House Bill 4789 as enrolled (Vetoed)
Sponsor: Rep. Joseph Palamara
House Committee: Health Policy
Senate Committee: Health Policy and Senior Citizens
Second Analysis (1-13-99)
THE APPARENT PROBLEM:
The field of athletic training, first established in 1950, has evolved into a highly specialized health profession that provides health services to professional athletic teams, intercollegiate athletes, high school athletes, physically active citizens, and amateur athletes. The National Football League, Major League Baseball, and the National Basketball Association, among others, require teams to employ athletic trainers. The National Collegiate Athletic Association requires member colleges and universities to have athletic trainers on staff. In addition, many high schools and youth sports organizations either employ or contract with a sports medicine clinic for athletic trainers to be on hand during sporting events. Over the past 12 years, athletic trainers have been increasingly in demand at hospitals and clinics and in industrial settings, such as the Department of Corrections and businesses or corporations.
Athletic trainers are not fitness trainers. Athletic trainers provide a wide range of services within the educational domains established by the National Athletic Trainers' Association (NATA), which include, among other things, risk management, assessment and evaluation (but not diagnosis), acute care, therapeutic exercise and modalities, and health care administration. Athletic trainers also provide emergency care; for example, last December, the athletic trainer for the Detroit Lions assisted in the emergency care given to Reggie Brown, a Lions linebacker who sustained a near-fatal spinal cord injury and stopped breathing on the field. An athletic trainer must undergo a rigorous educational and training program (completion of a bachelor's degree and courses in anatomy, physiology, kinesiology/biomechanics, psychology, and athletic training, among others), complete at least 800 hours of clinical experience under the supervision of a NATA-Board of Certification certified trainer, and pass a three-part national exam in order to be certified. Athletic trainers must also meet recertification standards, which include acquiring continuing education units. Athletic training has been recognized by the American Medical Association as an allied health profession and provides services under the direction and supervision of licensed physicians.
With the boom in interest and participation in exercise and fitness, participation in exercise and sports teams is increasing, as are sports-related injuries. Many hospitals and sports clinics now employ athletic trainers to work along with physical therapists in providing rehabilitation services. In industrial settings, many corporations and businesses have on-site training rooms, as well as physicians on site, to treat and rehabilitate injured workers and to provide services to prevent injuries from occurring. Nationwide, 60 percent of athletic trainers work in hospital, clinical, or industrial settings with the balance working in the traditional settings of professional, collegiate, and high school sports.
NATA has more than 24,000 members nationwide, and the Michigan Athletic Trainers Society has a membership of 600. Currently, 32 states either register or license athletic trainers. Michigan has 900 nationally certified athletic trainers, and is the largest employer of athletic trainers in an industrial setting. However, the state does not currently regulate the profession of athletic training. Reportedly, persons who have not been trained as athletic trainers, but are fitness trainers (which requires no training), have been passing themselves off to the public as athletic trainers. Consumers do not always know how to determine if someone calling himself or herself an athletic trainer has the proper credentials and training. One result is that athletic trainers working in the collegiate setting report athletes coming out of high school with preexisting pathologies due to improperly treated injuries and improper referral for medical care by persons claiming to be athletic trainers.
Because the profession of athletic training is well established, both in the state and nationally, and because there exists evidence of harm to consumers by non-certified persons using the title of athletic trainer, legislation has been proposed to establish a system of registration for certified athletic trainers.
THE CONTENT OF THE BILL:
House Bill 4789 would amend the Public Health Code (MCL 333.16131 and 333.16263) to create Part 179, entitled "Athletic Training," which would require the registration of athletic trainers and establish registration fees. "Registered athletic trainer" would be defined as an individual who engaged in the prevention, assessment, treatment, and rehabilitation of athletic injuries while under the direction and supervision of a licensed physician. "Athletic injury" would mean "an injury sustained by an individual as a result of that individual's participation in activities requiring physical strength, agility, flexibility, range of motion, speed, and stamina."
Registration. The Department of Consumer and Industry Services would have to issue a registration to an individual meeting all of the following requirements:
*Applied to the department on a departmental form.
*Paid the required fees (a $20 application processing fee and a $60 annual registration fee).
*Met other requirements as established in rules.
Registrations would be renewed annually. Beginning with the third renewal period after the bill's effective date, a renewal application would have to be accompanied by proof of the satisfactory completion of at least eight continuing education units within a three-year time period in subjects related to athletic training and approved by the department. Renewal applications would also have to be accompanied by 1) proof of successfully completing a course of training in first aid, cardiopulmonary resuscitation (CPR), and foreign body obstruction of the airway approved by the department and offered or approved by the American Red Cross, the American Heart Association, or a comparable organization; and 2) proof of holding at all times a valid certification in first aid and CPR that had been issued by the organization that offered the training. Only registered athletic trainers, as well as respiratory therapists and therapeutic recreators, would be permitted to use certain titles as specified by the bill. Further, the bill would specify that new or additional third party reimbursement for services rendered by a registered athletic trainer would not be required under the bill.
The department would have to promulgate rules to establish the minimum standards for registration as an athletic trainer. In promulgating rules, the department could consult the professional standards issued by the National Athletic Trainer's Association, the National Athletic Trainer's Association Board of Certification, or other nationally recognized professional association in doing so.
The bill is tie-barred to House Bill 5736, which would amend the Nonprofit Health Care Corporation Reform Act (MCL 550.1502 and 550.1502a), and House Bill 5737, which would amend the Worker's Disability Compensation Act of 1969 (MCL 418.315), to clarify that third-party reimbursements for services performed by a health care professional in a profession that was licensed or registered after January 1, 1998, would not be required.
FISCAL IMPLICATIONS:
The Senate Fiscal Agency reports that since the number of athletic trainers in the state is unknown, the amount of revenue to the state from registration fees would be indeterminate. However, the agency reports that according to the Department of Consumer and Industry Services, the proposed fee structure should be adequate to offset the cost of implementing and administering the new program; therefore, the fiscal impact should be minimal. (11-19-98)
ARGUMENTS:
For:
Not to be confused with fitness trainers, the profession of athletic trainer has been in existence since 1950. Traditionally providing services within the sports realm, the last decade has seen athletic trainers increasingly being utilized by hospitals, clinics, and corporations to provide rehabilitative and preventive care to patients and workers. Athletic trainers are highly trained health professionals, with a minimum of a bachelor's degree and many courses in health related courses such as anatomy and physiology. To be certified, athletic trainers must pass a stringent three-section exam and complete at least 800 hours of clinical experience under the direct supervision of a National Athletic Trainer's Association-Board of Certification (NATA-BOC) certified athletic trainer.
Athletic trainers operate under the direct supervision of licensed physicians, though some states allow for supervision by physical therapists.
Creating a system of registration would not expand the scope of practice of athletic trainers, as the practice guidelines are established by NATA. Educational guidelines are formulated with the cooperation and input of several national medical associations. Therefore, the bill would act primarily to protect the public from undertrained persons passing themselves off as athletic trainers, since an undertrained or untrained person acting in such a capacity could cause physical harm to an injured person. A non-certified person would not be acting under the direction of a physician, and so may not provide proper "triage" care in emergencies, where an injury is evaluated and the person referred for medical care. Under House Bill 4789, only persons registered under the bill could use the title of "certified athletic trainer" and other variations as specified in the bill. In this way, consumers would be assured that a person using the title "athletic trainer" was a trained professional providing services under the direction of a physician.
For:
Creating a system of registration for athletic trainers would not impede on the practice of physical therapists, although there is some overlap between the professions. According to information provided by the Michigan Athletic Trainers Society, athletic trainers design protocols for rehabilitation of musculoskeletal injuries, whereas physical therapists also provide rehabilitative services for neurological pathology and burn trauma. In some states, athletic trainers work under the direct supervision of physical therapists. Further, the companion bills, House Bill 5736 and 5737 would put language into the statute governing Blue Cross Blue Shield of Michigan and the workers' compensation law to specify that reimbursement for services performed by health care professionals in professions licensed or registered after January 1, 1998 would not be required just because the profession would now be regulated.
Against:
The bill was vetoed by the governor, due in part to the fact that no real threat to the public's health or safety by the lack of regulation of athletic trainers had been effectively demonstrated. Further, the national organization for athletic trainers already does an excellent job of ensuring that practitioners meet high professional standards. Besides, state regulation does not necessarily ensure a greater level of safety for consumers.
Against:
According to a representative from the Michigan Athletic Trainers Society, the NATA domains have traditionally used the term "athletic injury and illness"; however, the domains were revised in April of 1998 and will be implemented by the national accrediting organization in January 1999. The language in the bill as introduced reflects the revised domain criteria. The newly adopted domains, which define the educational domains used in preparing entry-level athletic trainers, are as follows:
*Risk management
*Assessment and evaluation
*Acute care
*General medical conditions and disabilities
*Pathology of injury and illness
*Nutritional aspects of injury and illness
*Therapeutic modalities
*Health care administration
*Professional development and responsibilities
*Psychosocial intervention and referral
Response:
Physical therapists have expressed a concern that the definition of "injury or illness" as used in House Bill 4789 is overly broad and could be used to expand the scope of practice of athletic trainers. Historically, athletic trainers have worked in the realm of athletics, providing services to athletes as part of the care provided by the team doctor. There is concern that athletic trainers could go beyond caring for injured athletes and could begin treating the general public. It is maintained that though athletic trainers do have considerable training to work with athletes who have been injured, they lack the necessary training to properly assess and work with a general population who may have varied and sundry underlying physical and medical conditions. Twenty-eight of the thirty-two states that currently regulate athletic trainers restrict "injury or illness" to "athletic injury or illness." If the intent of the legislation is to protect the public, then the bill should have such a restriction. Rebuttal:
As mentioned previously, NATA educational guidelines are formulated with the cooperation of the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Medical Association, and serve to establish, maintain, and promote appropriate standards of quality in educational programs for athletic trainers.
Further, a significant number of athletic trainers in Michigan work in non-athletic settings such as hospital rehab units, sports and physical therapy clinics, and in industrial settings such as General Motors and the Department of Corrections. In such settings, because they are working under the supervision and direction of physicians, athletic trainers are able to deliver a high quality of medical care to patients and workers and yet keep down ever-escalating medical costs. To add the word "athletic" before "injury" and to delete the reference to "illness" could force the termination of services by athletic trainers in hospitals, clinics, and in industrial settings.
Against:
Occupational licensure and registration statutes generally tend to be promoted by those in the affected profession, and act as economic protection against competition within the profession. The trend in Michigan, as well as across the country, has been to reduce government regulations, not create new regulatory structures.
Analyst: S. Stutzky