Turf wars plentiful in health care practice expansion process

The sunrise review process is one of the more obscure proceedings at the Arizona Legislature, but it’s also the battleground for recurring turf wars.

It was designed to allow medical professions to bring legislative attention to necessary regulations.

Instead, Arizona lobbyists argue that the process is now used to block applications by lower-level health care providers and to stifle change.

Lobbyist Barry Aarons, whose clients include the Arizona Association of Chiropractic, said “the battle lines become drawn.”

“Regardless of what [the proposal] is, the MDs are going to oppose it. In other cases, the naturopathic and osteopathic physicians are going to oppose it.”

Turf wars over the scope of practice of medical professionals are a recurring theme of sunrise applications. The process, first established in 1985 and expanded in 2008, is used to expand the scope of practice for existing health professions or to regulate new ones.

“Unfortunately, over the years, it has become more of a way to preempt the Legislature from dealing with scope of practice issues,” Aarons said. The sunrise application process is now “used to stop changes from being made.”

Typically, the applications are put forward by mid-level practitioners and opposed by more highly trained professionals who already provide the services in question. For example, in 2013, an application by the Arizona Optometric Association that would have allowed optometrists to prescribe medication and perform injections was strongly opposed by the Arizona Ophthalmological Society, resulting in no action. In 2016, the Arizona Dental Association opposed the licensing of a new mid-level profession of ‘dental therapists’.

Medical doctors have fought each of the six sunrise applications that lobbyist Don Isaacson has put forward on behalf of the Arizona Optometric Association in the last 25 years, he said.

“And there has been no bad result from these expansions that I’m aware of,” Isaacson said.

In each of the last four years, there has been a major fight over a medical profession’s scope of practice. And despite sunrise applications’ high rate of approval by the committee that hears them, known as the Senate Health and Human Services and House Health Committee of Reference, they rarely result in legislation. According to Aarons, that’s because even when applications are approved in committee, they may not have the votes to pass the House or Senate.

Isaacson said that during the regular session, some committee chairs won’t hear a bill that expands scope of practice unless it’s been approved through the sunrise process.

“The way it’s enforced, it’s a defacto entirely different legislative process,” he said

To have a scope of practice expansion considered, medical professions must submit a written report to the president of the Senate and the speaker of the House by September 1. Isaacson contrasted that with the process for submitting other bills during the regular session.

“I can put a bill in on any subject” in January, Isaacson said. “But if it’s to expand the scope of practice for optometry, I have to have it submitted by August.”

Isaacson said that all of the information included in the sunrise application could be presented at the regular hearing of a bill, and that providing it months in advance only allows opposition groups to better prepare their arguments against it.

One pattern that emerges from this parallel process is the necessity of reintroducing applications with slight modifications year after year.

An application by the Arizona Association of Nurse Anesthetists and the Arizona Nurses Association that would expand the prescriptive authority of Certified Registered Nurse Anesthetists was approved in 2011, 2015, and 2016, yet the Senate failed to even hear the corresponding bill during the 2016 session.

Another application by the Arizona In-Home Care Industry to regulate in-home care was approved in 2010, in 2013, and in 2014. In 2015, Gov. Doug Ducey finally signed SB1401, which required nonmedical in-home caregiver agencies to disclose hiring practices and employee policies to consumers.

All three of this year’s sunrise applications are resubmissions from last year. Two of those, from the Arizona Naturopathic Medical Association and Dental Care for Arizona, failed to pass in 2016.

The Arizona Naturopathic Medical Association applied in 2017 for the second consecutive year to allow naturopathic physicians to exempt K-12 students from receiving vaccines. The application, which was voted down in committee last year, follows a familiar pattern: facing opposition from established vaccine exemption providers, and making slight modifications to appease committee members.

“I think there’s a perception, but a very inaccurate perception, that naturopathic physicians are biased against vaccines,” said Baron Glassgow, the executive director of Arizona Naturopathic Medical Association.

The association added language to this year’s application that reaffirms naturopathic physicians’ commitment to providing only medically necessary exemptions that align with the national Centers for Disease Control and Prevention, and remains hopeful that they can change lawmakers’ minds.

Yet MDs, represented by the Arizona Medical Association, remain opposed to the change in scope of practice. They are one of four medical professions currently permitted to issue medical vaccine exemptions. Sharla Hooper, associate vice president for communications at the Arizona Medical Association, did not respond for comment for this story.

Another of this year’s sunrise applications, from the Arizona Community Health Workers Association, was approved in committee and passed the House, but was never heard in the Senate. Their 2016 application would have allowed community health workers to receive voluntary certification.

The association “had the option of resubmitting at the sunrise application or not,” said Floribella Redondo, co-founder and state board president of the Arizona Community Health Workers Association.

Redondo said the group chose to reapply this year because their proposal has been modified. Instead of offering voluntary certification, the association is seeking to register community health workers with the Department of Health Services and create a searchable registry of qualified care providers.

For Redondo, it’s been a positive experience going through the sunrise application process, where her organization has faced little opposition. “It’s been educational,” she said. “It’s an opportunity to come and talk about your [profession’s] issues.”

Isaacson said that the sunrise process works differently for new professions, but said that for scope of practice issues, sunrise applications are a “duplicative, wasteful process.”

Aarons said modifications might be in the works for the scope of practice process.

“There’s a possibility that we need to do away with it now,” he said.

The Senate Health and Human Services and House Health Committee of Reference met November 28 to review this year’s applications.