In veto, Hobbs sides with doctors vs. other medical providers

PHOENIX — Gov. Katie Hobbs is siding with doctors and against other medical providers in the latest round of an ongoing dispute.

It’s over the process the latter group must go through to be allowed to provide more services to the public.

The governor vetoed SB1248 on Friday, which would have eliminated the “sunrise process,’’ one of the procedural hoops now required by health-care professions seeking to expand their scope of practice. It involves additional hearings above and beyond getting legislators to change the law regulating the particular profession.

The process, more often than not, has ended up with medical doctors and osteopathic physicians arguing successfully that they are the only ones who should be entitled to provide certain services to the public.

In rejecting the change, Hobbs acknowledged there is an “imbalance of power’’ between what she called the “high level’’ providers, like doctors, and everyone else. And she agreed there are problems with the sunrise process and that additional regulatory burdens can be a barrier to expanding care in underserved communities.

“However, repealing the sunrise applications for scope of practice expansion altogether without replacing it with a better mechanism will not address the underlying issues, and poses a threat to the health and safety of Arizonans,’’ the Democratic governor wrote.

Sen. T.J. Shope, R-Coolidge, who sponsored the measure, called the veto “absurd.’’ He said his bill was designed to upend the “tremendous imbalance’’ that often occurs when lawmakers are faced with requests from medical groups.

“Too often, medical doctors will control the process to keep the medical providers that most of us see on a routine basis down in arbitrary ways,’’ he said. “This bill would have leveled the playing field.’’

Setback for nurse practitioners, others

The veto is a setback for groups such as optometrists, pharmacists and nurse practitioners. Over the years, they have come to the Legislature with arguments that they have the training to do more than they are allowed to do under the law — and that they can do it cheaper than medical doctors and provide needed services in areas with few, if any, doctors.

Under the current law, any group that wants to expand what its practitioners are allowed to do has to make its case to a special “committee of reference’’ months before the regular legislative session begins.

That sunrise process requires the group to explain several factors, including why increasing its scope is beneficial, whether practitioners have special education, and whether it may result in a savings in cost to the state and the public. That committee then submits a report to legislative leadership.

Regardless of what’s in that report, nothing precludes a lawmaker from sponsoring legislation to give the group what it wants. All the paperwork and the sunrise hearing just become unnecessary hurdles that don’t exist for other legislative changes, said Jessie Armendt, who represents dental hygienists and nurse anesthetists.

She said lawmakers get to decide and change laws on complex issues, ranging from tax policy to water law, all without the need for a pre-session review. It is only when it comes to medical issues, Armendt said, there is this extra step.

She pointed out to lawmakers that, with or without the sunrise process, any change in the scope of a group’s medical practice still needs to get a majority of the House and Senate votes as well as the signature of the governor, the same as any other law.

The sunrise process, according to Don Isaacson, lobbyist for the Arizona Optometric Association, provides an early advantage to the doctor groups “so that the medical profession can prepare to oppose it.’’

Isaacson said the sunrise process also creates “a presumption that anything other than the medical profession MD or DO is second class and has to bring a petition before the Legislature even begins in order to subsequently file legislation.’’

‘The stakes are high’

But Amanda Rusing, who lobbies for the Arizona Medical Association — the group that represents MDs and medical students — said the extra step is appropriate.

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“When it comes to professional regulation, especially in the health-care field, the stakes are high,’’ she told the Senate Health Committee at a January hearing.

“The decisions should be made by all of you with plenty of time and plenty of data to take a look at the situation and consider the positives and negatives,’’ Rusing told lawmakers. “These are heavy decisions with potentially serious patient consequences.’’

Lawmakers heard similar arguments from Jeremy Browning, who lobbies for osteopathic physicians.

“We need, the public deserves, the Legislature deserves all the data necessary to ensure that these individuals can practice safely in the state of Arizona,’’ he said.

That argument apparently resonated with Hobbs, who said a “critical eye’’ must preserve health and safety considerations for constituents.

“Some expansions provide authority to prescribe dangerous and/or addictive substances, to perform medical procedures, or to practice medicine with less supervision,’’ she wrote. “Some are much more mundane, but that does not mean that they should not be held to some level of scientific and public health scrutiny.’’

Hobbs, who as a legislator from 2011-18 participated in the sunrise process, said she sees a danger in eliminating the extra step.

“Without the sunrise application process, provider groups could fast-track their priorities through the legislative process without adequate attention to why the change is necessary, or if it will impact communities with the greatest needs,’’ she wrote in her veto.

Amanda Hagerman of the Goldwater Institute, testifying in support of the measure, said the process has instead proven to be a barrier to certain medical groups being able to provide care that she believes is within their training.

She said that is borne out by the fact that in the last 10 years only 14 of 41 applications to expand scope of practice have made it through.

“The sunrise process is more about limiting competition between health professions instead of putting the needs of Arizona patients first,’’ Hagerman said. “If people have appropriate training, we want them practicing in our state.’’

Hobbs vetoed the change even though it had the support of a number of Democratic lawmakers.

Democratic Sen. Eva Burch of Mesa said the key is expanding access to care. “Patients who have access to some care are doing better than patients who have access to no care at all,’’ she said.

Longtime dispute

The turf war has been going on for decades.

In the 1980s, House Speaker Frank Kelly held up the legislative process until colleagues agreed to support a measure he wanted to let optometrists use eye drops to dilate pupils, something that has become a common practice. Optometrists and ophthalmologists, who are medical doctors, have been sparring ever since.

More recently, pharmacists fought with doctors over whether they are qualified to decide when people need vaccinations. And just last year dentists won a fight with doctors and got the ability to administer Botox and certain fillers to help puff up lips, fill out cheeks and smooth wrinkled brows.

Friday’s veto is Hobbs’ 15th of the session, which began in January, following her rejection of 13 budget-related bills and a bid by GOP lawmakers to block cities from taxing residential rentals. She did, however, sign two bills, one of which eliminates the need for certain hearings on development plans and the other to conform Arizona’s tax code with changes in federal law.