Joe: [00:44:35] Yeah. I really think they need, and they may in other aspects of the agreement, or in other documents that sit outside of that, further define this, but that the gross view, the broad view of that kind of language. I'm not sure of any reason why they would be required to have that language. It sounds like somebody came up with the right idea. It is unfortunate that often hospital policies are drafted by people who do other things for a profession and don't necessarily bring in people who are trained to do this almost quasi legislation kind of process. And really don't know how far they stepped into it until something happens in a different way. In other words sometimes medical providers are happy to provide legal services when they don't necessarily have any experience whatsoever to do that. Just like lawyers prescribe medicine.
Sharron: [00:46:01] Well, a couple of years ago I attended a seminar on vicarious liability put on by a physician lawyer and it was a little different when they were talking about what at least in Kansas there is you know rules and regs about what that means supervision or when they sign a collaborative agreement. And that was a little more, you know, like the physician like if you sign this and this person messes up you may be liable. And you know that was from their side of things even in their rules and regs so.
Joe: [00:46:41] Well, Kansas is an odd place, because the Kansas Healthcare Stabilization Fund and now the midwives are considered the Kansas health care stabilization fund was created to help manage the professional liability risks within the state and the inaccessibility at the time for professional liability insurance for health care providers. And so they created their own definition of a health care provider and unless you are in that inside club, you were not a health care provider, so they had their own definition and midwives were not part of that until just recently. Now that they're part of that. What Kansas has done is completely eliminate vicarious liability between these various health care providers. Under the theory that's been referred to as the quid pro quo, excuse me, I do that every time I speak live. And the idea that each one has their own liability policy in that state with their own overarching health care stabilization fund isn't going to be responsible for two of them when one of them's already been responsible economically. And so by requiring the liability insurance on one hand, they remove the liability from the second person vicariously and so. So what you got there, Sharon, is old news. It changed when certified nurse midwives became health care providers under the Act. And that brings up probably something that's worthwhile to discuss in the last few minutes of this conversation and that is who do you get help from as you move through this process? When you're talking about global issues like the scope of this conversation that we've had tonight. It's appropriate to deal with people who are learned professionals. As you move closer to it being more and more important, you probably need somebody law trained to talk about the law issues.
[00:49:03] But as you move to specific roles in specific environments you need people who are experienced and have usually health law attorneys in a particular environment. Usually the whole state because most of this is moderated by state law and different structures of how you can organize and who can be parts of and who can have economic relationships between different forms of corporation, et-cetera, so that you may need, fairly quickly, to be in dialogue with somebody who is your state's attorney, meaning licensed and practices within that state. And experienced with health care for that environment in order to answer many of these questions and you cannot necessarily take on an assumption that someone who practices elsewhere can give you clear advice on the particulars of a relationship and its responsibilities until they've gone through all those accoutrements of healthcare including understanding accreditation, the state regulations, the federal regulations, and all of those bits and pieces as you work together to try to work in particulars for for an individual context. So global services like the ones that Grow Midwives offer sometimes do their best work by helping to connect with people who have specific skills for the specific problem in that geographic area. Any questions?
Unidentified: [00:50:58] I have a question. It's peculiar to our practice setting in Nevada. In 2013 we were able to get rid of the clause that required collaborative agreement. At the same time that we got rid of that clause, most of the hospital boards in the state voted that they would not allow an autonomous practitioner to apply for hospital privileges unless they were in the employ of a physician already credentialed. Is there any way around that kind of maneuvering? We also are seeing it with the insurance companies. So many of the insurance companies are not contracting with autonomous practitioners who are not sponsored by a physician. Do we need to get new laws?
Joe: [00:51:53] Well, they are different topics in a way. By eliminating the collaborative practice agreements. I don't know why those were eliminated, but that problem...
Unidentified: [00:52:09] They were eliminated because the Board of Medicine put into their regulations a definition for the collaborating physician. We were required to have a written collaborative agreement and the last line in the end of about 12 lines of regulation read that the collaborating position is responsible for all medical acts committed by the advanced practitioner of nursing.
Joe: [00:52:32] Aha. So they erased. So one act of legislation made collaborative practice a dirty word, so another act legislation simply erased the dirty word.
Unidentified: [00:52:48] Well, basically what it was was it was the board of medicine put it into regulations. The legislature never put in how the board should define the role of a collaborative physician, but they took it upon themselves to do it.
Joe: [00:53:00] Right. You know, had everybody been involved at the same time they could have just fixed the regulation and not created the problem. Hospitals were faced with a problem and this is an important aspect of how you go about problem solving. The hospital wanted to solve the problem by creating this sort of odd definition of what a collaborative practice agreement did. And then they turnaround and tripped over the same wire themselves. Whether or not it's the same group of people who decided that they had lost round one, they won round one, last round two and decided to win round three. Or however this dialogue began to happen. The problem is that when you have these private exclusionary-type contracts, there might be some fruit there to begin a conversation about a restrictive trade or similar kind of conversation saying that your excising us out from operating as an autonomous professional and is that your right to do in the medical environment?
Unidentified: [00:54:17] Because in our particular city and location, there is a single OB group practicing at the hospital. They refuse to work with nurse midwives on a you can work with us and be in our practice kind of basis.
Joe: [00:54:33] And that heightens the concern and the problem is something that may well be actionable. It's difficult to gauge. One of the things about health care law is that there is this overarching social policy consideration that an awful lot of health care law treats differently from other contracts and the best example I can think of is a collaborative is an agreement not to compete, a not compete at the end of a term of employment and the ones that involve physicians. The law's pretty clear I think pretty well across the United States and that the court has the ability to go in and restructure this contract which is a very unusual thing for courts to have the ability to do and limit it for duration or geographic scope or range of practice in order to serve this counter interest that the community has of having healthcare. So that a non compete can't eliminate for the community needed health care services. That same logic seems to apply in your Nevada problem. It's very, very different from collaborative or from vicarious liability, but it is very similar to the concept of what I was talking about about using it as a sword so to speak to keep what might be considered competitive practices away which, by the way, for the record, I'm not sure I'm willing to admit that a collaborative professionals and having midwives in the environment offering services in any way reduces the market place for the other providers of healthcare. I think you wind up with sort of a situation where economically by offering a greater range of services you spread the liability that comes along with the market place of having to take care of all these people who need to have their babies and they're going to have come hell or high water and midwifery services. Answer a call and it can be remarkably profitable without taking a dollar away from the other services in the Health Care Act environment.
Unidentified: [00:57:34] Thanks.
Joe: [00:57:34] You bet.
Unidentified: [00:57:35] I need to talk to you more later probably.
Unidentified: [00:57:39] Oh, we're around. Any other questions? We have about five minutes left.
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