cut the red tape holding APRNs back and promoting a legislative agenda that provides access to high quality care to all Tennesseans no matter where they live."
School Nurses: The pandemic highlighted a range of unmet needs, including adequate access statewide to school nurses. Murphy said TNA is working with sponsors to increase funding and improve the student-to-nurse ratio. "We know that the health of a student impacts their learning ability. Now more than ever, we need to ensure our students are physically and mentally healthy and able to learn no matter the setting."
Workplace Safety: Murphy noted concerns over safety in the workplace is an issue that needs to be revisited. "People who assault a healthcare provider when they are preforming their duties are no longer charged with increased fines," she explained. "We believe that increase was a deterrent that is essential to helping keep our workplaces safe. We will be working with sponsors to put healthcare workers back into the Tennessee code that was unfortunately removed in the 2020 August special session."