Michigan’s medical community is split over legislation that would give nurses with advanced training the authority to prescribe some medications.

Essentially, physician groups are working to prevent nurses from gaining responsibilities that are currently reserved only for doctors.

Senate Bill 2 would allow Advanced Practice Registered Nurses (APRNs) in Michigan to write prescriptions for patients without physician approval. This new authority would be limited to the particular nurse's scope of practice.

Michigan is one of 21 states that do not recognize APRNs. In 16 states and Washington, D.C., these nurses are allowed to practice autonomously with regard to providing diagnosis and treatment, and write prescriptions independently.

Those who support the legislation argue that it would help address the shortage of medical professionals that currently exists and is expected to grow. Those opposed to Senate Bill 2 argue that it would reduce the quality of health care patients receive by permitting APRNs to act as physicians without the appropriate education, certification and training.

The bill’s sponsor is Sen. Mark Jansen, R-Gaines Twp., who introduced the measure back on Jan. 16, 2013. It was passed narrowly by the Senate with a 20-18 vote on Nov. 13, 2013, and has now been in the House Health Policy Committee for nearly 10 months. It received its first hearing in that committee this past week, but the context of that hearing was that no vote would be taken on the measure.

Capitol Confidential asked Rep. Gail Haines, R-Waterford, who chairs the House Health Policy Committee, if the length of time the bill has been in committee signaled that she was opposed to the legislation.

“I’ve never been one to avoid holding hearings just because I’m on the fence,” Rep. Haines said. “I wanted to make sure I’d given Sen. Jansen ample time to work this bill. I haven’t seen a tremendous amount of support for it in the House. It would amend the public health code and it involves some complicated issues. APRNs have not been mentioned in Michigan’s health code since 1965. Several concerns have been raised about it.”

“There is no doubt that we’re on the verge of seeing a lot of new innovations in the field of health care,” Rep. Haines continued. “But whether this should be one of them is debatable.”

Capitol Confidential asked Sen. Jansen if the prospect of physician shortages under Obamacare was one of his primary reasons for introducing Senate Bill 2.

“I started on this three years ago, which was even before I was sure that we would really have that public health care change,” Sen. Jansen said. “So, I’d say that there are other reasons in addition to that which will continue to create shortages of doctors. That’s why I think we should involve all of our qualified people and allow them to do what they are qualified to do.”

The Michigan State Medical Society, which includes a membership of 14,000 physicians, is leading the battle in the legislature against Senate Bill 2. Its allies in the effort include the Michigan Academy of Family Physicians, the Michigan Radiological Society, the Michigan Osteopathic Association and the American Congress of OBGYN.

On the other side of the issue are other groups within the medical community that are urging lawmakers to support Senate Bill 2. They include the Michigan Primary Care Association, the Michigan Association of Health Plans, the Michigan Pharmacists Association, the Michigan Nurses Association and Spectrum Health.

One of the key arguments for Senate Bill 2 is the idea that continuing to limit the scope of practice of registered nurses will give them less reason to stay in Michigan or move to Michigan, worsening the shortage of medical professionals in the state.

With issues such as allowing these nurses to prescribe drugs, the question inevitably arises as to whether and to what degree opposition might involve one group (physicians) protecting its turf against what it sees as the encroachment of another (APRNs).

“It appears that those who oppose the bill see it as putting the proverbial camel’s nose in the tent,” Sen. Jansen said. “It is usually that way with issues that involve turf. But I really don’t see how they can be concerned that the nurses would set up their own shops. Insurance companies will not reimburse for this, so I couldn’t create that kind of situation even if I wanted to.”

“I’ve tried to work with them,” Sen. Jansen added. “I’ve changed this bill 23 times. This is really about providing care. As we have less and less doctors we’ll need to find more ways to utilize other qualified people.”

Dr. Kenneth Elmassian, immediate past-president of MSMS, said that opposition to Senate Bill 2 is based on protecting public health, not defending turf.

“The issue is preventing nurses from being allowed to perform as if they were physicians. It has nothing to do with protecting turf,” Elmassian said. “Senate Bill 2 is really all about the nurses’ agenda and Sen. Jansen’s agenda. We have a tremendous amount of respect for nurses; they are a vital part of the physician-led team. But they are not physicians and it is not in the best interest of public health to let them practice as though they were.”

If the bill isn’t passed in 2014, a new bill would likely be introduced in 2015 and the process would start all over again. Sen. Jansen will be termed out of the legislature by that time. Capitol Confidential asked Sen. Jansen if it is realistic to believe Senate Bill 2 could get passed and sent to the Governor before the end of this year.

“Right now I am anticipating that it could still get done this year,” Sen. Jansen said. “If it doesn’t, I’m hoping another legislator will carry on after I’m gone. I’ve spent time bringing Rep. Peter McGregor, R-Rockford, up to date on this issue. It looks like he will be, more or less, taking my place in the Senate.”

In addition to allowing APRNs to prescribe drugs to patients, Senate Bill 2 would also do the following:

• Prescribe APRN license fees, and a method for review and adjustment.
• Require an APRN to enter into a mentorship agreement if he or she had been licensed or certified for less than four years.
• Allow an APRN to issue a complementary starter dose of a prescription drug or Schedule 2 to 5 controlled substance.
• Create the APRN Task Force.
• Revise the membership of the Michigan Board of Nursing.
• Allow the Board of Nursing to require a licensee under Part 172 (nursing) to provide evidence of the completion of continuing education or competency courses, for license renewal.

The measure would also amend the code to include a licensed APRN among the individuals who may refer a patient for speech-language pathology services or occupational therapy, and among those who may prescribe physical therapy.

In the three years since Dansville Schools dropped Michigan Education Special Services Association insurance for a different high-deductible plan, it has saved $736,873.87 and its employees haven't had to pay for any health insurance premiums in that time, according to the superintendent.

MESSA is a third-party administrator affiliated with the Michigan Education Association that buys health insurance from Blue Cross Blue Shield of Michigan and resells it to school districts.

Dansville Superintendent Amy Hodgson said the $736,873 was how much more the district would have paid had it kept MESSA. She said the employees do have to make co-pays for things such as office visits. Dansville dropped MESSA in 2011-12.

Because of a 2011 law which has had big savings for taxpayers and districts, schools have the ability to choose an 80/20 option where employees pay 20 percent of the premium cost or the “hard cap,” which restricts the dollar amount a school district can spend on insurance premiums. The hard cap was set at $15,000 for the family plan in 2011 and increases every year at the rate of inflation.

Hodgson said Dansville has a hard cap plan, which allows them to cover the premium costs of their employees.

Since the 2011 bill that required employees to contribute to their own health care costs or put a cap on what schools could spend on it, MESSA has seen its program revenue decline, according to documents filed with the IRS.

MESSA’s program revenues have dropped from $1.25 billion in 2011 to $1.06 billion in 2013, a 15 percent drop.

“School districts are likely dropping MESSA because it's just not a good value,” said Audrey Spalding, education policy director at the Mackinac Center for Public Policy. “The 2011 law limiting health insurance costs has encouraged districts to shop around for better plans. As a result, districts throughout the state are saving money by leaving MESSA.”

Gary Fralick, spokesman for MESSA, did not return a request for comment.