By Syed Kaleem
Last month, the Pennsylvania State Senate surpassed expectations, based on previous years, and passed SB 25 – an amendment to the state’s Professional Nursing Law that includes expanding Certified Registered Nurse Practitioners’ (CRNPs’) scope of practice to include independence from physicians. However, in the context of its goals of increasing access to care in rural areas, valuable time and energy is being wasted with efforts to push this legislation instead of telemedicine regulations. A framework for telemedicine would move Pennsylvania’s healthcare landscape into the future would significantly increase access to care.
The Pennsylvania Medical Society sent a letter to Committee members before the bill passed stating their position that, “Removing physicians from the care team will not improve care nor will it improve access to care in remote areas of the state.”
Their claim that the change in policy will not “improve access to care in remote areas of the state” is an important consideration. No matter how many providers there are, access to healthcare in rural communities will remain scarce. One simple reason for this is that healthcare providers will not move to rural areas of the state when they have urban and suburban alternatives. This trend is already seen in Pennsylvania’s Primary Care Health Professional Shortage Areas (HPSAs), three-quarters which are either rural or partially-rural locations.
Thus, even if Pennsylvania’s cities and suburbs accumulate more providers, independent providers are more likely to move to a suburb in another state before ever moving to one of Pennsylvania’s rural communities. There are plenty of alternatives to Pennsylvania for an independently-practicing CRNP, as numerous other states have already established laws allowing them to provide care without physician supervision.
The Pennsylvania Coalition of Nurse Practitioners often cites that nurse practitioners are more likely than primary care physicians to practice in rural areas. However, the effects of legislation like SB 25 can be seen in states that already allow CRNPs to practice independently. In Arizona, only 287 CRNPs of 3,068 in the state practice in any sort of rurally-classified area. In New York, there were 65 NPs per 100,000 people statewide, 52.4 per 100,000 in its rural areas, and 67.6 per 100,000 in urban ones in 2017, in contrast to 77 NPs per 100,000 people in Pennsylvania in the same year. Rather than CRNP scope of practice, telemedicine should be thoroughly explored to impactfully improve rural access to healthcare.
Telemedicine is one of the most effective, evidence-based approaches to improving rural access to healthcare. Project ENABLE is a palliative care telehealth program targeted at rural patients with advanced cancer or heart failure. It was created in rural New Hampshire and Vermont and has shown success in different settings by improving quality of life, physical and mental health, and decreasing caregiver burden. Since its establishment, Project ENABLE has even expanded to other countries, including Honduras, Singapore, and Turkey.
Currently, Pennsylvania has established some bare-bones telemedicine reimbursement guidelines for the state’s Medicaid program. Unfortunately, there is no coverage for remote monitoring or store-and-forward telecommunications, and many specific details pertaining to the intricacies of specialized care are not included. To date, there is also no legislation providing a meaningful regulatory framework for the practice of telemedicine in the state of Pennsylvania.
However, there is hope in the Pennsylvania Congress for improving rural access to providers.
Two bills, Senator Elder Vogel Jr.’s SB 780 and Rep. Harry Readshaw’s HB 15, look promising for the future of telemedicine. Both seek to implement the necessary foundations for telemedicine’s use across the commonwealth from Congressmen on both sides of the political aisle. Since telemedicine is the most viable financial model for improving access to care for rural communities, Pennsylvania must focus the healthcare conversation on developing these two bills instead of debating the politics of CRNP scope-of-practice every few years, which carries no significant track record of improving rural access in other states. Let us move forward this year and avoid repeating last year’s failure by passing comprehensive telemedicine legislation in the Commonwealth.
Syed Kaleem is a medical student at Drexel University College of Medicine and alumnus of the University of Pittsburgh. @ZaneKaleem on Twitter.