HOUSE BILL REPORT

ESSB 6237

As Reported by House Committee On:

Health Care & Wellness

Health & Human Services Appropriations & Oversight

Title: An act relating to creating a career pathway for medical assistants.

Brief Description: Creating a career pathway for medical assistants.

Sponsors: Senate Committee on Health & Long-Term Care (originally sponsored by Senators Keiser, Conway, Kline, Frockt and Becker).

Brief History:

Committee Activity:

Health Care & Wellness: 2/15/12, 2/20/12 [DPA];

Health & Human Services Appropriations & Oversight: 2/22/12 [DPA(APPH w/o HCW)].

Majority Report: Do pass as amended. Signed by 11 members: Representatives Cody, Chair; Jinkins, Vice Chair; Schmick, Ranking Minority Member; Hinkle, Assistant Ranking Minority Member; Bailey, Clibborn, Green, Harris, Kelley, Moeller and Van De Wege.

Staff: Jim Morishima (786-7191).

Background:

I. Health Care Assistants.

A certified health care assistant is authorized to provide assistance to certain licensed health care practitioners, such as physicians, nurses, and naturopaths. A licensed health practitioner may delegate certain functions to the health care assistant such as administering skin tests, injections, and performing blood withdrawals.

Each health care assistant is certified by the facility in which they are employed, or by the practitioner who delegates functions to the health care assistant, pursuant to standards adopted by the Department of Health (DOH) in rule. The facility or practitioner must submit a roster of certified health care assistants to the DOH.

Health care assistants are divided into seven different categories based on differing educational, training, and experiential requirements. The different tasks each category of health care assistant may perform are as follows (all health care assistants may administer vaccines):

• Category A: venous and capillary invasive procedures for blood withdrawal;

• Category B: arterial invasive procedures for blood withdrawal;

• Category C: intradermal, subcutaneous, and intramuscular injections for diagnostic agents and the administration of skin tests;

• Category D: intravenous injections for diagnostic agents;

• Category E: intradermal, subcutaneous, and intramuscular injections and the administration of skin tests;

• Category F: intravenous injections for therapeutic agents; and

• Category G: hemodialysis.

II. Medical Assistants.

Medical assistants are assistive personnel who provide administrative or clinical tasks under the supervision of other health care practitioners. Although a variety of national organizations certify medical assistants, they are currently not a credentialed health profession in Washington.

In 2011 the DOH completed a sunrise review of a proposal to credential medical assistants. In its report, the DOH supported credentialing medical assistants, but also made recommendations regarding clarifying the current health care assistant credential. The DOH made the following recommendations:

• Blend the existing health care assistant categories with a medical assistant certification.

  • Categories C and E would be replaced with a certified medical assistant credential.

  • Categories A and B would be replaced with a certified phlebotomist credential.

  • Category G would be replaced with a certified hemodialysis technician credential.

• Remove the requirement that a credential holder obtain a new credential every time he or she leaves a facility or delegator.

• Require the following qualifications for new applicants:

  • Certified medical assistants must complete a medical assistant training program and pass an examination (both the program and the exam must be approved by the Secretary of Health).

  • Certified phlebotomists must meet the same qualifications as category A and B health care assistants.

  • Certified hemodialysis technicians must meet the same qualifications as category G health care assistants.

• "Grandfather" current health care assistants in the following manner:

  • Category C or E health care assistants would become medical assistants upon renewal and submission of a practice arrangement plan.

  • Category A or B health care assistants would become phlebotomists upon renewal.

  • Category G health care assistants would become hemodialysis technicians upon renewal.

  • More research is necessary to determine what should be done with category D and F health care assistants.

• Set parameters around medication administration for medical assistants.

• Set parameters around office medical equipment usage for medical assistants.

• Include criteria that identify the nature of the tasks a medical assistant can perform.

III. Nursing Technicians.

A nursing technician is a person enrolled in a nursing program or a person who graduated from a nursing program within the last 30 days or within the past 60 days with permission from the Secretary of Health. A nursing technician may perform certain nursing tasks within the limits of his or her education and may only practice in a hospital or a nursing home.

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Summary of Amended Bill:

I. New Professions Created.

Four new professions are created: medical assistant-certified, medical assistant-registered, medical assistant-hemodialysis technician, and medical assistant-phlebotomist. No person may practice as one of the new professions unless he or she is appropriately certified or registered.

The Medical Quality Assurance Commission, the Board of Osteopathic Medicine and Surgery, the Podiatric Medical Board, the Nursing Care Quality Assurance Commission, the Board of Naturopathy, and the Optometry Board must each review and identify other specialty assistive personnel and the tasks they perform. The DOH must compile the information and submit it to the Legislature no later than December 15, 2012.

II. Qualifications for Certification/Registration.

A person meets the qualifications for certification as a medical assistant-certified if he or she satisfactorily completes a medical assistant training program approved by the Secretary of Health (Secretary), passes an examination approved by the Secretary, and meets any additional qualifications established by the Secretary in rule. A person who has not passed the examination may practice as a medical assistant-certified under an interim permit. The permit expires upon passage of the examination or after one year, whichever occurs first, and may not be renewed.

A person meets the qualifications for registration as a medical assistant-registered if he or she:

• is endorsed by a health care practitioner, clinic, or group practice, that meets qualifications established by the Secretary; and

• has a current attestation of his or her endorsement to perform specific medical tasks signed by a supervising health care practitioner filed with the DOH. A medical assistant-registered may only perform the medical tasks listed on the attestation.

A person meets the qualifications for certification as a medical assistant-hemodialysis technician if he or she meets qualifications adopted by the Secretary in rule. The qualifications must be equivalent to the current qualifications for hemodialysis technicians certified as health care assistants.

A person meets the qualifications for certification as a medical assistant-phlebotomist if he or she meets qualifications adopted by the Secretary in rule.

An applicant with military training or experience satisfies the training or experience requirements of any of the new professions unless the Secretary determines that the military training or experience is not substantially equivalent to state standards.

III. Scope of Practice.

A medical assistant-certified may perform the following tasks delegated by, and under the supervision of, a health care practitioner:

• fundamental procedures: wrapping items for autoclaving, procedures for sterilizing equipment and instruments, disposing of biohazardous materials, and practicing standard precautions;

• clinical procedures: performing aseptic procedures in settings other than hospitals, preparing of and assisting in sterile procedures in settings other than hospitals, taking vital signs, preparing patients for examination, capillary blood withdrawal, venipuncture, and intradermal, subcutaneous, and intramuscular injection, and observing and reporting patients' signs or symptoms;

• specimen collection: capillary puncture and venipuncture, obtaining specimens for microbiological testing, and instructing patients in the proper technique to collect urine and fecal specimens;

• diagnostic testing: electrocardiography, respiratory testing, and tests waived under the federal Clinical Laboratory Improvement Amendments (CLIA) program (the DOH may update this list by rule based on changes to the CLIA program);

• patient care: telephone and in-person screening limited to intake and gathering of information without requiring the exercise of judgment based on clinical knowledge, obtaining vital signs, obtaining and recording patient history, preparing and maintaining examination and treatment areas, preparing patients for, and assisting with, examinations, procedures, treatments, and minor office surgeries, maintaining medication records, and screening and following up on test results as directed by a health care practitioner; and

• administering medications that are (1) administered only by unit or single dosage or by a dosage calculated by a health care practitioner, (2) administered pursuant to a written order, and (3) limited to legend drugs, vaccines (including combination vaccines), and schedule III-IV controlled substances as authorized by a health care practitioner under the scope of his or her license. The Secretary may, by rule, limit the drugs that may be administered by a medical assistant-certified based on risk, class, or route.

A medical assistant-certified may also administer intravenous injections if he or she meets qualifications set by the Secretary. The qualifications must be substantially similar to the qualifications for category D and F health care assistants.

A medical assistant-registered may perform the same tasks as a medical assistant-certified, except a medical assistant-registered may not perform the following:

• aseptic procedures;

• blood withdrawal or injections;

• electrocardiography and respiratory testing;

• preparing patients for, and assisting with, routine and specialty examinations, procedures, treatments, and minor office surgeries;

• intravenous injections; and

• the administration of medications (a medical assistant-registered may, however, administer vaccines).

A medical assistant-hemodialysis technician may, under the delegation and supervision of a health care practitioner, perform hemodialysis and administer drugs and oxygen pursuant to rules adopted by the Secretary.

A medical assistant-phlebotomist may, under the delegation and supervision of a health care practitioner, perform capillary, venous, and arterial invasive procedures for blood withdrawal pursuant to rules adopted by the Secretary.

The following health care practitioners are authorized to delegate to, and supervise, a medical assistant:

• a physician or an osteopathic physician; and

• acting within the scope of his or her license:

  • a podiatric physician and surgeon;

  • a registered nurse;

  • an advanced registered nurse practitioner;

  • a naturopath;

  • an optometrist;

  • a physician assistant; and

  • an osteopathic physician assistant.

Prior to delegating a task to a medical assistant, a health care practitioner must determine:

• that the task is within the scope of practice of the health care practitioner;

• that the task is indicated for the patient;

• the appropriate level of supervision;

• that no law prohibits the delegation;

• that the medical assistant is competent to perform the task; and

• that the task itself is one that should be appropriately delegated considering that:

  • the task can be performed without the exercise of judgment based on clinical knowledge;

  • results of the task are reasonably predictable;

  • the task can be performed without a need for complex observations or critical decisions;

  • the task can be performed without repeated clinical assessments; and

  • the task, if performed improperly, would not result in life-threatening consequences or the danger of immediate and serious harm to the patient.

Protocols may be used as long as they do not involve clinical judgment and do not involve the administration of medications, other than vaccines.

IV. Portability.

A medical assistant-certified, medical assistant-hemodialysis technician, or a medical assistant-phlebotomist credential is transferable among different practice settings. A medical assistant-registered credential is not transferable to other practice settings.

V. Exemptions.

The following persons are exempt from certification or registration as a medical assistant:

• another health care practitioner acting within the scope of his or her license;

• a person performing functions in the discharge of official duties on behalf of the federal government;

• a person trained by a federally approved end-stage renal disease facility who performs end-stage renal dialysis in the home setting; and

• a person participating in an externship as part of an approved medical assistant training program under the direct supervision of an on-site health care provider.

Any medical assistant may perform blood withdrawal procedures in the residences of research study participants when the procedures have been authorized by the institutional review board of a comprehensive cancer center or nonprofit degree-granting institution of higher education and are conducted under the general supervision of a physician.

VI. Career Ladders.

Within existing resources, the Secretary must develop recommendations regarding a career path plan for medical assistants. When developing the recommendations, the Secretary must consult with stakeholders, including health care practitioner professional organizations, organizations representing health care workers, community colleges, career colleges, and technical colleges. The recommendations must include methods for including credit for prior learning. The purpose of the recommendations is to evaluate and map career paths for medical assistants and entry-level health care workers to transition by means of a career ladder into medical assistants or other health care professions. The recommendations must identify barriers to career advancement and career ladder training initiatives. The recommendations must be reported to the Legislature no later than December 15, 2012.

VII. Health Care Assistants.

Certified health care assistants are converted to medical assistants upon renewal of their certifications in the following manner:

• a category C, D, E, or F health care assistant will automatically become a medical assistant-certified;

• a category G health care assistant will automatically become a medical assistant-hemodialysis technician; and

• a category A or B health care assistant will automatically become a medical assistant-phlebotomist.

The health care assistant credential is eliminated effective July 1, 2016. Until July 1, 2016, the DOH must consider medical assistants and health care assistants as one profession for purposes of calculating licensing fees.

VIII. Nursing Technicians.

Nursing technicians may practice in a clinical setting.

Amended Bill Compared to Engrossed Substitute Bill:

The amended bill:

• removes the authority for the Secretary to establish categories of medical assistants. Instead, the bill creates four new professions: medical assistant-certified, medical assistant-registered, medical assistant-hemodialysis technician, and medical assistant-phlebotomist;

• removes the general categories of tasks a medical assistant may perform and replaces them with specific tasks that the four new professions may perform;

• allows a medical assistant to administer intravenous injections if he or she meets standards established by the Secretary;

• clarifies that protocols are not prohibited if they do not involve clinical judgment and do not involve the administration of medications, other than vaccines;

• removes the requirement that a medical assistant be at least 18 years of age;

• removes provisions allowing medical assistants from other jurisdictions to become medical assistants without passing the examination;

• allows a person to practice as a medical assistant-certified without passing the examination under an interim permit, which expires after one year or upon passage of the examination and may not be renewed;

• allows an optometrist to direct the practice of a medical assistant;

• removes the requirement that the Secretary establish a career ladder and instead requires the Secretary to develop recommendations regarding a career ladder;

• removes the requirement that the Secretary report to the Legislature prior to adopting rules to implement the new professions;

• requires the disciplining authorities relevant to the professions who may supervise medical assistants to review and identify other specialty assistive personnel and their tasks;

• requires the DOH to compile the information and transmit it to the Legislature by December 15, 2012;

• allows a person with military training to satisfy the training or experience requirements for the new professions, unless the Secretary determines that the military training or experience is not equivalent to state standards; and

• allows a nursing technician to work in a clinical setting.

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Appropriation: None.

Fiscal Note: Available. New fiscal note requested on February 21, 2012.

Effective Date of Amended Bill: The bill takes effect 90 days after adjournment of the session in which the bill is passed, except for sections 1 through 12, 14, 16, and 18, relating to the creation of the new medical assistant credentials, which take effect on July 1, 2013, and sections 15 and 17, relating to the elimination of the health care assistant credential, which take effect July 1, 2016.

Staff Summary of Public Testimony:

(In support) This bill comes out of the sunrise review. There are currently too many categories of health care assistants and no pathways for people to move forward in terms of skills and income.

(In support with amendments) Certifying medical assistants is a good idea. Medical assistants are entry-level professionals and a career ladder would be beneficial. There should be provisions in this bill dealing with students in internships/externships. The language in the House companion (Substitute House Bill 2227) would be preferable, once perfected.

(With concerns) Medical assistants should be regulated and health care assistants should be transitioned to the new credential. Patient safety will be supported through clear qualifications, scope, and training. Requiring a preliminary plan to be submitted to the Legislature could delay this process. The language in the House companion is preferable.

(Opposed) This scope of authority for medical assistants is too general, especially in the area of medication administration. The House and Senate versions should be merged.

Persons Testifying: (In support) Senator Keiser, prime sponsor.

(In support with amendments) Carl Nelson, Washington State Medical Association; Linda Hull, The Everett Clinic; and Gail McGaffick, Corinthian Colleges.

(With concerns) Karen Jensen, Department of Health; and Joe King, Group Health Cooperative.

(Opposed) Sofia Aragon, Washington State Nurses Association.

Persons Signed In To Testify But Not Testifying: None.

Majority Report: Do pass as amended by Committee on Health & Human Services Appropriations & Oversight and without amendment by Committee on Health Care & Wellness. Signed by 9 members: Representatives Dickerson, Chair; Appleton, Vice Chair; Schmick, Assistant Ranking Minority Member; Cody, Green, Harris, Kagi, Pettigrew and Walsh.

Minority Report: Do not pass. Signed by 1 member: Representative Overstreet.

Staff: Amy Skei (786-7109).

Summary of Recommendation of Committee On Health & Human Services Appropriations & Oversight Compared to Recommendation of Committee On Health Care & Wellness:

The Health and Human Services Appropriations and Oversight (APPH) Committee recommended that medications administered by a medical assistant-certified that are by a dosage calculated by a health care practitioner must also be verified by the health care practitioner. The APPH Committee also recommended technical corrections to the names of two of the health professions included in the definition of "health care practitioner."

Appropriation: None.

Fiscal Note: Available. New fiscal note requested on February 21, 2012.

Effective Date of Amended Bill: The bill takes effect 90 days after adjournment of the session in which the bill is passed, except for sections 1 through 12, 14, 16, and 18, relating to the creation of the new medical assistant credentials, which take effect on July 1, 2013, and sections 15 and 17, relating to the elimination of the health care assistant credential, which take effect July 1, 2016.

Staff Summary of Public Testimony:

(In support) Practices and clinics need a way to define what their medical assistants do in order to receive Medicaid and Medicare reimbursement. With the implementation of electronic medical records, there are grants available, and, in order to receive them, practices have to be able to define what their employees do.

The bill should be modified to deal with verification of dosages. Medical assistants are not allowed to express clinical judgment, so the bill should clarify that a health care practitioner will calculate the dose of a medication and verify that it is correct. This will make it clear that this will not be left up to the medical assistant.

(Opposed) None.

Persons Testifying: Carl Nelson, Washington State Medical Association; and Melissa Johnson, Washington State Nurses Association.

Persons Signed In To Testify But Not Testifying: None.