Enacted on May 21, 2008, the Genetic Information Nondiscrimination Act (GINA) prohibits that use of genetic information in health insurance and employment decisions. Genetic information includes an individual’s, genetic tests, family medical history, family member’s genetic tests, or a request for genetic information.
GINA prohibits insurance companies from both denying coverage and increasing premiums for healthy individuals based on their genetic predisposition of developing a disease in the future. The act also restricts employers from making hiring, firing, or promotion decisions based on an individual’s genetic data. Moreover, this law prohibits harassment of another person based on their genetic information.
GINA legislation received overwhelming support from both Democrats and Republications. In 2007, the House voted 420 for and 3 against. The National Institute of Health’s National Human Genome Research Institute as well as the Coalition for Genetic Fairness are two major supporters of GINA.
Founded in 1997, the Coalition for Genetic Fairness (CGF) was the first group to address genetic discrimination. CGF consists of patient and civil rights groups, and they spearheaded the federal genetic non-discrimination legislation. The CGF has published an excellent patient education document titled GINA and You.
Geneforum provides a list of the primary arguments against genetic nondiscrimination bills: (1) GINA is too weak and limited to cases where employers intentionally seek out genetic information, (2) employers should have the right to collect genetic information if it is relevant to worker safety, (3) insurance companies should still have access to genetic information for “improving quality of healthcare,” and (4) genetic discrimination is not happening, therefore the legislation is irrelevant.
Poignantly summarized by Wallack and Lawrence (2005), "A society that accepts the reality of human interconnection and effectively structures itself so that egalitarian and humanitarian values are more fully reflected in public policy will be a society that better understands the meaning of public health and responds more appropriately to its challenges. It will be a society that not only talks about community but translates its values into caring—and more effective—public policy."
For more information about GINA, check out the website www.dnapolicy.org and see the attached document, GINA Help.
Introducing The Professional Nursing Law
Originally developed in May 1951, The Professional Nursing Law (P.L. 317, No. 69) outlines the practice of professional nursing in the state of Pennsylvania. This law includes qualifications, scope of practice, and prescriptive authority for advanced practice nurses including certified registered nurse practitioners (CRNP). Notably, the General Assembly amended the law in both 2002 and 2007 to expand the CRNPs scope of practice (PCNP 2013).
Importantly, The Professional Nursing Law certifies rather than licenses its CRNPs, requires a collaborative agreement between CRNPs and physicians, and necessitates a Drug Review Committee (PCNP, 2013). Furthermore, this law prohibits direct reimbursement for services rendered by a CRNP (PCNP 2013).
So Tell Me About Senate Bill 1063
Introduced in July 2013, Senate Bill (SB) 1063 attempts to modernize The Professional Nursing Law. This bill would permit CRNPs to serve as licensed independent practitioners within their certified population focus. Significantly, the bill removes the collaborative agreement between the CRNP and physician (PCNP, 2013).
Small changes would be made to the CRNP scope of practice: CRNPs would be permitted to issue oral orders, make referrals for speech therapy, and order methadone treatment. SB 1063 will remove the Drug Review Committee which currently approves what category of drugs a CRNP can prescribe (PCNP, 2013).
Also, the proposed legislation will license rather than certify CRNPs, and it will change their title from CRNP to advanced practice registered nurse-certified nurse practitioner (APRN-CNP). Finally, this bill would designate six population foci in which CRNPs can be certified: family/individual across the lifespan, adult-gerontology, neonatal, pediatrics, women’s health/gender-related and psychiatric/mental health (PCNP, 2013).
But What's the Evidence?
Ample evidence exists which supports the proposed changes to The Professional Nursing Law. Since the development of the CRNP role in 1965, research consistently demonstrates that CRNP care is at least comparable to physician care (AANP, 2013). In their systematic review of advanced practice nurse outcomes, Stanik-Hutt et al. (2011) found that CRNPs provide effective, high quality health care with outcomes similar to and in some ways superior to physicians.
Moreover, the Kaiser Commission issue paper on Medicaid and the uninsured (2011) asserts that CRNPs can safely, successfully, and independently expand access to health care. Additionally, in March 2014, the Federal Trade Commission (FTC) published their perspective regarding the regulation of advanced practice nurses. In sum, the FTC believes competition in healthcare controls costs, improves quality, and promotes innovation (FTC, 2014). The FTC asserts that CRNP scope of practice restrictions and collaborative agreements with physicians actually impede quality competition, raise prices, and diminish access to care (FTC, 2014).
Ok, I'm Listening
If voted into law, SB 1063 will have national, state, and institutional impacts. SB 1063 would align Pennsylvania’s nursing regulatory act with 17 other states and the District of Columbia which license CRNPs as independent practitioners (PCNP, 2011). In their white paper regarding independent practice of certified nurse practitioners, the National Organization of Nurse Practitioner Faculties (NONPF) outline the impact of legislation such as SB 1063 (2013). Specifically, granting CRNPs independent practice improves access to care, quality of care, and cost of care at both a state and national level (NONPF, 2013).
First, removing the supervisory requirements of CRNPs by physicians will improve a patient’s access to care. No longer will a CRNPs ability to treat rest solely upon a physician’s willingness to enter into such an agreement (NONPF, 2013). Secondly, and as noted above, evidence-based research repeatedly reveals that CRNPs provide safe, high quality care (Newhouse, 2011).
Moreover, legislation such as SB 1063 directly affects health care expenditures in the United States. For example, a study conducted by Eibner et al (2009) estimates that removing restrictions on CRNP practice will save six billion dollars in health care costs over ten years. Also, the American Academy of Nurse Practitioners (2007) note, “NPs in a physician-practice were found to have the potential to decrease the cost per patient visit by as much as one third, particularly when seeing paints in a an independent rather than complementary manner” (AANP, 2007).
In sum, proposed legislation SB 1063 aims to modernize Pennsylvania’s law regulating CRNP practice. If this bill is signed into legislation, it will license CRNPs as independent practitioners and abolish the collaborative agreement with physicians. Ultimately, this will provide patients with improved access to care, quality of care, and cost of care.
I hope this post was helpful and that it clarified SB 1063. Please feel free to email me or comment below with your thoughts and experiences.
According to the World Health Organization (WHO), the purpose of health policy is to outline a vision for the future of health by delineating priorities and expectations of key decision makers. Importantly, in their publication The US Commitment to Global Health, the Institute of Medicine published five recommendations for improved global health: (1) scale up existing interventions, (2) generate and share knowledge to address health problems endemic to the global poor, (3) invest in people, institutions, and capacity buildings with global partners, (4) increase US financial commitments to global health, and (5) set the example of engaging in respectful partnerships.
I believe that policy can help achieve these goals by:
1. Developing standardized benchmarking of health reform
First, policies should require standardized benchmarking of healthcare reform as a means to measure what initiatives have been effective. Benchmarking would create accountability and shared responsibility. Daniel et al (2000) developed a benchmarking scale, ranging from -5 to 5, with 0 representing the status quo, to aid in measuring reform success. Their scale is based on nine predefined benchmarks: (1) intersectoral public health, (2) financial barriers to equitable access, (3) nonfinancial barriers to access, (4) comprehensiveness of benefits and tiering, (5) equitable financing, (6) efficacy, efficiency, and quality of healthcare, (7) administrative efficiency, (8) democratic accountability and empowerment, and (9) patient and provider autonomy.
2. Creating individualized plans most appropriate for the implementing country
Second, policies should support flexibility and customization of health initiatives. The initiatives should be defined by the unique needs of that population with the input of that country’s leaders, thinkers, and citizens.
3. Strengthening and integrating primary/general care
Next, broader health care access can be achieved by integrating primary, dental, and mental health care with a focus on geographically efficient distribution of facilities. In, 2008 the WHO published a global perspective paper urging policy makers to integrate these specialties.
4. Increasing citizen’s access to health information
Improving access to health information empowers individuals to care for themselves and their families. Policy should support projects that promote universal access to the Internet such as Google’s Project Loon. Universal access to the Internet enhances global health not only by providing access to health information, but also by offering telecommunication infrastructure.
5. Understanding and improving social determinants of health
Next, policies should attempt to prevent upstream effects on poor health by reducing a population’s exposure to risk factors. For example, the WHO calls for closing the health gap between countries within one generation by improving social determinates of health. Eloquently summarized by the WHO, “In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health. Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. Social injustice is killing people on a grand scale.” Policies could incentivize American business in undeveloped countries to invest in that countries public and environmental health. Policies could also require these American business to provide their workers with health insurance and free preventative services.
6. Encouraging innovative solutions to promote global health
Finally, policies should encourage innovative, out-of-the-box ideas for promoting global health and improving access to care. Policies for example can create “innovation funds” to support high risk projects. The Bill and Melinda Gates Foundation, for example, supports the Grand Challenges Explorations Initiative, which provide grants for bold, unorthodox ideas to overcoming challenges in global health. Another unconventional solution, the Health Impact Fund, incentivizes the pharmaceutical industry to develop new medications for poor countries by rewarding them based on the actual impact of the drug while waving the cost for research and development. Thomas Pogge summarizes the Health Impact Fund and its goal to redistribute pharmaceuticals to the developing world in his 2011TED talk Reimagining Pharmaceutical Innovation.
Any other thoughts? Email me or comment below with your ideas.