The following opinion piece submitted by State Representative Jason Spencer who represents House Seat 180 in the Georgia General Assembly. The views expressed below do not necessarily reflect those of AllOnGeorgia.
Rural Georgians are once again the brunt of myopic health care policy decisions coming from Atlanta. On the heels of the Jenkins County Hospital closure announcement, a bill designed to restore delegated prescriptive authority to Georgia’s board certified physician assistants (PAs) to treat traumatic pain injuries and other medical emergencies was vetoed by Gov. Nathan Deal on Tuesday.
The legislation, Senate Bill 125, sponsored by Sen. Rick Jeffares (R-McDonough), would have authorized a physician to delegate to a PA the authority to prescribe hydrocodone compound products. Most notably, this legislation was endorsed by the General Assembly’s Legislative Rural Caucus. The bill received a healthy support from both chambers with a vote of 164-10 in the House and 49-2 in the Senate. Of note, two medical doctors, one physician assistant (PAs) and one nurse, who are House members voted in favor of the bill. Senate members who are two medical doctors, one nurse and one anesthetist also voted in favor of the bill.
This legislation was in response to an October 2014 Federal Drug Enforcement Agency (DEA) decision to reschedule hydrocodone from a Schedule III opiate to a Schedule II opiate. Current Georgia law only allows physicians to delegate to physician assistants to prescribe schedule III medication and lower schedules. The move by the DEA essentially stripped the ability of PAs to treat acute pain injuries like broken bones and kidney stones. This change in DEA regulation limited the ability of PAs to treat severe traumas and painful medical emergencies, especially in the most medically underserved areas of rural Georgia. The solution to restoring this stripped authority was to change the state law to allow PAs to only prescribe hydrocodone.
While it is a fact that an opioid crisis is in full swing, the heavy hand of government notoriously over-regulates in its mission to try and keep the public safe. But what results from over-regulation is the casting of a large net where policy encompasses the wrong people it is trying to target. Unfortunately, this veto represents placing citizens in the rural part of the state in a “second class” status whereby they are deprived of proper and ethical pain control of traumatic injuries and painful medical emergencies which further pushes the abuse of opiates underground. However, a deregulation of policy such as Senate Bill 121 is actually a reasonable public safety solution.
Senate Bill 121 was created out of a report completed by the Georgia Senate Research Office. According to a 2016 Georgia Senate Research report on opioid abuse, 47 states have passed laws providing immunity to medical professionals who prescribe or dispense naloxone or persons who administer naloxone. Previously, laws required a doctor-patient relationship to be established before issuing a direct prescription to an at-risk drug user and third party prescriptions were prohibited. In the 2017 legislative session, Governor Deal signed a similar bill that would allow the naloxone to be exempt as a dangerous drug so the drug could be used more widely.
With this report, it is clear Governor Deal was swayed by such findings. Do we have an opioid problem? Yes, but it is not due to the mid-level practitioners having an inappropriate expansion of their scope of practice.
The following statement on Deal’s veto of SB 125:
Senate Bill 125 authorizes physicians to delegate their authority to prescribe hydrocodone compound products to physician assistants. This language would add several thousand prescribers to our healthcare system and, as a result, create the potential for hundreds of thousands more opioid prescriptions to be issued. Like many other states, Georgia is currently in the grips of an opioid abuse epidemic, and this change is incongruent with the state’s efforts to quell that problem. For the foregoing reasons, I hereby VETO SB 125.
However, many rural Georgians, who live miles away from a hospital, rely on PAs to deliver and administer health care every day. According to the Georgia Budget Policy Institute, Georgia’s health care professionals are spread unevenly statewide and many communities face severe provider shortages. Georgia has about 211 total doctors per 100,000 residents. The uneven distribution leaves 141 of Georgia’s 159 counties below the statewide average, while 65 counties have less than one-quarter of the statewide average or less than 53 doctors per 100,000 residents. Those geographic trends hold true across provider types, including nurses, physician assistants, and primary care physicians. Most of the gap in provider shortages are within the rural areas of the state.
Smaller communities in Georgia are designated as medically underserved. In more populous counties of the state, individual census tracts or cities could be designated as an underserved area as well. These areas of medically underserved areas, accompanied with the veto of SB 125, would hinder the scope of practice and standard of care for a majority of rural Georgians needing access to quality medical care.
In 2015, Gov. Nathan Deal’s Rural Hospital Stabilization Committee recommended appropriately expanding the ability of nurse practitioners and physician assistants that is within their training to provide health care services to more Georgia patients could ease provider shortages. From this committee, it was recommended that legislation should be created to appropriately expand the scope of practice for nurse practitioners and physician assistants. In this report, it was determined that, “with a growing physician shortage… these expansions could help bolster healthcare resources in rural communities.”
The veto decision is counter to these recommendations to expand access, and remove inappropriate health care regulations. The veto of HB 125 will unnecessarily harm patients who live in rural areas who have broken bones and kidney stones in an emergency medicine setting. Sometimes it can take up to a week for a patient who has received stabilizing treatment to be accepted by an orthopedist or urologist to continue to follow up care of kidney stones and severe fractures. Many times, it is the physician assistant in the rural setting (like an ER in a critical access hospital) that has the responsibility of rendering ethical and appropriate care. Doctors who owe a ton of student loan debt do not find it attractive to practice in rural areas. This fact has to be taken into consideration.
With this veto, the state government, along with the Drug Enforcement Agency (DEA), just relegated rural Georgians as second class citizens by not allowing trained medical providers to ethically treat their patients. Do those who live in the hinterlands really count as citizens like their metro-suburban counterparts? The veto statement assumes that all 4,000 licensed physician assistants prescribe pain medication – this is a false assumption. Many PAs do not prescribe opiates in their routine practices. A rational discussion of this issue will eventually prevail in the future, much like the medical cannabis discussion. Rural Georgians need to feel that we matter; especially in matters of health care policy.
I suppose we in rural Georgia are going to have to bite on bullets as a method for proper pain control in addition to consuming distilled spirits in the process. When the government over regulates this issue, people will find a way to treat their pain – with or without a health care provider’s medical supervision. People forget the consequences of prohibition in the 1920s – the same applies here. Those candidates who are running for Governor in 2018 must realize that rural Georgians need access to quality care where they chose to live free.