PHYSICAL EXAM; NURSE PRACTITIONER S.B. 979 (S-1), 981 (S-1), 982 (S-1), 985
(S-1), 987 (S-1), & 988 (S-1): FIRST ANALYSIS
Senate Bill 979 (Substitute S-1 as passed by the Senate)
Senate Bill 981 (Substitute S-1 as passed by the Senate)
Senate Bill 982 (Substitute S-1 as passed by the Senate)
Senate Bill 985 (Substitute S-1 as passed by the Senate)
Senate Bill 987 (Substitute S-1 as passed by the Senate)
Senate Bill 988 (Substitute S-1 as passed by the Senate)
Sponsor: Senator Bruce Patterson (S.B. 979, 987, & 988)
Senator Buzz Thomas (S.B. 981)
Senator Michael D. Bishop (S.B. 982)
Senator Wayne Kuipers (S.B. 985)
Committee: Health Policy
Date Completed: 4-21-04
RATIONALE
Under the Public Health Code, a licensed registered professional nurse who fulfills specific advanced educational and training requirements may obtain a specialty certification as a nurse practitioner from the Michigan Board of Nursing. According to the Michigan Nurses Association, a certified nurse practitioner may perform certain functions (some under the delegation or supervision of a physician), such as comprehensive physical examination and health assessment; management of health care during common acute and stable chronic illnesses; health counseling and guidance; diagnosis of health/illness status; prescription and administration of medications and therapeutic devices and measures; and ordering and interpreting laboratory tests and x-rays.
Various Michigan laws require that an applicant for a certain position, such as a school bus driver or fire fighter, undergo a physical examination by a licensed physician or physician's assistant as a condition of employment. It has been suggested that these laws be amended to allow a certified nurse practitioner to perform these routine physical exams, which fall within a nurse practitioner's scope of practice.
CONTENT
The bills would amend various statutes to provide that, under certain circumstances in which an individual is required to undergo a physical examination by a licensed physician, the examination could be performed by a physician's assistant or certified nurse practitioner.
The bills specify that the amendments would not require new or additional third party reimbursement or worker's compensation benefits for services rendered.
The bills are described below in further detail.
Senate Bill 979 (S-1)
Under the Pupil Transportation Act, all regular and substitute school bus drivers must meet annual physical requirements as authorized by the State Superintendent of Public Instruction. In meeting the physical requirements, a driver must be examined by a licensed physician or physician's assistant. The bill would amend the Act to allow a driver to be examined by a certified nurse practitioner, instead.
Senate Bill 981 (S-1)
Under the Michigan Vehicle Code, except under certain circumstances, a disabled person who applies for a windshield placard entitling him or her to free parking must provide a certification by a physician or physician's assistant attesting to the nature and estimated duration of the disabling condition, and verifying that the applicant qualifies for a free parking sticker. Under the bill, the certification and verification also could be provided by a certified nurse practitioner.
Senate Bill 982 (S-1)
Public Act 298 of 1966 provides for a board of civil service commissioners for sheriff's departments in certain counties. The Act requires all applicants for any position in a sheriff's department to undergo a physical examination, before taking an exam. The bill specifies that the physical examination could be performed by a licensed physician, a licensed physician's assistant, or a certified nurse practitioner.
Under the Act, an individual applying for admission to an examination must submit a formal application to the commission. The commission may refuse to examine an applicant or, after examination, to certify as eligible an applicant who falls under certain disqualifying factors. Currently, the disqualifying factors include being a habitual user of intoxicating liquor or drugs, or being guilty of any crime or infamous or notoriously disgraceful conduct. Under the bill, an applicant would be disqualified if he or she were a habitual user of intoxicating liquor or an illegal user of a controlled substance, or had been found guilty of a crime.
Senate Bill 985 (S-1)
Public Act 78 of 1935 provides for a board of civil service commissioners in municipalities with full-time, paid members in the fire and police departments; and requires each applicant for a position in the fire or police department to undergo a physical examination to determine that he or she is free from defects, deformity, or diseases that might incapacitate him or her from the performance of the position duties. The bill specifies that the physical examination could be performed by a physician, a licensed physician's assistant, or a certified nurse practitioner.
Senate Bill 987 (S-1)
Under Public Act 369 of 1974, a driver training school annually must file an application with the Department of State for the licensing of its employees as instructors. Each employee's application must include a dated medical examination report that is not more than two years old and is completed by a physician licensed to practice in Michigan. Under the bill, the medical examination report also could be completed by a licensed physician's assistant or a certified nurse practitioner.
Senate Bill 988 (S-1)
The bill would amend the Occupational Code to allow a licensed physician's assistant or certified nurse practitioner to perform a physical examination of a boxing contestant, which currently must be performed by a physician.
The Code states that it does not apply to a boxing contest in which all contestants pass a physical examination performed by a licensed physician before the contest. Under the bill, the physical examination also could be performed by a physician's assistant or nurse practitioner.
The Code requires a person seeking a license as a judge, referee, or boxer to pass a physical examination acceptable to the athletic board of control and present evidence of passage to the Department of Labor and Economic Growth. The bill specifies that the examination would have to be performed by a licensed physician, a licensed physician's assistant, or a certified nurse practitioner.
The Code also requires that a contestant be certified by a licensed physician to be in proper physical condition before participating in a boxing contest. Under the bill, the contestant also could be certified by a physician's assistant or nurse practitioner.
MCL 257.1853 (S.B. 979)
257.675 (S.B. 981)
51.360 (S.B. 982)
38.510 (S.B. 985)
256.605 (S.B. 987)
339.805a et al. (S.B. 988)
ARGUMENTS
(Please note: The arguments contained in this analysis originate from sources outside the Senate Fiscal Agency. The Senate Fiscal Agency neither supports nor opposes legislation.)
Supporting Argument
Requirements for a physical exam were written into various statutes before nurse practitioners were recognized in Michigan, more than 25 years ago. Nurse practitioners undergo extensive training, including clinical and didactic work, and must obtain national certification. They are board-certified to perform physical exams necessary for surgical clearance, for children participating in school sports, and for children about to enter kindergarten, as well as annual gynecological exams. The U.S. Department of Transportation allows nurse practitioners to perform physical exams for commercial drivers. They may perform comprehensive health histories and risk assessments, order and interpret laboratory work, and counsel clients and families regarding their health care.
Many patients choose to see nurse practitioners, rather than physicians, as their primary care providers. It is unreasonable to expect patients who regularly see a nurse practitioner to go to an unfamiliar provider for a routine exam. Expanding the procedures that a nurse practitioner may perform would reduce inconvenience and costs for patients who otherwise would have to go to several providers for different procedures. For example, a bus driver could go to a nurse practitioner for both the required physical exam and her annual gynecological exam, saving time and money. This arrangement also would allow physicians to dedicate more time to patients with more complex health issues. Reportedly, increased utilization of nurse practitioners within the veterans' affairs system has resulted in shorter wait times for patients.
According to Senate Health Policy Committee testimony, most other states allow nurse practitioners to perform required physical exams. This function is well within a nurse practitioner's scope of practice, and the law should be changed to reflect this.
Supporting Argument
Physician's assistants already may perform required physical exams under some of the statutes the bills would amend. It would be appropriate to extend this ability to physician's assistants under all the statutes, particularly in situations in which nurse practitioners would be allowed to perform the exams.
Opposing Argument
Although nurse practitioners are qualified to perform a physical exam in many situations, they should not be allowed to perform physical exams of boxing contestants and certify that they are fit to perform, as Senate Bill 988 (S-1) would allow. Due to repeated impacts and effects of past injuries, certifying that a boxer is in proper condition to fight is distinct from performing a routine exam on a prospective bus driver.
In the last 10 years, boxing has caused the death of 700 people. An assessment of a boxer by a less-qualified professional simply should not be allowed. In fact, the American Association of Ringside Physicians implemented a certification program in January 2004, to ensure that only qualified ringside physicians are working at boxing matches. A certified ringside physician has completed additional educational and training requirements, and so is more prepared to handle situations that arise in a boxing match than is a regular physician.
Response: Although the physical exam performed before a boxing match requires more sensitive observation and evaluation than one performed to determine if a bus driver is capable of driving, it still would fall within a nurse practitioner's scope of practice. In addition to the routine exams nurse practitioners perform every day, they frequently treat patients, such as car accident victims, who require them to make more nuanced decisions. Many nurse practitioners staff emergency rooms and are prepared to make serious judgments.
Legislative Analyst: Julie Koval
FISCAL IMPACT
Senate Bills 979 (S-1) & 981 (S-1)
The bills would have no fiscal impact on State or local government.
Senate Bills 982 (S-1) & 985 (S-1)
The bills would have no effect on State revenues or expenditures. The bills could
reduce local unit expenses by a negligible amount by allowing a presumably less expensive medical practitioner to perform required physical examinations.
Senate Bills 987 (S-1) & 988 (S-1)
The bills would have no fiscal impact on State or local government.
Fiscal Analyst: Bill Bowerman
Joe Carrasco
Maria Tyszkiewicz
David ZinAnalysis was prepared by nonpartisan Senate staff for use by the Senate in its deliberations and does not constitute an official statement of legislative intent. sb979etal./0304