Truth and Transparency: Reviewing New Jersey's Health Care Transparency Act
One of the biggest challenges in healthcare today is a lack of transparency when it comes to the training and licensure of healthcare professionals. As members of the healthcare team have taken an increased role in providing medical care, patients may be treated by physicians, nurse practitioners, physician assistants, and other healthcare practitioners, and understanding who is who can be difficult. In fact, an AMA study found that only 55% of respondents thought it was easy to identify who is a licensed physician. Moreover, 79% of respondents said that they would support legislation to require that patients be informed of the level of education, skills, and training of all health care professionals.
Fortunately, some states are taking action to ensure truth and transparency among healthcare practitioners, with New Jersey leading the way. Today we are joined by two special guests to discuss the New Jersey Health Care Transparency Act, which was passed in 2020: Marlene Kalayilparampil, MHA, FHELA is the manager of government relations for the Medical Society of New Jersey, and Dr. Flowers is a practicing physician in New Jersey.
Rebekah Bernard MD 0:07
Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard, and today I'm joined by two very special guests to discuss the importance of transparency. One of the biggest challenges in healthcare today is a lack of transparency when it comes to training and licensure of health care professionals, as members of the healthcare team have taken an increasing role in providing medical care. Patients may be treated by physicians, nurse practitioners, physician assistants and other health care practitioners and understanding who is who can be difficult. In fact, an AMA study found that only 55% of respondents thought that it was easy to identify who is a licensed physician. Moreover, 79% of respondents said that they would support legislation to require that patients be informed of the level of education skills and training of healthcare practitioners. Fortunately, some states are taking action to ensure truth and transparency among healthcare practitioners and New Jersey is leading the way. Today I am joined by Marlene Kalayilparampil, the manager of government relations for the Medical Society of New Jersey, and I'm also joined by Dr. Flowers. She's a practicing physician in New Jersey as well. Welcome both of you to the show.
Dr. Flowers 1:26
Thank you for having us.
Rebekah Bernard MD 1:28
Marlene, can we start out with you since you have been involved in the creation of this bill and advocacy for it? Tell us about New Jersey's new law which took effect this July.
Marlene Kalayilparampil 1:39
The truth in advertising law was a bill that we became involved here at MSNJ back in November 2019. When MSNJ convened and led a specialty society meeting which included all specialty societies within the state and their presidents in respect respective lobbyists. were invited to the table, we identified key issues that we all can align on. And the number one issue that everyone agreed on was limiting scope of practice expansion for non physicians.
And then right around the same time in December 2019. In New Jersey, there was an immunization bill, a measure in which MSNJ supported that would limit vaccine exemptions to only those persons for medical contraindications. And a member of the legislative leadership was approached by someone claiming that things are harmful, harmful to children, and providing information to which they claimed was medically accurate. That legislator then asked for that person's name. And they said their doctor so and so the legislator then asked what type of Doctor are you and they said, they're a chiropractor. So that made him completely outraged for, you know, a chiropractor giving information saying that's medically accurate. And that's what led us to quickly contact the AMA. We use their model legislation and tweaked it in accordance with the law here. And he was actually one of our sponsors, the senate president.
Rebekah Bernard MD 3:01
Wow, that is such a cool story. And it just goes to show how you guys having those relationships already in place. So when that happened, that legislator reached out and you were able to jump on it, what an amazing opportunity.
Marlene Kalayilparampil 3:13
Absolutely. And that's how we were able to get that bill introduced in February of 2020. And then the pandemic HIPAA, we kept pushing. And of course, with the pandemic, in New Jersey, there was a waiver place where there was a lift on supervision for non physicians, that made us very concerned. And of course, at the time, you know, it was all hands on deck, we needed every help we can to save our patients here in New Jersey, but we knew that that's going to probably, you know, hurt us in the end when things go back to normal. And there will be folks who want to keep that permanent. So he quickly worked on it. And by December of 2020, the legislature passed unanimously, and it was signed by the governor and it took effect in July of 2021.
Rebekah Bernard MD 3:59
Wow, that is amazing how quickly that actually went through because usually these laws just seem to take forever. So just to kind of recap a little bit of what the law says. It's called the New Jersey health care Transparency Act. And it requires that healthcare professionals clearly inform patients of their training and qualifications when they're providing in person care to patients, and when advertising their practice. Dr. Flower, why do you think this law is important?
Dr. Flowers 4:28
Several reasons and much of what you've just spoken about, expand on right now. The title doctor was usually reserved for physicians for dentists and for chiropractors, although people will generally know who they're seeing because it's for such different issues. Now, doctorates in healthcare seem to be replacing masters, nurse practitioners, physical therapists, occupational therapists, all great people and important roles, but they are now getting the title Dr. And using it they're often in a way as if they were a physician, which is very confusing for patients, even for other clinicians it's it's confusing, then thing to know too is the newer particularly with the nurse practitioner, Doctor programs, the DNP. It's actually less clinical training and less experienced required than the traditional NP, the traditional NP program. These are like nurses who've been practicing for many years, and they have to fly to get in. And this was a more rigorous process and they got more hands on training, obviously, nowhere near as much as the position. We're right now, how many of these are just online, have very limited clinical training. And the doctorate comes from writing an essay, which as you can tell you an essay, you learn about the one subject to write an essay on, not about, you know, the millions of things you need to know for medicine. But these people are now using the term doctor in a way that deceives it deceives people into thinking they're speaking with the physician, because that's the logical assumption.
This law will hopefully help clarify for patients who they're speaking with. And even if the term doctor isn't used, you're in a hospital room. Eight zillion people come in and white coats the dietician, the phlebotomist, the nurse, the nursing assistant, everyone has a white coat, and patients don't go know what questions to ask to know who they're actually getting advice from. And I think it's important to know that I don't think this is something that's derogatory towards the non physician practitioners, because it's just letting them express who they are. If a patient likes the dietician, they'll have good thoughts about oh, wow, I've learned a lot from this dietician, rather than Oh, that doctor was just talking to me about food and not about medicine. It's you know,
Everyone has a role, and we're not saying any of these roles don't belong there. We're saying patients need to know what the role is and what the training is for each person.
Rebekah Bernard MD 6:57
Yeah, you're exactly right. It's really just about truth and transparency. And within the the text of the bill, they actually had some justification for it. And they stated that of course, there are so many people using the term doctor, you mentioned doctor of nurse practice, and we know that 85% of all DNP or Doctorate of Nursing Practice programs are non clinical. In other words, they're not gaining extra clinical experience. So we know that there are more people using the term that aren't physicians. And they found also, as I alluded to that American medical association study, they cited that within the bill of the text saying that
27% of patients believe a chiropractor is a medical doctor, which they're not. 39% believe a Doctor of Nursing Practice is a medical doctor which they're not. 43% think a psychologist is a medical doctor, 47% think an optometrist is a medical doctor, and there are differences in what we do.
So can you talk Marlene about some of the specifics of the bill, tell us a little bit about what the identification requirements are.
Marlene Kalayilparampil 8:01
The field has required all healthcare practitioners to wear either a badge or their embroidery on their white coat, indicating what their name is, could be first and last name, it can be a first initial and last name or first name and last initial, and that was mostly in part due to the hospital approaching us thing they have had a lot of their staff complain about patients reaching out to them on social media, harassing them and such. So we went ahead and work with them on that measure. Also within the badge, it would also include credential information, as well as any board certifications. And at the bottom of the badge in the embroidered section of the lab coat, it should say clearly and this is again for the patient transparency part of it so they understand if you are an MD or DO it'll say physician if you're an APN or RN, it will say nurse, chiropractor, pharmacists, anyone that may have a doctorate for example, they would have exactly what their profession is indicated right at the bottom of their badge. So that for us was a major thing that we really want to make sure it was passed within this bill and we were able to get everyone on board for agreeing to that as well.
Rebekah Bernard MD 9:21
Yeah, I see why they thought that it was a good idea to allow first name only but this is a sort of an issue that a lot of physicians have experienced where when they are labeled by their first name somehow that seems to garner them a little bit less respect especially for women physicians, what are your thoughts on that Dr. Flowers?
Dr. Flowers 9:41
Yeah, I definitely agree with you. I've had plenty of patients come in usually older male for you know, Oh, hi, Sherry. How are you? And not you know, not using my last name or my title. I think it's reasonable to be up to the practitioner whether they want their last name used or not as long as the actual information about their credit. says there Personally, I like to use mine. But I can definitely see particularly people who work with adolescents and younger adults, even kids who are more likely to use social media to find them. I think it's it can be very helpful for them.
Rebekah Bernard MD 10:15
Yeah, I was giving this some thought the other day because I was having kind of a lively discussion on social media with both men, physicians and women physicians about the use of first names in clinical settings, patients calling, you know, 'hey, Rebekah,' or, you know, Dr. Rebekah feels a little better to me than then just Rebekah, for a lot of women physicians, not all but most of them felt like really, it was very important that they be referred to as Doctor, the men were a little less adamant about it, although there were a few that were and then I was thinking about, from my perspective, one of the reasons that I like it is because I think about the patient goes home, and they think about what I told them and they say, 'Well, you know, Rebekah told me I should go on a diet', versus, you know,' Dr. Bernard told me I should,' there's just something a little more weighty, I think about having that doctor a little bit more authority, and in the sense that I think it might help people even think about your advice in a different way.
Dr. Flowers 11:10
I agree with that.
Rebekah Bernard MD 11:11
I definitely do. Maybe I'm off base, but it's an interesting discussion. So the first thing then is that all practitioners have to wear identification, and they need to include very prominently, what their title is physician, nurse, respiratory therapist, whatever. Now, Marlene, tell us about the advertising rules.
Marlene Kalayilparampil 11:30
Sure, regarding the advertising rules, the Act would require that any advertisement for a healthcare professional, licensed or certified to practice in New Jersey to include the type of licensure the professional was issued advertisements must exclude anything that's deceptive or misleading information relating to the healthcare professional, including any affirmative communication or representation that mistakes falsely described holds out or falsely details a professional skills training, expertise, education, public or private board certification or licensure.
Rebekah Bernard MD 12:03
Now have you seen you or Dr. Flowers? Have you guys seen any evidence of false advertising that kind of indicates that a person is a physician when really they're not?
Dr. Flowers 12:12
I haven't seen it in advertising, but I have had plenty of patients tell me Oh, I saw Dr. So-and-so and I'm like, 'Oh, you know, they're, they're not a physician.' These people usually often if you don't even have doctorates, and I don't know if it's the patient, just doing it out of a sense of respect, that they're, you know, they calling them doctors a respectful way to treat anyone providing health care, or if the non physician practitioner is calling themselves doctor or trying to actually, you know, put smoke in front of the person's eyes and make them think that they are a physician, but I haven't seen a lot of ads advertising for physicians anyway.
Rebekah Bernard MD 12:54
I guess I would say the places that I may have seen it would be on actually sites like health grades, sometimes it will say, for example, that a person attended medical school and they're a nurse practitioner. Sometimes I've seen a biggie will be psychiatric nurse practitioners listed as psychiatrists. I see that quite often. And that's upsetting because psychiatry is go to school for a long time to learn how to take care of mentally ill patients, and they deserve their due. And so have you seen any other evidence of that? Marlene?
Marlene Kalayilparampil 13:24
Yeah, I've actually heard more about nurse anesthetist calling themselves nurse anesthesiologist. And that is completely inaccurate, and more recently, actually came across the New Jersey Society of optometric physicians. And that was very alarming to me. I did some research to see if this is even accurate, because there's no way but yeah, things like that. I've come across and there's been a few others that have been made, made mSj aware of practices that are maybe physical therapy, but they're representing themselves as p m&r, and we have made sure that those were reported to our CME.
Rebekah Bernard MD 14:03
Now the third aspect, we've got the wearing a badge and identification, we have not deceptive, deceptive and advertising. And then the third is a signage requirement. And it's quite specific. It says that a poster or other signage with sufficiently sized font is to be placed in a clear and conspicuous manner in the office where the healthcare professional provides healthcare services to patients in an ambulatory setting. The poster must convey the type of licensure and professional degree held by the professional. So what are your thoughts about that Dr. Flowers about having signs in your practice? And has that changed your practice?
Dr. Flowers 14:40
No, we've had signs from the start. I think it's helpful, you know, patients, especially if a physician is not there that day, so they're going to get the covering clinician, they should know, you know, is the person covering have equal training to my physician, or is it someone with less years of training, it's not to say that they can't see that But they should know who's providing the medical advice.
Rebekah Bernard MD 15:02
Yeah, I mean, it makes sense. And I think one of the big places that this is critically important are urgent care settings. We just had a podcast with Jeremy Wattenbarger, who's seven year old passed away after a nurse practitioner did not make a correct diagnosis. And they thought she was a physician and she was working in an urgent care and there was no signage and no way for them to know otherwise. So it seems like that's a really important setting. Yeah, and the other side, sorry, it is it's it's really a tragedy and the you know, Mr. Wattenberger said, 'you know, if we had known it wasn't a physician looking as our daughter looked, we probably would have gone ahead and taken her to an ER, but we felt like, well, the doctor said she's gonna be okay.' So it's really, the lack of transparency was a major factor in their decision making there.
I think about there's a couple of specialists that aren't really there, their PA is that are practicing in my town, and apparently, their supervising physician is in a town that's three hour drive away. And there's nowhere that you can even find that information. I only had to it wasn't on any of the office notes. It wasn't anywhere on the Billboard. So this is definitely happening in many areas. Unfortunately, I've seen that in New Jersey too. The other thing that is an add on to that is, as you mentioned, if a non physician practitioner is covering the office that day, or if they work in collaboration, that the physician supervising must have their hours posted in that office. And it says here that if a physician supervises or participates in a collaborative practice agreement, they must clearly and conspicuously post in the office, the schedule of regular hours when the physician is present in the office. And I think that's really important. What are your thoughts on that? Dr. Flowers?
Dr. Flowers 16:55
No, I think that's a really important point that a lot of people wouldn't think of you obviously things are gonna change doctors hours might change during certain weeks. So that might be a way. But I do think it's a good point for them to know is there actually a physician on site when I'm seeing somebody else, if the physician needs to be called upon
Rebekah Bernard MD 17:14
Marlene, was there any pushback to that part of the law or any of these aspects were that you saw a little more challenges from different allied health professionals?
Marlene Kalayilparampil 17:25
We actually expected to hear more from the nurse practitioners of being against us, but it made more sense for the patient, to have that option and knowing when that physician then and any other non physicians that are in that practice, and who will be taking care of them. So when they schedule next time, or even when they're there, at that moment, they'll have an understanding of who is going to be there. And if the physician will be able to take care of them in case any adverse event were to happen under the watch of a non physician. So it was a critical element. And it's one that, you know, no one can really oppose anyone that's a healthcare professional as it's meant for the patient, and it gives them that autonomy.
Rebekah Bernard MD 18:07
Well, that's good to hear, especially as other states think about maybe instituting this same type of legislation. And as you mentioned, you use the AMA model legislation, so the verbiage and things like that is already there. It's just that we need to find a representative that would be willing to sponsor this kind of bill. Does that sound right?
Marlene Kalayilparampil 18:27
Absolutely. And anyone who would be interested in enacting a bill like such reaching out to the AMA would be the best way to go about because they provided so much help because this particular bill has gone through several versions in the past, I want to say 10 to 12 years, and it's been difficult to pass in many states, including New Jersey, I think it was even attempted here in New Jersey many years ago. But with the new iteration of the bill, we were able to get all specialties healthcare providers to be on board because there was a lot of issues within our physician community. They were a little against, especially when it came to a board certification.
Rebekah Bernard MD 19:07
Well yeah, let's talk about board certification. Because this is we just had a podcast with Paul Matthew, who's on the board of the National Board of physicians and surgeons, which is in a recertification body that's a competitor with the A BMS, and actually I initially board certified with the ABMS in family medicine in 2002. I recertified in 2009. And then when maintenance of certification was introduced in 2015, and it was time for me to renew I decided I didn't really want to go through the expense and the aggravation and the time. So I decided to let my ABMs lapse and I joined the NBPAS. But the state of Florida and now and I guess based on this legislation here in New Jersey, people who are recertified through that board may not advertise as board certified Is that how you understand the law?
Marlene Kalayilparampil 19:58
The act pretty much creates certain restrictions on advertising or holding oneself out as being certified by a public or private Board of medicine. 'Advertisement of board certification is permitted if the board is a member of the ABMS or the AOA, a non ABMS or non AOA board must require certain prerequisites for certifications outlined in the act in order for such certified professionals to advertise the board certification.'
Rebekah Bernard MD 20:23
You know, I tried to find those but I couldn't find them I'd love to know because I completed a residency and I did pass my exam on the first try and did fine on it and I recertified again and then I just decided I didn't want to keep doing all that. Not that I mind the test really it's more of the expense and then the the modules and also just kind of feeling a little bit bullied into it as how I felt. So it would be nice to be able to identify myself that at least that I was initially board certified in some way. And I just don't know how to do that within the parameters of the way I mean Florida has a similar thing like this as well. I know that the end the NBPAS wants to work with all the state boards of medicine to try to allow them as a you know a they're calling it like a free market type option for physicians not for initial certification. We all agree that everyone should have their initial certifications through the ABMs. It should be standardized, but as far as recertification. Do you have any thoughts on that Dr. Flowers?
Dr. Flowers 21:23
I was not aware of the National Board of physicians and surgeons. But I do know I'm actually just coming out for my first recertification. But seeing my father who's a physician, what he went through every time for the recertification and he is very those very up to date with medicine. But studying for these exams doesn't really prepare you for what you're doing. It doesn't enhance your clinical knowledge very much it it's basically rote learning. And so much of it is not relevant. And so much of it is like learning how to answer test questions. Again, like you said, the expense is huge for some of these tests, you have to travel to certain places, some of them are done in not great testing environments where it's it's hard to focus, there are loud noises, there are other things going on other people walking through. So it really is it's um, the certification process. They are working on changing to a more longitudinal plan. We do certification, you can do maintenance of certification, we're learning throughout which I think it's a much better option. Obviously, you haven't had a chance to do that, because it has just started. But it's interesting. I didn't realize that there was another another board option.
Rebekah Bernard MD 22:34
So yeah, since I'm direct primary care, and I don't have any insurance credentialing or hospital credentialing, it really doesn't matter, unless you know, except for maybe two patients if they really need wanted to have a Board Certified physician. So I can't say I'm board certified anymore in it, it does kind of get a little bit under my skin only in the sense that a nurse practitioner can call themselves board certified for the rest of their entire career. They take a two hour two to three hour 200 question test one time, and then they can just certify their hours. And that can be volunteer hours. And now they're always calling themselves board certified. And I can't do that. So I guess it's a little frustrating. So hopefully, that's something that we'll see some changes made on that. Well, let's just get to one other question, which is that this law was passed in July. And have you seen any evidence of any changes being made? It sounds like Marlene, you mentioned that you've been able to report a few people that are not following the law. What other things have you seen?
Marlene Kalayilparampil 23:37
Well, we know the hospitals, majority of them are already complying with this law as it was already in place and a lot of facilities but I know what the Medical Society in New Jersey we have announced to our members through our E news and other meetings that we've had, so we've kept our members abreast, we have not seen any anything else I did go and see a physician with my mother in law, and she was not aware about the law going into effect. So you know, we got to do a better job and understanding how to get this information to physicians in New Jersey members and non members of our medical society. So that's something we're working on.
Dr. Flowers 24:15
Yeah, I haven't heard a word about it. I actually messaged Marlene the other day to say when is the study again, it needs to just not be there on paper. It needs to be enforced it people need to be educated about it. People need to be prompted and be given a timeline like you must make these changes by this date. And they're doing that with requirements for COVID and health care for vaccination and testing and health care. And they're doing a great job. I think getting that message out. They could use the same exact method to get this message out. And and I think it's reasonable to give them if they're not aware of it yet to give them a time frame to get new signs and badges and everything but needs to happen.
Rebekah Bernard MD 24:54
Are there any teeth to the law like what are the consequences of not complying with this law?
Marlene Kalayilparampil 25:00
I'm want to go back real quick because I believe the hold up and getting doctors notifications is also because the regulations have not come out by the Board of Medical Examiners. So we are still waiting those guidance from them. We've been in touch along with other specialty societies have been reaching out and asking for an update. And still crickets. They were supposed to have it done by February of this year, and still, nothing has come out. They said they would have already by July 1 and nothing and here we are, it's September 12.
Rebekah Bernard MD 25:33
Maybe that's where they'll come out with the certain prerequisites, maybe that'll be part of that final information. We'll see. Well, good. Well, any other final words that you guys would like to share as far as what our listeners out here can learn from what you guys did in New Jersey and help patients in their state have truth and transparency?
Dr. Flowers 25:54
I think the most important thing is, is Speak up. When you see something that's that's not right. Don't be afraid to reach out to your representatives, everyone deserves to know the full truth of who's taking care of their health, and then make an informed decision.
And again, we're not saying everyone needs to see a physician for all their health care, but we're saying everyone needs to know who they're seeing.
Marlene Kalayilparampil 26:16
I would just mention one of our former presidents at the medical society, he would always say when you're in medicine, you're in politics, it's very important for physicians to be aware of what is going on in their states and become very much active within their medical societies or specialty societies because there are other non physician groups out there that have strong lobbying arms, right? And so they can get such legislation for themselves with scope expansion passed, and if positions just sit idly around, it's not going to help their cause at all. So I would say definitely, just like Dr. Flower said, definitely speak up.
Rebekah Bernard MD 26:52
Yeah, we definitely encourage all physicians to get involved in the political process. I think, just speak out. When you see something that isn't right. Try to find other physicians that are like minded and find out what's going on with them and how they're handling it. Reach out to your state medical society or your specialty society representatives to your legislators. I mean, these are, if we don't do anything, then really we're just a part of the problem as well, even though it's hard and it's takes time and it takes energy. But you know, we have to stand up for what's right to make sure that our patients get the best care possible. And I want to thank both of you for what you've done for patient advocacy, and for taking your time to come on our podcast and share this really important information with our listeners. If you'd like to learn more about this topic, I encourage you to get the book patients at risk, the rise of the nurse practitioner and physician assistant in health care. It's available at Amazon and Barnes and Noble. And we would love for you to subscribe to our podcasts and our YouTube channel. It's called patients at risk. And if you're a physician, and you'd like to learn more about getting involved with patient advocacy, join our group physicians for patient protection. Our website is physicians for patient protection.org thank you so much and we'll see you on the next podcast.
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