(1)Existing law, the Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing and authorizes the board to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the board or the equivalent of those educational standards. The act makes the violation of any of its provisions a misdemeanor punishable upon conviction by imprisonment in the county jail for not less than 10 days nor more than one year, or by a fine of not less than $20 nor more than $1,000, or by both that fine and imprisonment.

This bill would additionally require an applicant for a certificate to practice nurse-midwifery to provide evidence of current advanced level national certification by a certifying body that meets standards established and approved by the board. The bill would also require the board to create and appoint a Nurse-Midwifery Advisory Committee consisting of certified nurse-midwives in good standing with experience in hospital settings, alternative birth settings, and home settings, a nurse-midwife educator, as specified, 2 qualified physicians, and a consumer of midwifery care. This The bill would require the committee to consist of a majority of certified nurse-midwives and would require the committee to make recommendations to the board on all matters related to nurse-midwifery practice, education, disciplinary actions, standards of care, and other matters specified by the board, and would require the committee to meet regularly, but at least twice a year. This bill would prohibit corporations and other artificial legal entities from having professional rights, privileges, or powers under the act, except as specified. The bill would authorize specified entities to employ a certified nurse-midwife and charge for professional services rendered by that certified nurse-midwife, as provided.

(2)The act authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn, and provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.

This bill would delete those provisions and would instead authorize a certified nurse-midwife to manage a full range of gynecological and obstetric care services for women from adolescence beyond menopause, as provided. The bill would authorize a certified nurse-midwife to practice under that gynecological and obstetric care services authorization without supervision of a physician and surgeon in certain settings, including, but not limited to, a home setting, as specified. This The bill would prohibit entities described in those specified settings from interfering with, controlling, or otherwise directing the professional judgment of such a certified nurse-midwife, as specified. The bill would declare that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the client and the resources of the medical personnel available in the setting of care, and would provide that the practice of nurse-midwifery emphasizes informed consent, preventive care, and early detection and referral of complications to a physician and surgeon.

(3)The act authorizes a certified nurse-midwife to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the certified nurse-midwifes educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified.

This bill would delete the requirement that drugs or devices are furnished or ordered in accordance with standardized procedures and protocols. The bill would authorize a certified nurse-midwife to furnish and order drugs or devices in connection with care rendered in a home, and would authorize a certified nurse-midwife to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a certified nurse-midwife and that are consistent with nurse-midwifery education preparation.

(4)The act also authorizes a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center, if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon.

This bill would also authorize a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a home, and would delete all requirements that those procedures be performed pursuant to protocols developed and approved by the supervising physician and surgeon. The bill would require a certified nurse-midwife to provide emergency care to a patient during times when a physician and surgeon is unavailable.

This bill would provide that a consultative relationship between a certified nurse-midwife and a physician and surgeon by it self itself is not a basis for finding the physician and surgeon liable for any acts or omissions on the part of the certified nurse-midwife. The bill would also update cross-references as needed.

(5)Because the act makes a violation of any of its provisions a misdemeanor, this bill would expand the scope of an existing crime and therefore this bill would impose a state-mandated local program.

(7)Existing law prohibits a licensee, as defined, from referring a person for laboratory, diagnostic, nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the licensee or his or her immediate family has a financial interest with the person or entity that receives the referral, and makes a violation of that prohibition punishable as a misdemeanor. Under existing law, the Medical Board of California is required to review the facts and circumstances of any conviction for violating the prohibition, and to take appropriate disciplinary action if the licensee has committed unprofessional conduct. Existing law provides that, among other exceptions, this prohibition does not apply to a licensee who refers a person to a health facility if specified conditions are met.

This bill would include a certified nurse-midwife under the definition of a licensee, which would expand the scope of an existing crime and therefore impose a state-mandated local program. The bill would require the Board of Registered Nursing to review the facts and circumstances of any conviction of a certified nurse-midwife for violating that prohibition, and would require the board to take appropriate disciplinary action if the certified nurse-midwife has committed unprofessional conduct. The bill would additionally authorize a licensee to refer a person to a licensed alternative birth center, as defined, or a nationally accredited alternative birth center.

(8)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)Existing law, the Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing and authorizes the board to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the board or the equivalent of those educational standards. The act makes the violation of any of its provisions a misdemeanor punishable upon conviction by imprisonment in the county jail for not less than 10 days nor more than one year, or by a fine of not less than $20 nor more than $1,000, or by both that fine and imprisonment.

This bill would additionally require an applicant for a certificate to practice nurse-midwifery to provide evidence of current advanced level national certification by a certifying body that meets standards established and approved by the board. This The bill would also require the board to create and appoint a Nurse-Midwifery Advisory Council Committee consisting of certified nurse-midwives in good standing with experience in hospital settings, alternative birth settings, and home settings, a nurse-midwife educator, as specified, 2 qualified physicians, and a consumer of midwifery care. This bill would require the council committee to consist of a majority of certified nurse-midwives and would require the council committee to make recommendations to the board on all matters related to nurse-midwifery practice, education, disciplinary actions, standards of care, and other matters specified by the board, and would require the council committee to meet regularly, but at least twice a year. This bill would prohibit corporations and other artificial legal entities from having professional rights, privileges, or powers under the act, except as specified. The bill would authorize specified entities to employ a certified nurse-midwife and charge for professional services rendered by that certified nurse-midwife, as provided.

(2)The act authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn, and provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.

This bill would delete those provisions and would instead authorize a certified nurse-midwife to manage a full range of gynecological and obstetric care services for women from adolescence beyond menopause, as provided. The bill would authorize a certified nurse-midwife to practice in specified certain settings, including, but not limited to, a home setting. setting, as specified. This bill would declare that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the client and the resources of the medical personnel available in the setting of care, and would provide that the practice of nurse-midwifery emphasizes informed consent, preventive care, and early detection and referral of complications to a physician and surgeon.

(3)The act authorizes a certified nurse-midwife to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the certified nurse-midwifes educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified.

This bill would delete the requirement that drugs or devices are furnished or ordered in accordance with standardized procedures and protocols. The bill would authorize a certified nurse-midwife to furnish and order drugs or devices in connection with care rendered in a home, and would authorize a certified nurse-midwife to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a certified nurse-midwife and that are consistent with nurse-midwifery education preparation.

(4)The act also authorizes a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center, if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon.

This bill would also authorize a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a home, and would delete all requirements that those procedures be performed pursuant to protocols developed and approved by the supervising physician and surgeon. The bill would require a certified nurse-midwife to provide emergency care to a patient during times when a physician and surgeon is unavailable.

This bill would provide that a consultative relationship between a certified nurse-midwife and a physician and surgeon by it self is not a basis for finding the physician and surgeon liable for any acts or omissions on the part of the certified nurse-midwife. The bill would also update cross-references as needed.

(5)Because the act makes a violation of any of its provisions a misdemeanor, this bill would expand the scope of an existing crime and therefore this bill would impose a state-mandated local program.

(6)Existing law prohibits a licensee, as defined, from referring a person for laboratory, diagnostic, nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the licensee or his or her immediate family has a financial interest with the person or entity that receives the referral, and makes a violation of that prohibition punishable as a misdemeanor. Under existing law, the Medical Board of California is required to review the facts and circumstances of any conviction for violating the prohibition, and to take appropriate disciplinary action if the licensee has committed unprofessional conduct. Existing law provides that, among other exceptions, this prohibition does not apply to a licensee who refers a person to a health facility if specified conditions are met.

This bill would include a certified nurse-midwife under the definition of a licensee, which would expand the scope of an existing crime and therefore impose a state-mandated local program. The bill would require the Board of Registered Nursing to review the facts and circumstances of any conviction of a certified nurse-midwife for violating that prohibition, and would require the board to take appropriate disciplinary action if the certified nurse-midwife has committed unprofessional conduct. The bill would additionally authorize a licensee to refer a person to a licensed alternative birth center, as defined, or a nationally accredited alternative birth center.

(7)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)Existing law, the Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing and authorizes the board to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the board or the equivalent of those educational standards. The act makes the violation of any of its provisions a misdemeanor punishable upon conviction by imprisonment in the county jail for not less than 10 days nor more than one year, or by a fine of not less than $20 nor more than $1,000, or by both that fine and imprisonment.

This bill would additionally require an applicant for a certificate to practice nurse-midwifery to provide evidence of current advanced level national certification by a certifying body that meets standards established and approved by the board. This bill would also require the board to create and appoint a Nurse-Midwifery Advisory Council consisting of certified nurse-midwives in good standing with experience in hospital and nonhospital practice settings, alternative birth settings, and home settings, a nurse-midwife educator, as specified, and a consumer of midwifery care. This bill would require the council to consist of a majority of certified nurse-midwives and would require the council to make recommendations to the board on all matters related to nurse-midwifery practice, education, disciplinary actions, standards of care, and other matters specified by the board, and would require the council to meet regularly, but at least twice a year. This bill would also prohibit corporations and other artificial legal entities from having professional rights, privileges, or powers under the act, except as specified. The bill would authorize specified entities to employ a certified nurse-midwife and charge for professional services rendered by that certified nurse-midwife, as provided.

(2)The act authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn, and provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.

This bill would delete those provisions and would instead authorize a certified nurse-midwife to manage a full range of primary health gynecological and obstetric care services for women from adolescence beyond menopause, including, but not limited to, gynecologic and family planning services. as provided. The bill would authorize a certified nurse-midwife to practice in all specified settings, including, but not limited to, a home setting. This bill would declare that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the client and the resources of the medical personnel available in the setting of care, and would provide that the practice of nurse-midwifery emphasizes informed consent, preventive care, and early detection and referral of complications to a physician and surgeon. This bill would authorize a certified nurse-midwife to provide peripartum care in an out-of-hospital setting to low-risk women with uncomplicated singleton-term pregnancies who are expected to have uncomplicated birth.

(3)The act authorizes a certified nurse-midwife to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the certified nurse-midwifes educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified.

This bill would delete the requirement that drugs or devices are furnished or ordered in accordance with standardized procedures and protocols. The bill would authorize a certified nurse-midwife to furnish and order drugs or devices in connection with care rendered in a home, and would authorize a certified nurse-midwife to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a certified nurse-midwife and that are consistent with nurse-midwifery education preparation.

(4)The act also authorizes a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center, if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon.

This bill would also authorize a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a home, and would delete all requirements that those procedures be performed pursuant to protocols developed and approved by the supervising physician and surgeon. The bill would require a certified nurse-midwife to provide emergency care to a patient during times when a physician and surgeon is unavailable.

This bill would provide that a consultative relationship between a certified nurse-midwife and a physician and surgeon by it self is not a basis for finding the physician and surgeon liable for any acts or omissions on the part of the certified nurse-midwife. The bill would also update cross-references as needed.

(5)Because the act makes a violation of any of its provisions a misdemeanor, this bill would expand the scope of an existing crime and therefore this bill would impose a state-mandated local program.

(6)Existing law prohibits a licensee, as defined, from referring a person for laboratory, diagnostic, nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the licensee or his or her immediate family has a financial interest with the person or entity that receives the referral, and makes a violation of that prohibition punishable as a misdemeanor. Under existing law law, the Medical Board of California is required to review the facts and circumstances of any conviction for violating the prohibition, and to take appropriate disciplinary action if the licensee has committed unprofessional conduct. Existing law provides that, among other exceptions, this prohibition does not apply to a licensee who refers a person to a health facility if specified conditions are met.

This bill would include a certified nurse-midwife under the definition of a licensee, which would expand the scope of an existing crime and therefore impose a state-mandated local program. The bill would also require the Board of Registered Nursing to review the facts and circumstances of any conviction of a certified nurse-midwife for violating that prohibition, and would require the board to take appropriate disciplinary action if the certified nurse-midwife has committed unprofessional conduct. The bill would additionally authorize a licensee to refer a person to a licensed alternative birth center, as defined, or a nationally accredited alternative birth center.

(7)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)Existing law, the Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing and authorizes the board to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the board or the equivalent of those educational standards. The act makes the violation of any of its provisions a misdemeanor punishable upon conviction by imprisonment in the county jail for not less than 10 days nor more than one year, or by a fine of not less than $20 nor more than $1,000, or by both that fine and imprisonment.

This bill would additionally require an applicant for a certificate to practice nurse-midwifery to provide evidence of current advanced level national certification by a certifying body that meets standards established and approved by the board. This bill would also require the board to create and appoint a Nurse-Midwifery Advisory Council consisting of certified nurse-midwives in good standing with experience in hospital and nonhospital practice settings, a nurse-midwife educator, as specified, and a consumer of midwifery care. This bill would require the council to make recommendations to the board on all matters related to nurse-midwifery practice, education, and other matters specified by the board, and would require the council to meet regularly, but at least twice a year. This bill would also prohibit corporations and other artificial legal entities from having professional rights, privileges, or powers under the act, except as specified.

(2)The act authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn, and provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.

This bill would delete those provisions and would instead authorize a certified nurse-midwife to manage a full range of primary health care services for women from adolescence beyond menopause, including, but not limited to, gynecologic and family planning services. The bill would authorize a certified nurse-midwife to practice in all settings, including, but not limited to, a home. This bill would declare that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the client and the resources of the medical personnel available in the setting of care, and would provide that the practice of nurse-midwifery emphasizes informed consent, preventive care care, and early detection and referral of complications to a physician and surgeon. This bill would authorize a certified nurse-midwife to provide peripartum care in an out-of-hospital setting to low-risk women with uncomplicated singleton-term pregnancies who are expected to have uncomplicated birth.

(3)The act authorizes a certified nurse-midwife to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the certified nurse-midwifes educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified.

This bill would delete the requirement that drugs or devices are furnished or ordered in accordance with standardized procedures and protocols. The bill would authorize a certified nurse-midwife to furnish and order drugs or devices in connection with care rendered in a home, and would authorize a certified nurse-midwife to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a certified nurse-midwife and that are consistent with nurse-midwifery education preparation.

(4)The act also authorizes a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center, if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon.

This bill would also authorize a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a patients home, and would delete all requirements that those procedures be performed pursuant to protocols developed and approved by the supervising physician and surgeon. The bill would require a certified nurse-midwife to provide emergency care to a patient during times when a physician and surgeon is unavailable.

This bill would provide that a consultative relationship between a certified nurse-midwife and a physician and surgeon by it self is not a basis for finding the physician and surgeon liable for any acts or omissions on the part of the certified nurse-midwife. The bill would also update cross-references as needed.

(5)Because the act makes a violation of any of its provisions a misdemeanor, this bill would expand the scope of an existing crime and therefore this bill would impose a state-mandated local program.

(7)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)Existing law, the Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing and authorizes the board to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the board or the equivalent of those educational standards. The act makes the violation of any of its provisions a misdemeanor punishable upon conviction by imprisonment in the county jail for not less than 10 days nor more than one year, or by a fine of not less than $20 nor more than $1,000, or by both that fine and imprisonment.

This bill would additionally require an applicant for a certificate to practice nurse-midwifery to provide evidence of current advanced level national certification by a certifying body that meets standards established and approved by the board. This bill would also require the board to create and appoint a Nurse-Midwifery Advisory Council consisting of certified nurse-midwives in good standing with experience in hospital and nonhospital practice settings, a nurse-midwife educator, as specified, and a consumer of midwifery care. This bill would require the council to make recommendations to the board on all matters related to nurse-midwifery practice, education, and other matters specified by the board, and would require the council to meet regularly, but at least twice a year.

(2)The act authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn, and provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.

This bill would delete those provisions and would instead authorize a certified nurse-midwife to manage a full range of primary health care services for women from adolescence beyond menopause, including, but not limited to, gynecologic and family planning services. The bill would authorize a certified nurse-midwife to practice in all settings, including, but not limited to, a home. This bill would declare that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the client and the resources of the medical personnel available in the setting of care, and would provide that the practice of nurse-midwifery emphasizes informed consent, preventive care and early detection and referral of complications to a physician and surgeon. This bill would authorize a certified nurse-midwife to provide peripartum care in an out-of-hospital setting to low-risk women with uncomplicated singleton-term pregnancies who are expected to have uncomplicated birth.

(3)The act authorizes a certified nurse-midwife to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the certified nurse-midwifes educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified.

This bill would delete the requirement that drugs or devices are furnished or ordered in accordance with standardized procedures and protocols. The bill would authorize a certified nurse-midwife to furnish and order drugs or devices in connection with care rendered in a home, and would authorize a certified nurse-midwife to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a certified nurse-midwife and that are consistent with nurse-midwifery education preparation.

(4)The act also authorizes a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center, if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon.

This bill would also authorize a certified nurse-midwife to perform and repair episiotomies and to repair first-degree and 2nd-degree lacerations of the perineum in a patients home, and would delete all requirements that those procedures be performed pursuant to protocols developed and approved by the supervising physician and surgeon. The bill would require a certified nurse-midwife to provide emergency care to a patient during times when a physician and surgeon is unavailable.

This bill would provide that a consultative relationship between a certified nurse-midwife and a physician and surgeon by it self is not a basis for finding the physician and surgeon liable for any acts or omissions on the part of the certified nurse-midwife. The bill would also update cross-references as needed.

(5)Because the act makes a violation of any of its provisions a misdemeanor, this bill would expand the scope of an existing crime and therefore this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1306

Author:(Burke)

As Amended Ver:June 30, 2016

Majority vote

Original Committee Reference: B. & P.

SUMMARY: Removes the physician supervision requirement for certified nurse midwives (CNMs), allowing CNMs to manage a full range of primary gynecological and obstetric health services. Specifically, this bill:

1. Prohibits a CNM from referring a patient for services if the CNM has a financial interest in the referral.
2. Requires an applicant for a certificate to practice nurse-midwifery to provide evidence of current advanced level national certification by a certifying body that meets standards established and approved by the Board of Registered Nursing (BRN).
3. Requires the BRN to create and appoint a Nurse-Midwifery Advisory Committee (committee) consisting of CNMs in good standing with experience in hospital and nonhospital practice settings, a nurse-midwife educator, two qualified physicians, as specified, and a consumer of midwifery care.
4. Requires the committee to consist of a majority of nurse-midwives and to make recommendations to the BRN on all matters related to nurse-midwifery practice, education, disciplinary actions, standards of care, and other matters specified by the BRN, and would require the council to meet regularly, but at least twice a year.
5. Authorizes a CNM to manage a full range of primary gynecological and obstetric care services for women from adolescence beyond menopause, including, but not limited to, primary health care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth, and the postpartum period, immediate care of the newborn, and treatment of male partners for sexually transmitted infections, utilizing consultation, collaboration, or referral to appropriate levels of health care services, as specified.
6. Authorizes a CNM to practice without supervision of a physician and surgeon in the following settings:
   1. A licensed clinic as described in Health and Safety Code Division 2 Chapter 1 (commencing with Section 1200).
   2. A facility as described in Health and Safety Code Division 2 Chapter 2 (commencing with Section 1250).
   3. A facility as described in Health and Safety Code Division 2 Chapter 2.5 (commencing with Section 1440).
   4. A medical group practice, including a professional medical corporation, a medical partnership, a medical foundation exempt from licensure pursuant to Health and Safety Code Section 1206, or another lawfully organized group of physicians that delivers, furnishes, or otherwise arranges for or provides health care services.
   5. A licensed alternative birth center, as described in Health and Safety Code Section 1204, or nationally accredited birth center.
   6. A nursing corporation, as defined in Business and Professions Code Section 2775.
   7. A home setting, except as specified.
7. Prohibits an entity which employs a CNM from not interfering with, controlling, or otherwise directing the professional judgment of a CNM, as specified.
8. Makes a CNM practicing without physician and surgeon supervision subject to all credentialing and quality standards held by the facility in which the CNM practices. Specifies that the peer review body shall include CNMs as part of the peer review body that reviews CNMs. Requires the peer review body of that facility to impose standards that ensure quality and patient safety in their facility. Specifies that the standards shall be approved by the relevant governing body unless found by a court to be arbitrary and capricious.
9. Provides that the practice of nurse-midwifery does not include the assisting of childbirth by any forcible or mechanical means or the performance of a version.
10. Declares that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the client and the resources of the medical personnel available in the setting of care, and provides that the practice of nurse-midwifery emphasizes informed consent, preventive care and early detection and referral of complications to a physician and surgeon.
11. Requires a CNM while practicing in a hospital setting to collaboratively care for women with more complex health needs.
12. Deletes the requirement that drugs or devices are furnished or ordered in accordance with standardized procedures and protocols.
13. Provides that, in a nonhospital setting, a Schedule II controlled substance shall be furnished by a CNM only during labor and delivery and only after a consultation with a physician and surgeon.
14. Authorizes a CNM to furnish and order drugs or devices in connection with care rendered in a home.
15. Authorizes a CNM to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a CNM and that are consistent with nurse-midwifery education preparation.
16. Deletes the requirement that, in order for a CNM to perform and repair episiotomies and to repair first-degree and second degree lacerations of the perineum, the procedures must be performed pursuant to protocols developed and approved by a supervising physician and surgeon. Further authorizes a CNM to perform the procedures in a patient's home.
17. Indicates that a consultative relationship between a CNM and a physician and surgeon by itself is not a basis for finding the physician and surgeon liable for any acts or omissions on the part of the CNM.
18. Makes conforming changes.

The Senate amendments:

1. Change the name of the Nurse-Midwifery Advisory Council to the Nurse-Midwifery Advisory Committee.
2. Change the composition of the committee and changed the requirements of the committee members.
3. Delete the provisions prohibiting corporations and other artificial legal entities from practicing mid-wifery.
4. Specify that CNMs must practice consistent with the Competencies for Basic Midwifery practice promulgated by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the BRN.
5. Amend the CNM scope of practice to mean managing "a full range of primary gynecological and obstetric care" rather than "a full range of primary health care services."
6. Specify the settings in which a CNM may practice without physician and surgeon supervision.
7. Further specify the conditions under which a CNM may provide peripartum care in a home without physician and surgeon supervision.
8. Provide that the entities under which a CNM might practice may not interfere with, control, or otherwise direct the professional judgment of a CNM.
9. Add the self-referral prohibition.
10. Add additional conforming and technical changes.

FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

COMMENTS:

Purpose. This bill is sponsored by the California Nurse Midwives Association. According to the author, "AB 1306 creates a level of parity in the law between [Licensed Midwives] and CNMs by removing the physician supervision requirements for CNMs, allowing them to practice independently within their scope of practice. If signed into law, CNMs will be able to provide a full range of services for women in all settings, furnish and order prescription drugs, supplies, and devices, order, obtain, and administer diagnostic tests, and receive reports.

"Most pregnancies and births are completely normal physiologic events. When permitted to work to the full extent of their education and experience, CNMs can expertly manage more births in California. Untethering CNMs from physician supervision requirements will increase access to primary health care services for thousands of women in both urban and rural areas."

Background. Midwifery is the care of childrearing women during pregnancy, labor and birth and during the postpartum period. Midwifery services are offered by CNMs, who are regulated by the BRN and Licensed Midwives (LMs) who are regulated by the Medical Board of California (MBC). While both CNMs and NMs practice midwifery, there are differences in their education requirements, practice settings and supervision requirements.

Education. CNMs are licensed registered nurses with a certificate to practice midwifery, have acquired additional training in the field of obstetrics and are certified by the American College of Nurse Midwives.

LMs have completed a three-year postsecondary education program in an accredited midwifery school approved by the Medical Board or via the Challenge Mechanism. The Challenge Mechanism is an approved midwifery education program which allows students to obtain credit by examination for previous midwifery education and clinical experience.

Practice Settings. LMs can practice in home, birth centers and clinics. CNMs can practice in the same settings, but, unlike LMs, they can also practice in hospital settings. In 2012, CNMs attended approximately 8.5% of all births in California – the majority of which took place in a hospital and 1365 were in free-standing birth centers. It is estimated that 90% of all CNM attended births take place in a hospital setting.

CNM care is a federally mandated Medicaid benefit. According to the Centers for Disease Control, in 2012, 30% of CNM attended births in California were Medicaid, 65% were private pay and 2% were self-pay.

Physician Supervision. In California, LMs are permitted to practice without the supervision of a physician. However, despite the fact that many states allow CNMs to practice independently, California is one of six states that still requires physician supervision of CNMs. California law specifies that the supervision shall not be construed to require the physical presence of the physician. It also requires that in order for a CNM to prescribe medication, a physician needs to be telephonically available.

According to the author, although the supervision requirement tethers CNMs to practice only where a physician can supervise, it does not consist of actual oversight of health care delivery, inspection or review of charts, co-signature on prescriptions, direct care of the patient or evaluation of CNM patients at any point during pregnancy or well-woman care.

Changes to CNMs' Scope of Practice. If this measure is enacted, a number of changes to the scope of practice for a CNM and authorization for a CNMs independent practice would be made. These include:

1. Management of a full range of primary gynecological and obstetric care services for women from adolescence beyond menopause, including, but not limited to, primary care and gynecologic and family planning services.
2. A CNM would no longer be required to adhere to standardized procedures and protocols when:
   1. Furnishing drugs or devices in connection with care rendered in a home;
   2. Procuring supplies and devices;
   3. Ordering, obtaining, and administering drugs and diagnostic tests;
   4. Ordering laboratory and diagnostic testing;
   5. Receiving reports that are necessary to his or her practice as a CNM;
   6. Performing and repairing episiotomies and to repair first-degree and second degree lacerations of the perineum in a patient's home; and,
   7. Providing emergency care to a patient during times when a physician and surgeon is unavailable.

ARGUMENTS IN SUPPORT:

The California Nurse Midwives Association (sponsor) writes in their letter of support, "AB 1306 provides no new authority for CNMs than they currently provide. It ensures they can practice as they currently do without physician supervision. …CNM attended births have documented excellent maternity care outcomes. …The excellent outcomes consistently achieved by nurse-midwives are the result of the midwifery model of care, not state-mandated relationships with physicians."

The California Association for Nurse Practitioners supports the bill and writes, "With the addition of millions of individuals to California's healthcare system due to ACA [Affordable Care Act] implementation, more healthcare providers are crucial to ensure quality, timely access to care. …AB 1306 will assist in addressing this problem by allowing nurse-midwives to work collaboratively with physicians to provide women's health care services across the state, including pregnancy and delivery care."

Access Women's Health Justice, Beach Cities Midwifery & Women's Health Care, Beachside Birth Center, California Association of Nurse Anesthetists, Yes2Kollege Education Resources, and the Women's Community Clinic, all similarly write in their support letters, "Physician collaboration is and has always been a hallmark of nurse-midwifery care and AB 1306 will not change that. …According to ACOG [American Congress of Obstetricians and Gynecologists], California is facing a workforce shortage of women's health care providers. …AB 1306 will not change the way that nurse-midwives currently practice and will not change the high quality of care provided by nurse-midwives."

ARGUMENTS IN OPPOSITION:

The California Medical Association (CMA) opposes the bill and writes, "The CMA believes that AB 1306 allows certified nurse midwives to independently engage in the practice of medicine and lacks several important patient protection statutes that include, but are not limited to: 1) the corporate practice of medicine, 2) self-referral and anti-kickback prohibitions, 3) standard of care and 4) prescribing oversight."

POLICY ISSUES FOR CONSIDERATION:

Examination Requirement. As highlighted by the opposition, this bill would authorize a CNM to work independently, without the supervision of a physician, and perform primary care services within the scope of gynecology. As such, the author may wish to amend the bill to include a requirement for an examination that would take place at the conclusion of the CNM's residency. This examination should include criteria similar to the United States Medical Licensing Examination, Step 3 which medical residents are required to take in order to show competency in practicing as an independent and unsupervised medical professional.

Corporate Practice of Medicine (CPM). The CPM is defined as any involvement of corporations in medicine. The CPM may also be defined more narrowly, for example, as the employment of a physician by a lay-controlled corporation that sells the services of the physician for a profit or provides the physician's services to its employees free of charge. The CPM now most commonly refers to the employment of physicians by hospitals, but is also still used to refer to employment of physicians by for-profit and non-profit corporate entities and government (see Business and Professions Code Section 2400).

Cross Collaboration Between Advisory Councils. This bill would impact the practice of CNMs. It would also create a Nurse Midwives Advisory Committee within the BRN. The MBC has a similar committee, the MBC Midwifery Advisory Council, which vets issues germane to the practice of midwifery. As such, it may be fruitful to require cross collaboration between the two committees as the practice of midwifery falls within the scope of practice for both CNMs and LMs.

Analysis Prepared by: Le Ondra Clark Harvey Ph.D. / B. & P. / (916) 319-3301 FN: 0003867

 THIRD READING  

Bill No: AB 1306

Author:

:

Vote:

SENATE BUS., PROF. & ECON. DEV. COMMITTEE: 7-0, 6/27/16

AYES: Hill, Block, Galgiani, Hernandez, Jackson, Mendoza, Wieckowski

NO VOTE RECORDED: Bates, Gaines

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 78-1, 6/3/15 - See last page for vote

SUBJECT:

SOURCE: California Nurse Midwives Association

DIGEST: This bill removes physician supervision requirements for a Certified Nurse Midwife (CNM) as specified, modifies practice parameters, establishes a Nurse-Midwifery Advisory Committee (Committee) within the Board of Registered Nursing (BRN), and protects against retaliation for CNMs who advocate for appropriate health care for their patients, as specified, among other changes.

ANALYSIS:

Existing law:

1. The Nursing Practice Act provides for the licensure and regulation of the practice of nursing by the BRN and authorizes the BRN to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the BRN. (Business and Professions Code (BPC) §§ 2700 et seq.)
2. Authorizes a CNM, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. (BPC § 2746.5 (a))
3. Provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.
   (BPC § 2746.5 (b))
4. Authorizes a CNM to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the CNM's educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified. (BPC §§ 2746.51 et seq.)
5. Authorizes the BRN to appoint a Nurse-Midwifery Committee of qualified physicians and nurses, including, but not limited to, obstetricians and nurse-midwives, to develop the necessary standards relating to educational requirements, ratios of nurse-midwives to supervising physicians, and associated matters. (BPC § 2746.2)Authorizes a CNM to furnish or order drugs or devices, including Schedule II-V controlled substances, pursuant to physician supervision, standardized procedures and protocols, and other conditions, as specified. (BPC § 2746.51)

This bill:

1. Extends protections against retaliation to CNMs who advocate for patients’ appropriate health care.
2. Prohibits CNMs from referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the CNM or his or her immediate family has a financial interest with the person or in the entity that receives the referral.
3. States that, notwithstanding the prohibition on referrals, a CNM may refer a person to a licensed alternative birth center or to a nationally accredited alternative birth center, among other facilities, if the recipient of the referral does not compensate the CNM for the patient referral, and any equipment lease arrangement between the licensee and the referral recipient complies with specified requirements.
4. Requires an applicant to acquire an advanced level national certification by a certifying body that meets standards established and approved by the BRN for certification as a nurse midwife.
5. Requires the BRN to create the Committee to make recommendations to the BRN on all matters related to nurse-midwifery practice, education, and other matters as specified by the BRN.
6. Requires the Committee to meet regularly, but at least twice per year.
7. Specifies that the Committee shall consist of:
   1. A majority of CNMs in good standing with experience in hospital settings, alternative birth center settings, and home settings.
   2. A nurse-midwife educator who has demonstrated familiarity with educational standards in the delivery of maternal-child health care.
   3. A consumer of midwifery care.
   4. At least two qualified physicians, including an obstetrician that has experience working with nurse-midwives.
8. Authorizes a CNM to manage a full range of primary gynecological and obstetric care services for women from adolescence to beyond menopause, consistent with the Core Competencies for Basic Midwifery practice promulgated by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the BRN. These services include, but are not limited to, primary health care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth, and the postpartum period, and treatment of male partners for sexually transmitted infections, utilizing consultation, collaboration, or referral to appropriate levels of health care services, as indicated.
9. Authorizes a CNM to practice without supervision of a physician and surgeon in the following settings, and specifies that such entities shall not interfere with, control, or otherwise direct the professional judgment of a CNM, as specified:
   1. A licensed clinic, as specified.
   2. A facility, as specified,
   3. A medical group practice, including a professional medical corporation; a medical partnership; a medical foundation exempt from licensure, as specified; or another lawfully organized group of physicians that delivers, furnishes, or otherwise arranges for or provides health care services.
   4. A licensed alternative birth center, as specified, or nationally accredited birth center.
   5. A nursing corporation, as specified.
   6. A home setting.
10. Limits a CNM to attend during a normal, low-risk pregnancy and childbirth in the home setting when all the following conditions apply:
    1. There is the absence of all of the following:
       1. Any preexisting maternal disease or condition creating risks beyond that of a normal, low-risk pregnancy or birth, as defined in the American College of Nurse-Midwives’ standard-setting documents and any future changes to those documents.
       2. Disease arising from or during the pregnancy creating risks beyond that of a normal, low-risk pregnancy or birth, as defined in the American College of Nurse-Midwives’ standard-setting documents and any future changes to those documents.
       3. Prior caesarean delivery.
    2. There is a singleton fetus.
    3. There is cephalic presentation at the onset of labor.
    4. The gestational age of the fetus is greater than 37 weeks 0/7 days and less than 42 weeks 0/7 days completed weeks of pregnancy at the onset of labor.
    5. Labor is spontaneous or induced in an outpatient setting.
11. States that if a potential CNM client meets the conditions specified in clauses (b) to (e) above, but fails to meet the conditions specified in (a) and the woman still desires to be a client of the CNM, the CNM shall provide the woman with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology. A CNM may assist the woman in pregnancy and childbirth only if an examination by a physician and surgeon trained in obstetrics and gynecology is obtained and, based upon review of the client’s medical file, the CNM determines that the risk factors presented by the woman’s condition do not increase the woman’s risk beyond that of a normal, low-risk pregnancy and birth. The CNM may continue care of the client during a reasonable interval between the referral and the initial appointment with the physician and surgeon.
12. States that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the patient and the resources and medical personnel available in the setting of care. It also emphasizes informed consent, preventive care, and early detection and referral of complications to physicians and surgeons. While practicing in a hospital setting, the CNM shall collaboratively care for women with more complex health needs.
13. Requires a CNM to be subject to all credentialing and quality standards held by the facility in which he or she practices. The peer review body shall include nurse-midwives as part of the peer review body that reviews nurse-midwives. The peer review body of that facility shall impose standards that assure quality and patient safety in their facility. The standards shall be approved by the relevant governing body unless found by a court to be arbitrary and capricious.
14. States that the practice of nurse-midwifery does not include the assisting of childbirth by any forcible or mechanical means or the performance of a version.
15. Requires any regulations promulgated by a state department that affect the scope of practice of a CNM to be developed in consultation with the Committee.
16. Prohibits any other law from being construed to prohibit a CNM from furnishing or ordering drugs or devices, including controlled substances classified in Schedule II, III, IV, or V under the California Uniform Controlled Substances Act, when the drugs or devices are furnished or ordered related to the provision of any of the following: 
    1. Family planning services.
    2. Routine health care or perinatal care.
    3. Care rendered, consistent with the CNM’s educational preparation or for which clinical competency has been established and maintained, to persons within specified facilities.
    4.  Care rendered in a home, as specified.
17. Deletes references to standardized procedures and protocols and physician supervision for the furnishing of drugs and devices by CNMs, except that in a nonhospital setting, a Schedule II controlled substance shall be furnished by a CNM only during labor and delivery and only after a consultation with a physician and surgeon.
18. Authorizes a CNM to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a CNM and consistent with nurse-midwifery education preparation.
19. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second-degree lacerations of the perineum in a nationally accredited birth center and in a home, as specified.
20. States that a consultative relationship between a CNM and a physician and surgeon shall not, by itself, provide the basis for finding a physician and surgeon liable for any act or omission of the CNM.
21. Makes clarifying and technical amendments.

Background

Certified Nurse Midwives (CNMs). CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth, as well as immediate care for the newborn. Current law requires a CNM be licensed as a registered nurse and graduate from an approved program in nurse-midwifery. There are 1,271 CNMs in California.

A CNM may furnish drugs and devices after completing at least six months of physician supervised experience in the furnishing of drugs and devices and a course in pharmacology. “Furnishing” is the ordering of a drug or device in accordance with standardized procedure or protocol.

Standardized procedures are policies and protocols developed by a health facility or organized health care system, with input from administrators and health professionals, which establish parameters for medical care. Protocols are a part of standardized procedures and are designed to describe the steps of medical care for given patient situations. Protocols are developed in consultation with a supervising physician.

CNMs as Independent Practitioners. According to the U.S. Library of Medicine, CNMs are well positioned as primary care practitioners. “Many studies over the past 20 to 30 years have shown that [CNMs] can manage most perinatal (including prenatal, delivery, and postpartum) care. They are also qualified to deliver most family planning and gynecological needs of women of all ages.” Echoing this sentiment, the Center for the Health Professions at the University of California at San Francisco (UCSF) states that research generally confirms that care provided by CNMs is at least as safe as that from physicians and costs less.

However, current laws and regulations hamper the ability of CNMs to practice to the full extent of their training, limiting their potential impact. The dean of the UCSF School of Nursing, Kathleen Dracup, states “Primary care delivery has changed dramatically in the past 50 years, and for the better; we are living longer and more comfortably, and [advance practice nurses] are often the people who have provided the primary care in partnership with primary care doctors. If regulations around nurse practitioners and midwives are updated and outdated views of primary care change, that will provide one very promising pathway toward effective health care reform.”

CNMs have demonstrated an ability to play a key role in the delivery of primary healthcare to Californians, and this bill will release them to practice independently, enabling many more individuals to access needed care.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

SUPPORT: (Verified 8/1/16)

California Nurse Midwives Association (source)

AARP

American Association of Birth Centers

American College of Nurse-Midwives

American Nurses Association/California

Association of California Healthcare Districts

Beach Cities Midwifery & Women’s Health Care

Beachside Birth Center

Black Women for Wellness

California Association for Nurse Practitioners

California Association of Midwives

California Association of Nurse Anesthetists, Inc.

California Hospital Association

Center on Reproductive Rights and Justice at the University of California, Berkeley School of Law

County of Santa Cruz Board of Supervisors

Inland Midwife Service

Maternal and Child Health Access

Numerous individuals

South Coast Midwifery & Women’s Healthcare, Inc.

United Nurses Associations of California/Union of Health Care Professionals

OPPOSITION: (Verified 8/1/16)

California Medical Association

Medical Board of California

ARGUMENTS IN SUPPORT: Writing in support of the bill, the California Association of Midwives, Maternal and Child Health Access (MCHA), Black Women for Wellness, the County of Santa Cruz Board of Supervisors, South Coast Midwifery & Women’s Healthcare, Inc., Beach Cities Midwifery & Women’s Health Care, Beachside Birth Center, the American Association of Birth Centers, AARP, the California Association of Nurse Anesthetists, Inland Midwife Service, and the Center on Reproductive Rights and Justice at the University of California, Berkeley School of Law state that AB 1306 separates the practice of nurse-midwives from physician practice, creating an opportunity for expansion of women’s health care services within their current scope of practice.  These organizations state, “California is one of six remaining states to include physician supervision language, language which contradicts national and international standards.  AB 1306 will not change the high quality of care provided by nurse-midwives nor the way that nurse-midwives currently practice.  Removing state-mandated supervision would allow the nurse-midwife to partner collaboratively with physicians, expanding options beyond working as a physician’s employee.  AB 1306 would directly and positively affect the California health care system by providing for improved physician and nurse-midwife collaboration and greater innovation in health care delivery.”

ARGUMENTS IN OPPOSITION: The California Medical Association (CMA) writes, “Since February 2015, the CMA has engaged in a productive stakeholder process with the author and the sponsors of AB 1306. This process resulted in collaboration and compromise by all those involved. Even though this bill reverses decades of California law that ensured high quality health care through physician supervision of allied health professionals, CMA adopted a neutral position because the bill contained provisions that helped ensure that CNMs could only practice independently in highly integrated settings such as acute care hospitals and clinics and that independently practicing CNMs are subject [to] the same patient and consumer protection laws that apply to practicing physicians. The latest amendments taken in Senate Business [Professions and Economic Development] Committee deleted the Corporate Practice of Medicine (CPM) bar language, which is a key component of these consumer protection measures.

“….the CMA believes that AB 1306 will likely result in increased cost[s] in our healthcare system. A University of Maryland Division of General Internal Medicine study called, “A Comparison of resource utilization in nurse practitioners and physicians, concluded that in a primary care setting, nurse practitioners may utilize more health care resources than physicians. The study compared health care resource utilization for adult patients assigned to a nurse practitioner with that for patients assigned to a resident or attending physicians. The reason for the disparity is that lower trained practitioners are less sure about their initial [diagnoses] and therefore order more tests and referrals than higher trained physicians.”

ASSEMBLY FLOOR: 78-1, 6/3/15

AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins

NOES: Beth Gaines

NO VOTE RECORDED: Mayes

Prepared by:

8/3/16 18:06:32

**** END ****

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2015 - 2016 Regular

Bill No: AB 1306 Hearing Date: June 27, 2016

Subject: Healing arts: certified nurse-midwives: scope of practice

SUMMARY:

Removes certain physician supervision requirements for a Certified Nurse Midwife (CNM), increases educational requirements, modifies practice parameters, establishes a Nurse-Midwifery Advisory Committee within the Board of Registered Nursing (BRN), and subjects certified nurse midwives to the ban on the corporate practice of medicine, as specified, among other changes.

Existing law:

1. The Nursing Practice Act provides for the licensure and regulation of the practice of nursing by the BRN and authorizes the BRN to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the BRN. (Business and Professions Code (BPC) §§ 2700 et seq.)
2. Authorizes a CNM, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. (BPC § 2746.5 (a))
3. Provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.
   (BPC § 2746.5 (b))
4. States that physician “supervision” shall not be construed to require the physical presence of the supervising physician. (BPC § 2746.5 (c))
5. Authorizes a CNM to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the CNM's educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified. (BPC §§ 2746.51 et seq.)
6. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon. (BPC § 2746.52)
7. Authorizes the BRN to appoint a Nurse-Midwifery Committee of qualified physicians and nurses, including, but not limited to, obstetricians and nurse-midwives, to develop the necessary standards relating to educational requirements, ratios of nurse-midwives to supervising physicians, and associated matters. (BPC § 2746.2)
8. Authorizes a CNM to furnish or order drugs or devices, including Schedule II-V controlled substances, pursuant to physician supervision, standardized procedures and protocols, and other conditions, as specified. (BPC § 2746.51)
9. Prohibits a physician from referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the physician or his or her immediate family has a financial interest with the person or in the entity that receives the referral. (BPC § 650.01)
10. Requires a physician and surgeon’s certificate to practice medicine. (BPC § 2052)
11. States that corporations and other artificial legal entities shall have no professional rights, privileges, or powers. Provides that the Medical Board of California (MBC) may in its discretion, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for professional services rendered patients is made by any such institution, foundation, or clinic. (BPC § 2400)
12. Establishes exceptions to the ban on the corporate practice medicine, thereby allowing certain types of facilities to employ physicians. (BPC § 2401)
13. Establishes the following protections against retaliation for health care practitioners who advocate for appropriate health care for their patients pursuant to Wickline v. State of California (192 Cal. App. 3d 1630): (BPC § 510)
    1. It is the public policy of the State of California that a health care practitioner be encouraged to advocate for appropriate health care for his or her patients. For purposes of this section, “to advocate for appropriate health care” means to appeal a payer’s decision to deny payment for a service pursuant to the reasonable grievance or appeal procedure established by a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer, or to protest a decision, policy, or practice that the health care practitioner, consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care, reasonably believes impairs the health care practitioner’s ability to provide appropriate health care to his or her patients.
    2. The application and rendering by any individual, partnership, corporation, or other organization of a decision to terminate an employment or other contractual relationship with or otherwise penalize a health care practitioner principally for advocating for appropriate health care consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care violates the public policy of this state.
    3. This law shall not be construed to prohibit a payer from making a determination not to pay for a particular medical treatment or service, or the services of a type of health care practitioner, or to prohibit a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff, hospital governing body, or payer from enforcing reasonable peer review or utilization review protocols or determining whether a health care practitioner has complied with those protocols.
       

This bill:

1. Prohibits CNMs from referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the CNM or his or her immediate family has a financial interest with the person or in the entity that receives the referral.
2. States that, notwithstanding the prohibition on referrals, a CNM may refer a person to a licensed alternative birth center or to a nationally accredited alternative birth center, among other facilities.
3. Requires an applicant to acquire an advanced level national certification by a certifying body that meets standards established and approved by the BRN for certification as a nurse midwife.
4. Requires the BRN to create and a Nurse-Midwifery Advisory Committee (Committee). States that the Committee shall make recommendations to the BRN on all matters related to nurse-midwifery practice, education, and other matters as specified by the BRN.
5. Requires the Committee to meet regularly, but at least twice per year.
6. Specifies that the Committee shall consist of:
   1. A majority of CNMs in good standing with experience in hospital settings, alternative birth center settings, and home settings.
   2. A nurse-midwife educator who has demonstrated familiarity with educational standards in the delivery of maternal-child health care.
   3. A consumer of midwifery care.
   4. At least two qualified physicians, including an obstetrician that has experience working with nurse-midwives.
7. Prohibits corporations and other artificial legal entities from having any professional rights, privileges, or powers. However, the BRN may in its discretion, after such investigation and review of such documentary evidence as it may require, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for
   
   professional services rendered patients is made by any such institution, foundation, or clinic.
8. Permits the following entities to employ a CNM and charge for professional services rendered by a CNM; however, the entity shall not interfere with, control, or otherwise direct the professional judgment of a CNM:
   1. A clinic operated by a nonprofit corporation as an entity organized and operated exclusively for scientific and charitable purposes.
   2. A hospital owned and operated by a health care district.
   3. A clinic operated primarily for the purpose of medical education or nursing education by a public or private nonprofit university medical school, which is approved by the MBC or the Osteopathic Medical Board of California, provided the CNM holds an academic appointment on the faculty of the university, including, but not limited to, the University of California medical schools and hospitals.
   4. A licensed alternative birth center, as specified, or a nationally accredited alternative birth center owned or operated by a nursing corporation, as specified.
   5. A health facility, as specified, if the CNM is practicing under the supervision of a physician and surgeon.
   6. A clinic, as specified.
9. States that, for purposes of Item #8) above, that supervision shall not be construed to require the physical presence of a supervising physician and surgeon. States that a facility that employs a CNM shall not require supervision by a physician and surgeon of the CNM.
10. Deletes references in current law to supervision by a physician and surgeon.
11. Authorizes a CNM to manage a full range of primary gynecological and obstetric care services for women from adolescence to beyond menopause, consistent with the Core Competencies for Basic Midwifery practice promulgated by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the BRN. These services include, but are not limited to, primary health care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth, and the postpartum period, and treatment of male partners for sexually transmitted infections, utilizing consultation, collaboration, or referral to appropriate levels of health care services, as indicated.
12. Authorizes permissible settings in which a CNM may practice, including the home, but a CNM may only attend during normal, low-risk pregnancy and childbirth when the following conditions apply:
    1. There is the absence of all of the following:
       1. Any preexisting maternal disease or condition creating risks beyond that of a normal, low-risk pregnancy or birth, as defined in the American College of Nurse-Midwives’ standard-setting documents and any future changes to those documents.
       2. Disease arising from or during the pregnancy creating risks beyond that of a normal, low-risk pregnancy or birth, as defined in the American College of Nurse-Midwives’ standard-setting documents and any future changes to those documents.
       3. Prior caesarean delivery.
    2. There is a singleton fetus.
    3. There is cephalic presentation at the onset of labor.
    4. The gestational age of the fetus is greater than 37 weeks 0/7 days and less than
       42 weeks 0/7 days completed weeks of pregnancy at the onset of labor.
    5. Labor is spontaneous or induced in an outpatient setting.
13. States that if a potential CNM client meets the conditions specified in clauses (b) to (e) above, but fails to meet the conditions specified in (a) and the woman still desires to be a client of the CNM, the CNM shall provide the woman with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology. A CNM may assist the woman in pregnancy and childbirth only if an examination by a physician and surgeon trained in obstetrics and gynecology is obtained and, based upon review of the client’s medical file, the CNM determines that the risk factors presented by the woman’s condition do not increase the woman’s risk beyond that of a normal, low-risk pregnancy and birth. The CNM may continue care of the client during a reasonable interval between the referral and the initial appointment with the physician and surgeon.
14. States that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the patient and the resources and medical personnel available in the setting of care. It also emphasizes informed consent, preventive care, and early detection and referral of complications to physicians and surgeons. While practicing in a hospital setting, the CNM shall collaboratively care for women with more complex health needs.
15. Requires a CNM to be subject to all credentialing and quality standards held by the facility in which he or she practices. The peer review body shall include nurse-midwives as part of the peer review body that reviews nurse-midwives. The peer review body of that facility shall impose standards that assure quality and patient safety in their facility. The standards shall be approved by the relevant governing body unless found by a court to be arbitrary and capricious.
16. Requires any regulations promulgated by a state department that affect the scope of practice of a CNM to be developed in consultation with the Committee.
17. Deletes references to standardized procedures and protocols and physician supervision for the furnishing of drugs and devices by CNMs, except that in a nonhospital setting, a Schedule II controlled substance shall be furnished by a CNM only during labor and delivery and only after a consultation with a physician and surgeon.
18. Authorizes a CNM to furnish or order drugs or devices related to the provision of care rendered in a home, as specified.
19. Authorizes a CNM to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a CNM and consistent with nurse-midwifery education preparation.
20. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second-degree lacerations of the perineum in a home, as specified.
21. States that a consultative relationship between a CNM and a physician and surgeon shall not, by itself, provide the basis for finding a physician and surgeon liable for any act or omission of the CNM.
22. Makes clarifying and technical amendments.

FISCAL EFFECT:

This bill has been keyed “fiscal” by Legislative Counsel. According to the Assembly Appropriations Committee analysis dated May 13, 2015, this bill will result in minor costs to the BRN Fund for advisory committee meetings. The analysis notes that the potential impact on BRN enforcement costs resulting from the bill is unclear, but will likely be minor, as removing the requirement for supervision does not significantly change the practice of midwifery.

COMMENTS:

1. Purpose. This bill is sponsored by the California Nurse Midwives Association. According to the Author’s office, “Approximately 1,200 CNMs are licensed in California by the BRN to practice midwifery – the care of childbearing women during pregnancy, labor and birth, and during the postpartum period. While most states allow CNMs to practice independently, California is one of only six states that require physician supervision of CNMs.

“California law requires a CNM to practice under the supervision of a physician, but specifies that the supervision requirement shall not be construed to require the physical presence of the physician. Although the supervision requirement tethers CNMs to practice only where a physician can supervise, it does not consist of actual oversight of health care delivery, inspection or review of charts, co-signatures on prescriptions, direct care of the patient, or evaluation of CNM patients at any point during pregnancy or well-woman care. In communities without obstetricians/ gynecologists, the supervision requirement limits access to care for women, even when a CNM is available to provide care.

“In 2013, the Legislature removed physician supervision of licensed midwives (LMs) AB 1308 , Bonilla, Chapter 665, Statutes of 2013). CNMs are required to have a higher level of education and training than LMs in order to qualify for licensure (licensed as a registered nurse and graduate of a Board-approved nurse-midwifery program), and yet are still subject to physician supervision to practice.

“AB 1306 allows CNMs to practice to the full extent of the education and training, without physician supervision. The bill keeps their existing scope of practice in place and aligns their education and practice requirements with national standards. In addition, the bill includes consumer protections to guard against kickbacks and self-referrals, as well as additional structure for CNMs serving patients in home and birth center settings.”

1. CNMs. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth, as well as immediate care for the newborn. Current law requires a CNM be licensed as a registered nurse and graduate from an approved program in nurse-midwifery. There are 1,271 CNMs in California.

A CNM may furnish drugs and devices after completing at least six months of physician supervised experience in the furnishing of drugs and devices and a course in pharmacology. “Furnishing” is the ordering of a drug or device in accordance with standardized procedure or protocol.

Standardized procedures are policies and protocols developed by a health facility or organized health care system, with input from administrators and health professionals, which establish parameters for medical care. Protocols are a part of standardized procedures and are designed to describe the steps of medical care for given patient situations. Protocols are developed in consultation with a supervising physician.

This bill would remove the requirements of physician supervision and largely remove the restrictions on the independent furnishing of drugs and devices by CNMs.

1. CNMs as Independent Practitioners. According to the U.S. Library of Medicine, CNMs are well positioned as primary care practitioners. “Many studies over the past 20 to 30 years have shown that [CNMs] can manage most perinatal (including prenatal, delivery, and postpartum) care. They are also qualified to deliver most family planning and gynecological needs of women of all ages.” Echoing this sentiment, the Center for the Health Professions at the University of California at San Francisco (UCSF) states that research generally confirms that care provided by CNMs is at least as safe as that from physicians and costs less.

However, current laws and regulations hamper the ability of CNMs to practice to the full extent of their training, limiting their potential impact. The dean of the UCSF School of Nursing, Kathleen Dracup, states “Primary care delivery has changed dramatically in the past 50 years, and for the better; we are living longer and more comfortably, and [advance practice nurses] are often the people who have provided the primary care in partnership with primary care doctors. If regulations around nurse practitioners and midwives are updated and outdated views of primary care change, that will provide one very promising pathway toward effective health care reform.”

CNMs have demonstrated an ability to play a key role in the delivery of primary healthcare to Californians, and this bill will release them to practice independently, enabling many more individuals to access needed care.

1. Ban on the Corporate Practice of Medicine (CPM). This bill subjects CNMs to the ban on CPM, which previously has only been applied to physicians. CPM is usually referred to in the context of a prohibition, banning hospitals from employing physicians. The ban on CPM evolved in the early 20^th century when mining companies had to hire physicians directly to provide care for their employees in remote areas. However, problems arose when physicians' loyalty to the mining companies conflicted with patients' needs. Eventually, physicians, courts, and legislatures prohibited CPM in an effort to preserve physicians' autonomy and improve patient care.

Over the years, various state and federal statutes have weakened the CPM prohibition. According to a 2007 report issued by the California Research Bureau, “California’s CPM doctrine has been defined largely through lawsuits and Attorney General opinions over decades, and then riddled by HMO and other legislation; its power and meaning are now inconsistent…. Although some non-profit clinics may employ physicians, California applies the CPM doctrine to most other entities.... Teaching hospitals may employ physicians, but other hospitals, including most public and non-profit hospitals, may not employ physicians. Professional medical corporations are expressly permitted to engage in the practice of medicine, and may employ physicians. [However, t]hese medical corporations may operate on a for-profit basis, although the profit motive was one of the original rationales of the CPM prohibition.” Indeed, the greatest cost pressures typically come from health insurers, and not the facilities themselves.

The following entities may currently employ physicians:

• A clinic operated primarily of the purpose of medical education by a public or private nonprofit university medical school.
• A clinic operated by a nonprofit corporation as an entity organized and operated exclusively for scientific and charitable purposes.
• A narcotic treatment program.
• A hospital owned and operated by a licensed charitable organization that offers only pediatric subspecialty care, as specified.
• A health maintenance organization (HMO).

California is one of only five remaining states that adhere to some form of the ban. The American Medical Association, historically the driving force behind the CPM prohibition, no longer views physician employment as a violation of medical ethics and has removed the doctrine from its ethical code.

1. The Changing Healthcare Employment Landscape. The nationwide trend in healthcare is toward direct employment. According to a 2011 survey from the consulting firm Accenture:

“U.S. physicians continue to sell their private practices and seek employment with healthcare systems, according to a new survey from Accenture.  As physicians migrate from private practice to larger health systems, the new landscape will require healthcare information technology (IT), medical device manufacturers, pharmaceutical companies and payers to revise their business models and offerings.  At the same time, hospitals will need to determine how to retain and recruit the correct mix of physicians, especially in high-growth service lines, including cardiovascular care, orthopedics, cancer care and radiology.  Patients will increasingly move to large health systems, as opposed to the current trend of visiting doctors in private, small practice settings.

“’Health reform is challenging the entire system to deliver improved care through insight driven health,’ said Kristin Ficery, senior executive, Accenture Health.  ‘We see an increasing number of physicians leaving private practice to join hospital systems, which will force all stakeholders to revise and refine their business models, product offerings and service strategies.’” 

Benefits to employment include: 

• Relief from administrative responsibilities, especially those relating to insurance billing.
• Malpractice insurance.
• Greater access and support for healthcare IT tools, facilities, and medical equipment.
• A predictable work week.
• Economic stability.

These realities are the same facing CNMs, who are currently employed by hospitals and other facilities. CNMs would be unable to continue to realize the benefits of employment in many facilities according to the terms of this bill.

1. Impact on Health Care Access. The potential impact of the ban on CPM for CNMs is not only on those currently employed; it will affect future employment opportunities for CNMs and consumers’ access to care.

California currently has a physician shortage. As of 2013, just 16 of California's 58 counties had the federal government's recommended supply of primary care physicians, with the Inland Empire and the San Joaquin Valley facing the worst shortages. In addition, nearly 30 percent of the state's doctors are nearing retirement age, the highest percentage in the nation, according to the Association of American Medical Colleges. There are not enough physicians in training, and certainly not enough physicians planning to specialize in primary care, to backfill this deficit.

If this bill only contained the elimination of the physician supervision requirement, it would likely result in the increased employment by hospitals and clinics of CNMs, given their versatility: CNMs can provide a wide range of services in a variety of settings, and facilities would no longer have to struggle to find physicians willing to supervise them. Particularly for rural hospitals and other areas where it is challenging to attract physicians, employing CNMs would be a desirable option for expanding hospitals’ and clinics’ ability to meet basic community needs.

However, restricting the employment opportunities for these practice types by including their services in the ban on CPM will necessarily limit healthcare access to those individuals who would otherwise receive their care.

1. The Need for Equity in the Workplace Between CNMs and Physicians. Supporters of the CPM ban argue that it is necessary for equity in the workforce to subject any profession that becomes independent of physician supervision to be subject to the same business constraints as physicians.
   
   This does not appear to be a valid argument in consideration of the following:
2. Physicians and CNMs have very different practice scopes. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth on his or her own responsibility, as well as immediate care for the newborn. CNM care includes preventative measures and the detection of abnormal conditions in mother and child, but CNMs cannot assist childbirth by any artificial, forcible, or mechanical means. CNMs are not authorized to perform surgery, although this bill will allow them to perform and repair episiotomies and first-degree and second-degree lacerations of the perineum in a home, as specified.

Obstetrician-gynecologists (OB/GYN) are physicians who possess special knowledge, skills and professional capability in the medical and surgical care of the female reproductive system and associated disorders. OB/GYNs are necessary for abnormal cases of pregnancy, advanced conditions, and surgeries. Resident education in obstetrics-gynecology must include four years of accredited, clinically-oriented graduate medical education, which must be focused on reproductive health care and ambulatory primary health care for women, including health maintenance, disease prevention, diagnosis, treatment, consultation, and referral.

There will always be a need for OB/GYNs, and while there will be some practice overlap in the provision of basic care, the professions are not, nor will they be, interchangeable.

1. Physicians still have control of medical staffing decisions at hospitals and may not have incentives to hire physician extenders like CNMs. Current law requires that hospitals have a dual structure – an administrative governing body which oversees the hospital operations, and a medical staff which provides medical services and is generally responsible for ensuring that its members provide appropriate medical care to patients at the hospital.

In order to practice at a hospital, a physician must be granted privileges by the medical staff. To the extent that CNMs may provide some overlapping functions with OB/GYNs, hospitals may prefer to hire some CNMs in addition to OB/GYNs to handle cases of normal childbirth and provision of primary care. Because this bill would revoke employment by hospitals by CNMs, CNMs would have to apply for staff privileges from physicians. Given the nature of their overlapping scopes, it is likely that medical staff would be reluctant to replace or supplement OB/GYNs with CNMs.

1. Arguments in Support. Writing in support of the bill, the California Association of Midwives, Maternal and Child Health Access (MCHA), Black Women for Wellness, the County of Santa Cruz Board of Supervisors, South Coast Midwifery & Women’s Healthcare, Inc., Beach Cities Midwifery & Women’s Health Care, Beachside Birth Center, the American Association of Birth Centers, AARP, the California Association of Nurse Anesthetists, Inland Midwife Service, and the Center on Reproductive Rights and Justice at the University of California, Berkeley School of Law state,
   AB 1306 separates the practice of nurse-midwives from physician practice, creating an opportunity for expansion of women’s health care services within their current scope of practice.  These organizations state that “California is one of six remaining states to include physician supervision language, language which contradicts national and international standards.  AB 1306 will not change the high quality of care provided by nurse-midwives nor the way that nurse-midwives currently practice.  Removing state-mandated supervision would allow the nurse-midwife to partner collaboratively with physicians, expanding options beyond working as a physician’s employee.  AB 1306 would directly and positively affect the California health care system by providing for improved physician and nurse-midwife collaboration and greater innovation in health care delivery.”

The American College of Nurse-Midwives (ACNM) states, “California nurse-midwives are highly trained providers who earn graduate degrees and are trained in the disciplines of midwifery and nursing.  AB 1306 would require all nurse-midwives to pass a national certification examination to demonstrate mastery of ACNM’s core competencies, which meet or exceed national recommendations for midwifery care, as a condition of licensure.  Safe, quality health care can best be provided to women and their infants when policymakers permit CNMs to provide independent midwifery care within their scope of practice.”

The American Nurses Association/California, the California Association for Nurse Practitioners, the United Nurses Associations of California/Union of Health Care Professionals, and the California Nurse Midwife Association (CNMA) state that a CNM is an advanced practice nurse who is educated in Master’s Degree programs accredited by the American Commission on Midwifery Education through the US Department of Education and have a higher level of education and training than Licensed Midwives.  According to these organizations, “with the increasing number of Californians insured under Covered California and the Affordable Care Act, there is a growing shortage of providers to meet the demand for primary care services.  This bill untethers CNMs from physician supervision requirements to promote the expansion of primary health care access for thousands of women.  In addition, the bill eliminated barriers that physicians encounter from malpractice carriers that prohibit them from supervising CNMs due to fears of vicarious liability.”

1. Arguments in Opposition. The California Hospital Association, Ridgecrest Regional Hospital, Henry Mayo Newhall Hospital, San Gorgonio Memorial Hospital, San Benito Health Care District, Community Hospital of the Monterey Peninsula, Lompoc Valley Medical Center, Sutter Health, Sharp Healthcare, Watsonville Community Hospital, Natividad Medical Center, St. Helena Hospital Napa Valley, Mammoth Hospital, Coalinga Regional Medical Center, Ceders-Sinai, Lodi Health, El Camino Hospital, Adventist Health, and Loma Linda University Health state that their opposition is in response to the amendment that subjects CNMs to the ban on the corporate practice of medicine.  These organizations state, “This corporate practice ban would prevent CNMs from being employed by hospitals, professional corporations, and most other employers that would like to make CNMs available to their patient population.  The current ban in AB 1306 is more restrictive than provisions that exist for physicians.  This restriction is an unnecessary and unreasonable barrier for employment of CNMs and hinders access to care for California women.”

The Medical Board of California has taken an oppose unless amended position, stating, “This bill does not have the same clear guidance and restrictions on what types of patients that [CNMs] can accept and does not clearly delineate when a patient should be transferred to a physician or require a physician consult for higher risk patients.  Because this bill does not currently include parameters on independent CNM practice that would ensure consumer protection, the Board is opposed to this bill unless it is amended to address these concerns.”

The California Association of Clinical Nurse Specialists CACNS) writes, “While CACNS lauds this effort for CNMs to achieve full practice authority, the acceptance of amendments that will include the CPM ban will limit opportunities for Californians to access nurse midwifery services by placing undue restrictions on employment opportunities for CNMs…. Acceptance of the amendments for the CPM ban also assumes that CNMs practice Medicine. All nurses, regardless of role, practice Nursing. CNMs are educated and trained by nurses. Core competencies, scope, and standards of practice were created by and for CNMs, not physicians. The national certification exam was created by and for CNMs. CNMs have their own nursing science. Lastly, CNMs are licensed as nurses, not physicians. These fundamental distinctions are important to recognize since the CPM ban applies to the practice of Medicine….

“If the authors are willing to remove the employment components of the CPM ban and leave intact the spirit of the CPM ban that focuses on the prohibition of non-clinical corporations in the practice of nursing, then CACNS would be happy to reconsider our position on the bill.”

1. Related Legislation. SB 323 (Hernandez) of 2015, would authorize a nurse practitioner who holds a national certification to practice without physician supervision in specified settings. (Status: This bill is pending reconsideration in the Assembly Business and Professions Committee.)
2. Prior Related Legislation. SB 1308 (Bonilla, Chapter 665, Statutes of 2013) authorized a midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing and receive reports that are necessary to his/her practice of midwifery and consistent with his/her scope of practice; expanded the disclosures required to be made by a midwife to a prospective client to include the specific procedures that warrant consultation with a physician and surgeon; and made other correcting and conforming changes.

SB 1950 (Figueroa, Chapter 1085, Statutes of 2002) required the MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery.

SB 1479 (Figueroa, Chapter 303, Statutes of 2000) expanded the disclosures required to be given by licensed midwives and also required midwives to register birth certificates for home births.

SB 350 (Killea, Chapter 1280, Statutes of 1993) enacted the Licensed Midwifery Practice Act of 1993 to provide for the licensing and regulation of non-nurse and non-physician assistant midwives by the MBC.

SUPPORT AND OPPOSITION:

Support:

California Nurse Midwives Association (Sponsor)

Association of California Healthcare Districts

AARP

(7/1/15 version):

American Association of Birth Centers

American College of Nurse-Midwives

American Nurses Association/California

Beach Cities Midwifery & Women’s Health Care

Beachside Birth Center

Black Women for Wellness

California Association of Midwives

California Association of Nurse Anesthetists

Center on Reproductive Rights and Justice at the University of California, Berkeley

School of Law

County of Santa Cruz Board of Supervisors

Inland Midwife Service

Maternal and Child Health Access

South Coast Midwifery & Women’s Healthcare, Inc.

United Nurses Associations of California/Union of Health Care Professionals

Numerous individuals

Opposition:

Adventist Health

California Association for Nurse Practitioners

California Hospital Association

Sutter Health

(7/1/15 version):

California Association of Clinical Nurse Specialists

California Hospital Association

Ceders-Sinai

Coalinga Regional Medical Center

Community Hospital of the Monterey Peninsula

Corona Regional Medical Center

El Camino Hospital

Henry Mayo Newhall Hospital

Lodi Health

Loma Linda University Health

Lompoc Valley Medical Center

Mammoth Hospital

Medical Board of California

Natividad Medical Center

Ridgecrest Regional Hospital

San Antonio Regional Hospital

San Benito Health Care District

San Gorgonio Memorial Hospital

Sharp Healthcare

St. Helena Hospital Napa Valley

Watsonville Community Hospital

-- END --

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2015 - 2016 Regular

Bill No: AB 1306 Hearing Date: July 13, 2015

Subject: Healing arts: certified nurse-midwives: scope of practice.

SUMMARY:

Removes physician supervision requirements for a Certified Nurse Midwife, increases educational requirements, establishes a Nurse-Midwifery Advisory Council within the Board of Registered Nursing, and subjects certified nurse midwives to the ban on the corporate practice of medicine, among other changes.

Existing law:

1. The Nursing Practice Act provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing (BRN) and authorizes the BRN to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the BRN. (Business and Professions Code (BPC) §§ 2700 et seq.)

2. Authorizes a Certified Nurse Midwife (CNM), under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. (BPC § 2746.5 (a))

3. Provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal.
   (BPC § 2746.5 (b))

4. States that physician “supervision” shall not be construed to require the physical presence of the supervising physician. (BPC § 2746.5 (c))

5. Authorizes a CNM to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the CNM's educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified. (BPC §§ 2746.51 et seq.)

6. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon. (BPC § 2746.52)

7. Authorizes the BRN to appoint a Nurse-Midwifery Committee of qualified physicians and nurses, including, but not limited to, obstetricians and nurse-midwives, to develop the necessary standards relating to educational requirements, ratios of nurse-midwives to supervising physicians, and associated matters. (BPC § 2746.2)

8. Authorizes a CNM to furnish or order drugs or devices, including Schedule II-V controlled substances, pursuant to physician supervision, standardized procedures and protocols, and other conditions, as specified. (BPC § 2746.51)

9. Prohibits a physician from referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the physician or his or her immediate family has a financial interest with the person or in the entity that receives the referral. (BPC § 650.01)

10. Requires a physician and surgeon’s certificate to practice medicine. (BPC § 2052)

11. States that corporations and other artificial legal entities shall have no professional rights, privileges, or powers. Provides that the Medical Board of California (MBC) may in its discretion, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for professional services rendered patients is made by any such institution, foundation, or clinic. (BPC § 2400)

12. Establishes exceptions to the ban on the corporate practice medicine, thereby allowing certain types of facilities to employ physicians. (BPC § 2401)

13. Establishes the following protections against retaliation for health care practitioners who advocate for appropriate health care for their patients pursuant to Wickline v. State of California (192 Cal. App. 3d 1630):

    1. It is the public policy of the State of California that a health care practitioner be encouraged to advocate for appropriate health care for his or her patients. For purposes of this section, “to advocate for appropriate health care” means to appeal a payer’s decision to deny payment for a service pursuant to the reasonable grievance or appeal procedure established by a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer, or to protest a decision, policy, or practice that the health care practitioner, consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care, reasonably believes impairs the health care practitioner’s ability to provide appropriate health care to his or her patients.

    2. The application and rendering by any individual, partnership, corporation, or other organization of a decision to terminate an employment or other contractual relationship with or otherwise penalize a health care practitioner principally for advocating for appropriate health care consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care violates the public policy of this state.

    3. This law shall not be construed to prohibit a payer from making a determination not to pay for a particular medical treatment or service, or the services of a type of health care practitioner, or to prohibit a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff, hospital governing body, or payer from enforcing reasonable peer review or utilization review protocols or determining whether a health care practitioner has complied with those protocols. (BPC § 510)

This bill:

1. Prohibits CNMs from referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the CNM or his or her immediate family has a financial interest with the person or in the entity that receives the referral.

2. States that, notwithstanding the prohibition on referrals, a CNM may refer a person to a licensed alternative birth center or to a nationally accredited alternative birth center, among other facilities.

3. Requires an applicant to acquire an advanced level national certification by a certifying body that meets standards established and approved by the BRN for certification as a nurse midwife.

4. Deletes the authorization for the BRN to appoint a Nurse-Midwifery Committee, and instead requires the BRN to create and appoint, with assistance from the MBC, a Nurse-Midwifery Advisory Council (Council). States that the Council shall make recommendations to the BRN on all matters related to nurse-midwifery practice, education, and other matters as specified by the BRN.

5. Requires the Council to meet regularly, but at least twice per year.

6. Specifies that the Council shall consist of:

1. A majority of CNMs in good standing with experience in hospital settings, alternative birth center settings, and home settings.

2. A nurse-midwife educator who has demonstrated familiarity with educational standards in the delivery of maternal-child health care.

3. A consumer of midwifery care.

4. At least two qualified physicians appointed by the MBC, including an obstetrician that has experience working with nurse-midwives.

7. Prohibits corporations and other artificial legal entities from having any professional rights, privileges, or powers. However, the BRN may in its discretion, after such investigation and review of such documentary evidence as it may require, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for professional services rendered patients is made by any such institution, foundation, or clinic.

8. Permits the following entities to employ a CNM and charge for professional services rendered by a CNM; however, the entity shall not interfere with, control, or otherwise direct the professional judgment of a certified nurse-midwife:

1. A clinic operated by a nonprofit corporation as an entity organized and operated exclusively for scientific and charitable purposes.

2. A hospital owned and operated by a health care district.

3. A clinic operated primarily for the purpose of medical education or nursing education by a public or private nonprofit university medical school, which is approved by the MBC or the Osteopathic Medical Board of California, provided the CNM holds an academic appointment on the faculty of the university, including, but not limited to, the University of California medical schools and hospitals.

4. A licensed alternative birth center, as specified, or a nationally accredited alternative birth center owned or operated by a nursing corporation, as specified.

9. Deletes references in current law to supervision by a physician and surgeon.

10. Authorizes a CNM to manage a full range of primary gynecological and obstetric care services for women from adolescence to beyond menopause, consistent with the Core Competencies for Basic Midwifery practice promulgated by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the BRN. These services include, but are not limited to, primary health care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth, and the postpartum period, and treatment of male partners for sexually transmitted infections, utilizing consultation, collaboration, or referral to appropriate levels of health care services, as indicated.

11. Authorizes permissible settings in which a CNM may practice, including the home, but only when the following conditions apply:

1. There is the absence of all of the following:

1. Any preexisting maternal disease or condition likely to complicate the pregnancy.

2. Disease arising from the pregnancy likely to cause significant maternal and/or fetal compromise.

3. Prior caesarean delivery.

2. There is a singleton fetus.

3. There is cephalic presentation at the onset of labor.

4. The gestational age of the fetus is greater than 37 weeks 0/7 days and less than
   42 weeks 0/7 days completed weeks of pregnancy at the onset of labor.

5. Labor is spontaneous or induced in an outpatient setting.

12. States that if a potential CNM client meets the conditions specified in clauses (b) to (e) above, but fails to meet the conditions specified in (a) and the woman still desires to be a client of the CNM, the CNM shall consult with a physician and surgeon trained in obstetrics and gynecology. A CNM may assist the woman in pregnancy and childbirth only if a physician and surgeon trained in obstetrics and gynecology is consulted and the physician and surgeon who performed the consultation determines that the risk factors presented by her disease or condition are not likely to significantly affect the course of pregnancy and childbirth.

13. States that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the patient and the resources and medical personnel available in the setting of care. It also emphasizes informed consent, preventive care, and early detection and referral of complications to physicians and surgeons. While practicing in a hospital setting, the certified nurse-midwife shall collaboratively care for women with more complex health needs.

14. Requires a CNM to be subject to all credentialing and quality standards held by the facility in which he or she practices. The peer review body shall include nurse-midwives as part of the peer review body that reviews nurse-midwives. The peer review body of that facility shall impose standards that assure quality and patient safety in their facility. The standards shall be approved by the relevant governing body unless found by a court to be arbitrary and capricious.

15. Requires any regulations promulgated by a state department that affect the scope of practice of a CNM to be developed in consultation with the Council.

16. Deletes references to standardized procedures and protocols and physician supervision for the furnishing of drugs and devices by CNMs, except that in a nonhospital setting, a Schedule II controlled substance shall be furnished by a CNM only during labor and delivery and only after a consultation with a physician and surgeon.

17. Authorizes a CNM to furnish or order drugs or devices related to the provision of care rendered in a home, as specified.

18. Authorizes a CNM to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a CNM and consistent with nurse-midwifery education preparation.

19. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second-degree lacerations of the perineum in a home, as specified.

20. States that a consultative relationship between a CNM and a physician and surgeon shall not, by itself, provide the basis for finding a physician and surgeon liable for any act or omission of the CNM.

21. Makes clarifying and technical amendments.

FISCAL EFFECT:

This bill has been keyed “fiscal” by Legislative Counsel. According to the Assembly Appropriations Committee analysis dated May 13, 2015, this bill will result in minor costs to the BRN Fund for advisory council meetings. The analysis notes that the potential impact on BRN enforcement costs resulting from the bill is unclear, but will likely be minor, as removing the requirement for supervision does not significantly change the practice of midwifery.

COMMENTS:

1. Purpose. This bill is sponsored by the California Nurse Midwives Association. According to the Author’s office, “Approximately 1,200 CNMs are licensed in California by the BRN to practice midwifery – the care of childbearing women during pregnancy, labor and birth, and during the postpartum period. While most states allow CNMs to practice independently, California is one of only six states that require physician supervision of CNMs.

“California law requires a CNM to practice under the supervision of a physician, but specifies that the supervision requirement shall not be construed to require the physical presence of the physician. Although the supervision requirement tethers CNMs to practice only where a physician can supervise, it does not consist of actual oversight of health care delivery, inspection or review of charts, co-signatures on prescriptions, direct care of the patient, or evaluation of CNM patients at any point during pregnancy or well-woman care. In communities without obstetricians/ gynecologists, the supervision requirement limits access to care for women, even when a CNM is available to provide care.

“In 2013, the Legislature removed physician supervision of licensed midwives (LMs) (AB 1308, Bonilla, Chapter 665, Statutes of 2013). CNMs are required to have a higher level of education and training than LMs in order to qualify for licensure (licensed as a registered nurse and graduate of a Board-approved nurse-midwifery program), and yet are still subject to physician supervision to practice.

“AB 1306 allows CNMs to practice to the full extent of the education and training, without physician supervision. The bill keeps their existing scope of practice in place and aligns their education and practice requirements with national standards. In addition, the bill includes consumer protections to guard against kickbacks and self-referrals, as well as additional structure for CNMs serving patients in home and birth center settings.”

2. CNMs. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth, as well as immediate care for the newborn. Current law requires a CNM be licensed as a registered nurse and graduate from an approved program in nurse-midwifery. There are 1,271 CNMs in California.

A CNM may furnish drugs and devices after completing at least six months of physician supervised experience in the furnishing of drugs and devices and a course in pharmacology. “Furnishing” is the ordering of a drug or device in accordance with standardized procedure or protocol.

Standardized procedures are policies and protocols developed by a health facility or organized health care system, with input from administrators and health professionals, which establish parameters for medical care. Protocols are a part of standardized procedures and are designed to describe the steps of medical care for given patient situations. Protocols are developed in consultation with a supervising physician.

This bill would remove the requirements of physician supervision and largely remove the restrictions on the independent furnishing of drugs and devices by CNMs.

2. CNMs as Independent Practitioners. According to the U.S. Library of Medicine, CNMs are well positioned as primary care practitioners. “Many studies over the past 20 to 30 years have shown that [CNMs] can manage most perinatal (including prenatal, delivery, and postpartum) care. They are also qualified to deliver most family planning and gynecological needs of women of all ages.” Echoing this sentiment, the Center for the Health Professions at the University of California at San Francisco (UCSF) states that research generally confirms that care provided by CNMs is at least as safe as that from physicians and costs less.

However, current laws and regulations hamper the ability of CNMs to practice to the full extent of their training, limiting their potential impact. The dean of the UCSF School of Nursing, Kathleen Dracup, states “Primary care delivery has changed dramatically in the past 50 years, and for the better; we are living longer and more comfortably, and [advance practice nurses] are often the people who have provided the primary care in partnership with primary care doctors. If regulations around nurse practitioners and midwives are updated and outdated views of primary care change, that will provide one very promising pathway toward effective health care reform.”

CNMs have demonstrated an ability to play a key role in the delivery of primary healthcare to Californians, and this bill will release them to practice independently, enabling many more individuals to access needed care.

2. Ban on the Corporate Practice of Medicine (CPM). This bill subjects CNMs to the ban on CPM, which previously has only been applied to physicians. CPM is usually referred to in the context of a prohibition, banning hospitals from employing physicians. The ban on CPM evolved in the early 20^th century when mining companies had to hire physicians directly to provide care for their employees in remote areas. However, problems arose when physicians' loyalty to the mining companies conflicted with patients' needs. Eventually, physicians, courts, and legislatures prohibited CPM in an effort to preserve physicians' autonomy and improve patient care.

Over the years, various state and federal statutes have weakened the CPM prohibition. According to a 2007 report issued by the California Research Bureau, “California’s CPM doctrine has been defined largely through lawsuits and Attorney General opinions over decades, and then riddled by HMO and other legislation; its power and meaning are now inconsistent…. Although some non-profit clinics may employ physicians, California applies the CPM doctrine to most other entities.... Teaching hospitals may employ physicians, but other hospitals, including most public and non-profit hospitals, may not employ physicians. Professional medical corporations are expressly permitted to engage in the practice of medicine, and may employ physicians. [However, t]hese medical corporations may operate on a for-profit basis, although the profit motive was one of the original rationales of the CPM prohibition.” Indeed, the greatest cost pressures typically come from health insurers, and not the facilities themselves.

The following entities may currently employ physicians:

• A clinic operated primarily of the purpose of medical education by a public or private nonprofit university medical school.

• A clinic operated by a nonprofit corporation as an entity organized and operated exclusively for scientific and charitable purposes.

• A narcotic treatment program.

• A hospital owned and operated by a licensed charitable organization that offers only pediatric subspecialty care, as specified.

• A health maintenance organization (HMO).

California is one of only five remaining states that adhere to some form of the ban. The American Medical Association, historically the driving force behind the CPM prohibition, no longer views physician employment as a violation of medical ethics and has removed the doctrine from its ethical code.

5. The Changing Healthcare Employment Landscape. The nationwide trend in healthcare is toward direct employment. According to a 2011 survey from the consulting firm Accenture:

“U.S. physicians continue to sell their private practices and seek employment with healthcare systems, according to a new survey from Accenture.  As physicians migrate from private practice to larger health systems, the new landscape will require healthcare information technology (IT), medical device manufacturers, pharmaceutical companies and payers to revise their business models and offerings.  At the same time, hospitals will need to determine how to retain and recruit the correct mix of physicians, especially in high-growth service lines, including cardiovascular care, orthopedics, cancer care and radiology.  Patients will increasingly move to large health systems, as opposed to the current trend of visiting doctors in private, small practice settings.

“’Health reform is challenging the entire system to deliver improved care through insight driven health,’ said Kristin Ficery, senior executive, Accenture Health.  ‘We see an increasing number of physicians leaving private practice to join hospital systems, which will force all stakeholders to revise and refine their business models, product offerings and service strategies.’” 

Benefits to employment include: 

• Relief from administrative responsibilities, especially those relating to insurance billing.

• Malpractice insurance.

• Greater access and support for healthcare IT tools, facilities, and medical equipment.

• A predictable work week.

• Economic stability.

These realities are the same facing CNMs, who are currently employed by hospitals and other facilities. CNMs would be unable to continue to realize the benefits of employment in many facilities according to the terms of this bill.

5. Impact on Health Care Access. The potential impact of the ban on CPM for CNMs is not only on those currently employed; it will affect future employment opportunities for CNMs and consumers’ access to care.

California currently has a physician shortage. As of 2013, just 16 of California's 58 counties had the federal government's recommended supply of primary care physicians, with the Inland Empire and the San Joaquin Valley facing the worst shortages. In addition, nearly 30 percent of the state's doctors are nearing retirement age, the highest percentage in the nation, according to the Association of American Medical Colleges. There are not enough physicians in training, and certainly not enough physicians planning to specialize in primary care, to backfill this deficit.

If this bill only contained the elimination of the physician supervision requirement, it would likely result in the increased employment by hospitals and clinics of CNMs, given their versatility: CNMs can provide a wide range of services in a variety of settings, and facilities would no longer have to struggle to find physicians willing to supervise them. Particularly for rural hospitals and other areas where it is challenging to attract physicians, employing CNMs would be a desirable option for expanding hospitals’ and clinics’ ability to meet basic community needs.

However, restricting the employment opportunities for these practice types by including their services in the ban on CPM will necessarily limit healthcare access to those individuals who would otherwise receive their care.

5. The Need for Equity in the Workplace Between CNMs and Physicians. Supporters of the CPM ban argue that it is necessary for equity in the workforce to subject any profession that becomes independent of physician supervision to be subject to the same business constraints as physicians.
   
   This does not appear to be a valid argument in consideration of the following:

1. Physicians and CNMs have very different practice scopes. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth on his or her own responsibility, as well as immediate care for the newborn. CNM care includes preventative measures and the detection of abnormal conditions in mother and child, but CNMs cannot assist childbirth by any artificial, forcible, or mechanical means. CNMs are not authorized to perform surgery, although this bill will allow them to perform and repair episiotomies and first-degree and second-degree lacerations of the perineum in a home, as specified.

Obstetrician-gynecologists (OB/GYN) are physicians who possess special knowledge, skills and professional capability in the medical and surgical care of the female reproductive system and associated disorders. OB/GYNs are necessary for abnormal cases of pregnancy, advanced conditions, and surgeries. Resident education in obstetrics-gynecology must include four years of accredited, clinically-oriented graduate medical education, which must be focused on reproductive health care and ambulatory primary health care for women, including health maintenance, disease prevention, diagnosis, treatment, consultation, and referral.

There will always be a need for OB/GYNs, and while there will be some practice overlap in the provision of basic care, the professions are not, nor will they be, interchangeable.

2. Physicians still have control of medical staffing decisions at hospitals and may not have incentives to hire physician extenders like CNMs.

Current law requires that hospitals have a dual structure – an administrative governing body which oversees the hospital operations, and a medical staff which provides medical services and is generally responsible for ensuring that its members provide appropriate medical care to patients at the hospital.

In order to practice at a hospital, a physician must be granted privileges by the medical staff. To the extent that CNMs may provide some overlapping functions with OB/GYNs, hospitals may prefer to hire some CNMs in addition to OB/GYNs to handle cases of normal childbirth and provision of primary care. Because this bill would revoke employment by hospitals by CNMs, CNMs would have to apply for staff privileges from physicians. Given the nature of their overlapping scopes, it is likely that medical staff would be reluctant to replace or supplement OB/GYNs with CNMs.

5. Arguments in Support. Writing in support of the bill, the California Association of Midwives, Maternal and Child Health Access (MCHA), Black Women for Wellness, the County of Santa Cruz Board of Supervisors, South Coast Midwifery & Women’s Healthcare, Inc., Beach Cities Midwifery & Women’s Health Care, Beachside Birth Center, the American Association of Birth Centers, AARP, the California Association of Nurse Anesthetists, Inland Midwife Service, and the Center on Reproductive Rights and Justice at the University of California, Berkeley School of Law state,
   AB 1306 separates the practice of nurse-midwives from physician practice, creating an opportunity for expansion of women’s health care services within their current scope of practice.  These organizations state that “California is one of six remaining states to include physician supervision language, language which contradicts national and international standards.  AB 1306 will not change the high quality of care provided by nurse-midwives nor the way that nurse-midwives currently practice.  Removing state-mandated supervision would allow the nurse-midwife to partner collaboratively with physicians, expanding options beyond working as a physician’s employee.  AB 1306 would directly and positively affect the California health care system by providing for improved physician and nurse-midwife collaboration and greater innovation in health care delivery.”

The American College of Nurse-Midwives (ACNM) states, “California nurse-midwives are highly trained providers who earn graduate degrees and are trained in the disciplines of midwifery and nursing.  AB 1306 would require all nurse-midwives to pass a national certification examination to demonstrate mastery of ACNM’s core competencies, which meet or exceed national recommendations for midwifery care, as a condition of licensure.  Safe, quality health care can best be provided to women and their infants when policymakers permit CNMs to provide independent midwifery care within their scope of practice.”

The American Nurses Association/California, the California Association for Nurse Practitioners, the United Nurses Associations of California/Union of Health Care Professionals, and the California Nurse Midwife Association (CNMA) state that a CNM is an advanced practice nurse who is educated in Master’s Degree programs accredited by the American Commission on Midwifery Education through the US Department of Education and have a higher level of education and training than Licensed Midwives.  According to these organizations, “with the increasing number of Californians insured under Covered California and the Affordable Care Act, there is a growing shortage of providers to meet the demand for primary care services.  This bill untethers CNMs from physician supervision requirements to promote the expansion of primary health care access for thousands of women.  In addition, the bill eliminated barriers that physicians encounter from malpractice carriers that prohibit them from supervising CNMs due to fears of vicarious liability.”

5. Arguments in Opposition. The California Hospital Association, Ridgecrest Regional Hospital, Henry Mayo Newhall Hospital, San Gorgonio Memorial Hospital, San Benito Health Care District, Community Hospital of the Monterey Peninsula, Lompoc Valley Medical Center, Sutter Health, Sharp Healthcare, Watsonville Community Hospital, Natividad Medical Center, St. Helena Hospital Napa Valley, Mammoth Hospital, Coalinga Regional Medical Center, Ceders-Sinai, Lodi Health, El Camino Hospital, Adventist Health, and Loma Linda University Health state that their opposition is in response to the amendment that subjects CNMs to the ban on the corporate practice of medicine.  These organizations state, “This corporate practice ban would prevent CNMs from being employed by hospitals, professional corporations, and most other employers that would like to make CNMs available to their patient population.  The current ban in AB 1306 is more restrictive than provisions that exist for physicians.  This restriction is an unnecessary and unreasonable barrier for employment of CNMs and hinders access to care for California women.”

The Medical Board of California has taken an oppose unless amended position, stating, “This bill does not have the same clear guidance and restrictions on what types of patients that [CNMs] can accept and does not clearly delineate when a patient should be transferred to a physician or require a physician consult for higher risk patients.  Because this bill does not currently include parameters on independent CNM practice that would ensure consumer protection, the Board is opposed to this bill unless it is amended to address these concerns.”

The California Association of Clinical Nurse Specialists CACNS) writes, “While CACNS lauds this effort for CNMs to achieve full practice authority, the acceptance of amendments that will include the CPM ban will limit opportunities for Californians to access nurse midwifery services by placing undue restrictions on employment opportunities for CNMs…. Acceptance of the amendments for the CPM ban also assumes that CNMs practice Medicine. All nurses, regardless of role, practice Nursing. CNMs are educated and trained by nurses. Core competencies, scope, and standards of practice were created by and for CNMs, not physicians. The national certification exam was created by and for CNMs. CNMs have their own nursing science. Lastly, CNMs are licensed as nurses, not physicians. These fundamental distinctions are important to recognize since the CPM ban applies to the practice of Medicine….

“If the authors are willing to remove the employment components of the CPM ban and leave intact the spirit of the CPM ban that focuses on the prohibition of non-clinical corporations in the practice of nursing, then CACNS would be happy to reconsider our position on the bill.”

5. Related Legislation This Year. SB 323 (Hernandez) of 2015, would authorize a nurse practitioner who holds a national certification to practice without physician supervision in specified settings. (Status: This bill is pending reconsideration in the Assembly Business and Professions Committee.)

5. Prior Related Legislation. SB 1308 (Bonilla, Chapter 665, Statutes of 2013) authorized a midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing and receive reports that are necessary to his/her practice of midwifery and consistent with his/her scope of practice; expanded the disclosures required to be made by a midwife to a prospective client to include the specific procedures that warrant consultation with a physician and surgeon; and made other correcting and conforming changes.

SB 1950 (Figueroa, Chapter 1085, Statutes of 2002) required the MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery.

SB 1479 (Figueroa, Chapter 303, Statutes of 2000) expanded the disclosures required to be given by licensed midwives and also required midwives to register birth certificates for home births.

SB 350 (Killea, Chapter 1280, Statutes of 1993) enacted the Licensed Midwifery Practice Act of 1993 to provide for the licensing and regulation of non-nurse and non-physician assistant midwives by the MBC.

13. Suggested Amendments.

1. Expand Exemptions to the Ban on CPM for CNMs. Until a more comprehensive debate on the merits of the ban on CPM as it relates to all health professions is undertaken, it is recommended that exemptions for nonprofit clinics and hospitals be added to this bill to ensure the provision of basic healthcare services to underserved individuals. The exemption for nonprofit entities would avoid the conflict of interest that detractors argue is inherent in a for-profit, non-medical employer situation.

On page 14, between lines 16 and 17, insert:

“A clinic operated under subdivision (a) of Section 1204 of the Health and Safety Code”

On page 14, between lines 21 and 22, insert:

“A nonprofit hospital, as defined in Section 129405 of the Health and Safety Code”

2. Remove References to the Medical Board of California. This bill deletes the authorization for the BRN to appoint a Nurse-Midwifery Committee, and instead requires the BRN to create and appoint a Nurse-Midwifery Advisory Council, at least two members of which would be qualified physicians appointed by the MBC, including an obstetrician that has experience working with nurse-midwives.

There is no precedent for DCA boards to have appointment authority over the composition of another board’s committee. BRN is capable of appointing physician members to the Council proposed in this bill and as such, language referencing a MBC appointment should be removed.

On page 13, line 36, strike “appointed by the Medical Board of California”

3. Technical Amendments Regarding Home Birth Conditions. The following language would provide greater semantic clarity to the circumstances in which a CNM may attend a home birth.

On page 15, line 39, strike “likely” and add “with the potential”

On page 15, line 40, add “or birth” after pregnancy.

On page 16, line 1, after “from” add “or during,” strike “likely” and add “with the potential”

On page 16, line 2, strike “significant”

On page 16, line 6, after “is” add “equal to or” and replace “370/7” with “37 0/7”

On page 16, line 7, add a space between “42” and “0/7”

4. Other Technical Amendments: The following amendments correct consistency and drafting concerns:

On page 17, line 5, delete the comma after “forcible”

On page 15, line 6, delete “of those means”

On page 12, line 32, after “1204 of” add “or within an alternative birth center as defined in subdivision (b)(4) of Section 1204 of,”

On page 14, line 24, after Board, add “of California”

On page 14, line 25, after “of California,” add “or the Board of Registered Nursing”

On page 14, line 28, after “schools” add “, nursing schools,”

SUPPORT AND OPPOSITION:

Support:

California Nurse Midwives Association (Sponsor)

American Association of Birth Centers

American College of Nurse-Midwives

American Nurses Association/California

Beach Cities Midwifery & Women’s Health Care

Beachside Birth Center

Black Women for Wellness

California Association of Midwives

California Association of Nurse Anesthetists

Center on Reproductive Rights and Justice at the University of California, Berkeley

School of Law

County of Santa Cruz Board of Supervisors

Inland Midwife Service

Maternal and Child Health Access

South Coast Midwifery & Women’s Healthcare, Inc.

United Nurses Associations of California/Union of Health Care Professionals

Numerous individuals

Opposition:

AARP

Adventist Health

Association of California Healthcare Districts

California Association of Clinical Nurse Specialists

California Association for Nurse Practitioners

California Hospital Association

Ceders-Sinai

Coalinga Regional Medical Center

Community Hospital of the Monterey Peninsula

Corona Regional Medical Center

El Camino Hospital

Henry Mayo Newhall Hospital

Lodi Health

Loma Linda University Health

Lompoc Valley Medical Center

Mammoth Hospital

Medical Board of California

Natividad Medical Center

Ridgecrest Regional Hospital

San Antonio Regional Hospital

San Benito Health Care District

San Gorgonio Memorial Hospital

Sharp Healthcare

St. Helena Hospital Napa Valley

Sutter Health

Watsonville Community Hospital

-- END --

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2015 - 2016 Regular

Bill No: AB 1306 Hearing Date: July 6, 2015

Subject: Healing arts: certified nurse-midwives: scope of practice

SUMMARY:

Removes physician supervision requirements for a Certified Nurse Midwife (CNM), increases educational requirements, establishes a Nurse-Midwifery Advisory Council within the Board of Registered Nursing (BRN), and subjects CNMs to the ban on the corporate practice of medicine, among other changes.

Existing law:

1. The Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing (BRN), within the Department of Consumer Affairs (DCA), and authorizes the BRN to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the BRN or the equivalent of those educational standards. (Business and Professions Code (BPC) §§ 2700 et seq.)

2. Authorizes a CNM, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. (BPC § 2746.5 (a))

3. Provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. (BPC § 2746.5 (b))

4. States that physician “supervision” shall not be construed to require the physical presence of the supervising physician. (BPC § 2746.5 (c))

5. Authorizes a CNM to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the CNM's educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified. (BPC § 2746.51 et seq.)

6. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center, if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon. (BPC § 2746.52)

7. Authorizes the BRN to appoint a Nurse-Midwifery Committee of qualified physicians and nurses, including, but not limited to, obstetricians and nurse-midwives, to develop the necessary standards relating to educational requirements, ratios of nurse-midwives to supervising physicians, and associated matters. (BPC § 2746.2)

8. Authorizes a CNM to furnish or order drugs or devices, including Schedule II-V controlled substances, pursuant to physician supervision, standardized procedures and protocols, and other conditions, as specified. (BPC § 2746.51)

9. Prohibits a physician from referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the physician or his or her immediate family has a financial interest with the person or in the entity that receives the referral. (BPC § 650.01)

10. Requires a physician and surgeon’s certificate to practice medicine. (BPC § 2052)

11. States that corporations and other artificial legal entities shall have no professional rights, privileges, or powers. Provides that the Medical Board of California (MBC) may in its discretion, after such investigation and review of such documentary evidence as it may require, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for professional services rendered patients is made by any such institution, foundation, or clinic. (BPC § 2400)

12. Establishes exceptions to the ban on the corporate practice medicine, thereby allowing certain types of facilities to employ physicians. (BPC § 2401)

13. Establishes the following protections against retaliation for health care practitioners who advocate for appropriate health care for their patients pursuant to Wickline v. State of California (192 Cal. App. 3d 1630):

    1. It is the public policy of the State of California that a health care practitioner be encouraged to advocate for appropriate health care for his or her patients. For purposes of this section, “to advocate for appropriate health care” means to appeal a payer’s decision to deny payment for a service pursuant to the reasonable grievance or appeal procedure established by a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer, or to protest a decision, policy, or practice that the health care practitioner, consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care, reasonably believes impairs the health care practitioner’s ability to provide appropriate health care to his or her patients.

    2. The application and rendering by any individual, partnership, corporation, or other organization of a decision to terminate an employment or other contractual relationship with or otherwise penalize a health care practitioner principally for advocating for appropriate health care consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care violates the public policy of this state.

    3. This law shall not be construed to prohibit a payer from making a determination not to pay for a particular medical treatment or service, or the services of a type of health care practitioner, or to prohibit a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff, hospital governing body, or payer from enforcing reasonable peer review or utilization review protocols or determining whether a health care practitioner has complied with those protocols. (BPC § 510)

This bill:

1. Subjects CNMs to the prohibition on referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the CNM or his or her immediate family has a financial interest with the person or in the entity that receives the referral.

2. States that, notwithstanding the prohibition on referrals, a CNM may refer a person to a licensed alternative birth center or to a nationally accredited alternative birth center, among other facilities.

3. Requires an applicant to acquire an advanced level national certification by a certifying body that meets standards established and approved by the BRN for certification as a nurse midwife.

4. Deletes the authorization for the BRN to appoint a Nurse-Midwifery Committee, and instead requires the BRN to create and appoint, with assistance from the MBC, a Nurse-Midwifery Advisory Council (Council). States that the Council shall make recommendations to the BRN on all matters related to nurse-midwifery practice, education, and other matters as specified by the BRN.

5. Requires the Council to meet regularly, but at least twice a year.

6. Specifies that the Council shall consist of:

1. Majority of CNMs in good standing with experience in hospital settings, alternative birth center settings, and home settings.

2. A nurse-midwife educator who has demonstrated familiarity with educational standards in the delivery of maternal-child health care.

3. A consumer of midwifery care.

4. At least two qualified physicians appointed by the MBC, including an obstetrician that has experience working with nurse-midwives.

7. Prohibits corporations and other artificial legal entities from having any professional rights, privileges, or powers. However, the BRN may in its discretion, after such investigation and review of such documentary evidence as it may require, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for professional services rendered patients is made by any such institution, foundation, or clinic.

8. Permits the following entities to employ a CNM and charge for professional services rendered by a CNM; however, the entity shall not interfere with, control, or otherwise direct the professional judgment of a certified nurse-midwife:

1. A nonprofit clinic.

2. A hospital owned and operated by a health care district.

3. A clinic operated primarily for the purpose of medical education or nursing education by a public or private nonprofit university medical school, which is approved by the MBC the Osteopathic Medical Board of California, provided the CNM holds an academic appointment on the faculty of the university, including, but not limited to, the University of California medical schools and hospitals.

4. A licensed alternative birth center, as specified, or a nationally accredited alternative birth center owned or operated by a nursing corporation, as specified.

9. Deletes references in current law to supervision by a physician and surgeon.

10. Authorizes a CNM to manage a full range of primary gynecological and obstetric care services for women from adolescence to beyond menopause, consistent with the Core Competencies for Basic Midwifery practice promulgated by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the BRN. These services include, but are not limited to, primary health care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth, and the postpartum period, and treatment of male partners for sexually transmitted infections, utilizing consultation, collaboration, or referral to appropriate levels of health care services, as indicated.

11. Authorizes permissible settings in which a CNM may practice, including the home, but only when the following conditions apply:

1. There is the absence of all of the following:

1. Any preexisting maternal disease or condition likely to complicate the pregnancy.

2. Disease arising from the pregnancy likely to cause significant maternal and/or fetal compromise.

3. Prior caesarean delivery.

2. There is a singleton fetus.

3. There is cephalic presentation at the onset of labor.

4. The gestational age of the fetus is greater than 370/7 weeks and less than 420/7 completed weeks of pregnancy at the onset of labor.

5. Labor is spontaneous or induced in an outpatient setting.

12. States that if a potential CNM client meets the conditions specified in clauses (b) – (e) above, but fails to meet the conditions specified in (a) and the woman still desires to be a client of the CNM, the CNM shall consult with a physician and surgeon trained in obstetrics and gynecology. A CNM may assist the woman in pregnancy and childbirth only if a physician and surgeon trained in obstetrics and gynecology is consulted and the physician and surgeon who performed the consultation determines that the risk factors presented by her disease or condition are not likely to significantly affect the course of pregnancy and childbirth.

13. States that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the patient and the resources and medical personnel available in the setting of care. It also emphasizes informed consent, preventive care, and early detection and referral of complications to physicians and surgeons. While practicing in a hospital setting, the certified nurse-midwife shall collaboratively care for women with more complex health needs.

14. Requires a CNM to be subject to all credentialing and quality standards held by the facility in which he or she practices. The peer review body shall include nurse-midwives as part of the peer review body that reviews nurse-midwives. The peer review body of that facility shall impose standards that assure quality and patient safety in their facility. The standards shall be approved by the relevant governing body unless found by a court to be arbitrary and capricious.

15. Requires any regulations promulgated by a state department that affect the scope of practice of a CNM to be developed in consultation with the Council.

16. Deletes references to standardized procedures and protocols and physician supervision for the furnishing of drugs and devices by CNMs, except that, in a nonhospital setting, a Schedule II controlled substance shall be furnished by a CNM only during labor and delivery and only after a consultation with a physician and surgeon.

17. Authorizes a CNM to furnish or order drugs or devices related to the provision of care rendered in a home, as specified.

18. Authorizes a CNM to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a CNM and consistent with nurse-midwifery education preparation.

19. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second-degree lacerations of the perineum in a home, as specified.

20. States that a consultative relationship between a CNM and a physician and surgeon shall not, by itself, provide the basis for finding a physician and surgeon liable for any act or omission of the CNM.

21. Makes clarifying and technical amendments.

FISCAL EFFECT:

This bill has been keyed “fiscal” by Legislative Counsel. According to the Assembly Appropriations Committee analysis dated May 13, 2015, this bill will result in minor costs to the BRN Fund for advisory council meetings. The analysis notes that the potential impact on BRN enforcement costs resulting from the bill is unclear, but will likely be minor, as removing the requirement for supervision does not significantly change the practice of midwifery.

COMMENTS:

1. Purpose. This bill is sponsored by the California Nurse Midwives Association. According to the Author’s office, “Approximately 1,200 CNMs are licensed in California by the BRN to practice midwifery – the care of childbearing women during pregnancy, labor and birth, and during the postpartum period. While most states allow CNMs to practice independently, California is one of only six states that require physician supervision of CNMs.

“California law requires a CNM to practice under the supervision of a physician, but specifies that the supervision requirement shall not be construed to require the physical presence of the physician. Although the supervision requirement tethers CNMs to practice only where a physician can supervise, it does not consist of actual oversight of health care delivery, inspection or review of charts, co-signatures on prescriptions, direct care of the patient, or evaluation of CNM patients at any point during pregnancy or well-woman care. In communities without obstetricians/gynecologists, the supervision requirement limits access to care for women, even when a CNM is available to provide care.

“In 2013, the Legislature removed physician supervision of licensed midwives (LMs) (AB 1308, Bonilla, Chapter 665, Statutes of 2013). CNMs are required to have a higher level of education and training than LMs in order to qualify for licensure (licensed as a registered nurse and graduate of a Board-approved nurse-midwifery program), and yet are still subject to physician supervision to practice.

“AB 1306 allows CNMs to practice to the full extent of the education and training, without physician supervision. The bill keeps their existing scope of practice in place and aligns their education and practice requirements with national standards. In addition, the bill includes consumer protections to guard against kickbacks and self-referrals, as well as additional structure for CNMs serving patients in home and birth center settings.”

2. CNMs. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth, as well as immediate care for the newborn. Current law requires CNM be licensed as a registered nurse and graduate from an approved program in nurse-midwifery. There are 1,271 CNMs in California.

A CNM may furnish drugs and devices after certification that he or she has completed at least six months of physician and surgeon supervised experience in the furnishing of drugs and devices and a course in pharmacology. “Furnishing” is the ordering of a drug or device in accordance with standardized procedure or protocol.

Standardized procedures are defined as policies and protocols developed by a health facility or organized health care system, with input from administrators and health professionals, which establish parameters for medical care. Protocols are a part of standardized procedures and are designed to describe the steps of medical care for given patient situations. Protocols are developed in consultation with a supervising physician. “Supervision” requires telephonic availability but not the physical presence of the physician.

This bill would remove the requirements of physician supervision and largely remove the restrictions on the independent furnishing of drugs and devices by CNMs.

2. CNMs as Independent Practitioners. According to the U.S. Library of Medicine, CNMs are well positioned as independent primary care practitioners. “[CNMs] have improved primary health care services for women in rural and inner-city areas. The National Institute of Medicine has recommended that [CNMs] be given a larger role in delivering women's health care.

“Many studies over the past 20 to 30 years have shown that [CNMs] can manage most perinatal (including prenatal, delivery, and postpartum) care. They are also qualified to deliver most family planning and gynecological needs of women of all ages. Some may check and manage common adult illnesses, as well.”

In addition, a 2015 article in the peer-reviewed Journal of Midwifery & Women’s Health, “Midwives as Primary Care Providers for Women,” conclude that “Midwives certified by the American Midwifery Certification Board are prepared to provide primary care to women from menarche across the lifespan and to well newborns to 28 days using consultation, collaboration, and referral to other providers as needed.”

2. Ban on the Corporate Practice of Medicine (CPM). This bill subjects CNMs to the ban on CPM, which previously has only been applied to physicians. The corporate practice of medicine (CPM) is usually referred to in the context of a prohibition, banning hospitals from employing physicians. The ban on CPM evolved in the early 20^th century when mining companies had to hire physicians directly to provide care for their employees in remote areas. However, problems arose when physicians' loyalty to the mining companies conflicted with patients' needs. Eventually, physicians, courts, and legislatures prohibited CPM in an effort to preserve physicians' autonomy and improve patient care.

Over the years, various state and federal statutes have left the CPM prohibition substantially weakened and largely nonsensical. According to a 2007 report issued by the California Research Bureau, “California’s CPM doctrine has been defined largely through lawsuits and Attorney General opinions over decades, and then riddled by HMO and other legislation; its power and meaning are now inconsistent…. Although some non-profit clinics may employ physicians, California applies the CPM doctrine to most other entities. Non-profit associations may employ physicians under specific circumstances and non-profit corporations may employ physicians in clinics meeting specific requirements. Teaching hospitals may employ physicians, but other hospitals, including most public and non-profit hospitals, may not employ physicians.  Professional medical corporations are expressly permitted to engage in the practice of medicine, and may employ physicians. [However, t]hese medical corporations may operate on a for-profit basis, although the profit motive was one of the original rationales of the CPM prohibition.” Indeed, the greatest cost pressures typically come from health insurers, and not the facilities themselves.

The following entities may currently employ physicians:

• A clinic operated primarily of the purpose of medical education by a public or private nonprofit university medical school.

• A clinic operated by a nonprofit corporation as an entity organized and operated exclusively for scientific and charitable purposes.

• A narcotic treatment program.

• A hospital owned and operated by a health care district.

• A hospital owned and operated by a licensed charitable organization, that offers only pediatric subspecialty care, as specified.

California is one of only five remaining states that adhere to some form of the ban. The American Medical Association, historically the driving force behind the CPM prohibition, no longer views physician employment per se as a violation of medical ethics and has removed the doctrine from its ethical code.

5. The Changing Healthcare Employment Landscape. California’s ban on CPM is becoming a hindrance to efficiency and the state’s competitiveness in a rapidly changing healthcare environment. Extending an outdated ban on employment to an expanding and vital class of health care providers will not benefit consumers or the professionals themselves. According to a 2011 survey from the consulting firm Accenture:

“U.S. physicians continue to sell their private practices and seek employment with healthcare systems, according to a new survey from Accenture.  As physicians migrate from private practice to larger health systems, the new landscape will require healthcare information technology (IT), medical device manufacturers, pharmaceutical companies and payers to revise their business models and offerings.  At the same time, hospitals will need to determine how to retain and recruit the correct mix of physicians, especially in high-growth service lines, including cardiovascular care, orthopedics, cancer care and radiology.  Patients will increasingly move to large health systems, as opposed to the current trend of visiting doctors in private, small practice settings.

“The rate of independent physicians being employed by health systems will grow by an annual five percent over three years. By 2013, less than one-third of physicians are expected to remain truly independent. 

“’Health reform is challenging the entire system to deliver improved care through insight driven health,’ said Kristin Ficery, senior executive, Accenture Health.  ‘We see an increasing number of physicians leaving private practice to join hospital systems, which will force all stakeholders to revise and refine their business models, product offerings and service strategies.’ 

“According to the survey, physicians are increasingly attracted to the benefits offered by hospital-based employment opportunities.  These benefits include: 

• Relief from administrative responsibilities.

• Greater access to leading-edge healthcare IT tools, facilities and equipment.

• A more manageable work week.

• Stability in a business environment made uncertain by developments such as payment reforms.”

These realities are the same facing CNMs, who are currently employed by hospitals and other facilities. CNMs would be unable to continue to realize the benefits of employment should this measure pass.

5. Health Care Access. The potential impact of the ban on CPM for CNMs is not only on those currently employed; it will affect future employment opportunities that will be lost as the result of it.

The elimination of the physician supervision requirement for CNMs, standing on its own, would likely result in the increased employment by hospitals and clinics of CNMs, given their versatility: CNMs can provide a wide range of services in a variety of settings, and hospitals would no longer have to struggle to find physicians willing to supervise them. Particularly for rural hospitals and other areas where it is challenging to attract physicians, employing CNMs would be a desirable option for expanding hospitals’ and clinics’ ability to meet basic community needs.

5. California’s CPM Equality Argument. Supporters of the CPM ban argue that it is necessary for equity in the workforce to subject any profession that becomes independent of physician supervision to be subject to the same business constraints as physicians. This is not a valid argument because the professions are not on equal footing.

1. Physicians and CNMs have very different practice scopes. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth on his or her own responsibility, as well as immediate care for the newborn. CNM care includes preventative measures and the detection of abnormal conditions in mother and child, but CNMs cannot assist childbirth by any artificial, forcible, or mechanical means. CNMs are not authorized to perform surgery, although this bill will allow them to perform and repair episiotomies and first-degree and second-degree lacerations of the perineum in a home, as specified.

Obstetrician-gynecologists (OB/GYN) are physicians who possess special knowledge, skills and professional capability in the medical and surgical care of the female reproductive system and associated disorders. OB/GYNs are necessary for abnormal cases of pregnancy, advanced conditions, and surgeries. Resident education in obstetrics-gynecology must include four years of accredited, clinically-oriented graduate medical education, which must be focused on reproductive health care and ambulatory primary health care for women, including health maintenance, disease prevention, diagnosis, treatment, consultation, and referral.

There will always be a need for OB/GYNs, and while there will be some practice overlap, the professions are not, nor will they be according to the terms of this bill, interchangeable.

2. Physicians still have control of medical staffing decisions at hospitals and may not have incentives to hire physician extenders like CNMs.

Current law requires that hospitals have a dual structure – an administrative governing body, which oversees the hospital operations, and a medical staff, which provides medical services and is generally responsible for ensuring that its members provide appropriate medical care to patients at the hospital.

In order to practice at a hospital, a physician must be granted privileges by the medical staff. To the extent that CNMs may provide some overlapping functions with OB/GYNs, hospitals may prefer to hire some CNMs in addition to OB/GYNs to handle cases of normal childbirth and provision of primary care. Because this bill would revoke employment by hospitals by CNMs, CNMs would have to apply for staff privileges from physicians. Given the nature of their overlapping scopes, it is likely that medical staff would be reluctant to replace or supplement OB/GYNs with CNMs.

5. Additional Means of Protecting Medical Decision Making. In tandem with the exceptions made to the ban on CPM, California has enacted legislation sharply limiting actual and potential corporate control over physicians.

The Knox-Keene Act, which regulates health maintenance organizations (HMOs), subjects HMOs to the following requirements:

• Capitated payment agreements or shared-risk arrangements must not be tied to specific medical decisions.

• Health plans must furnish medical services in a manner providing continuity of care.

• Health plans must provide ready referral to other providers when good professional practice requires it.

• All services must be readily available, and to the extent feasible, readily accessible, to all enrollees.

• Health plans must assure that medical decisions are made by qualified medical providers, without influence of fiscal or administrative management.

Multiple sections in California statute and regulation ensure the primacy of an individual’s professional medical decision-making, including this broad statute contained in BPC § 501:

“It is the public policy of the State of California that a health care practitioner be encouraged to advocate for appropriate health care for his or her patients. For purposes of this section, ‘to advocate for appropriate health care’ means to appeal a payer’s decision to deny payment for a service pursuant to the reasonable grievance or appeal procedure established by a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer, or to protest a decision, policy, or practice that the health care practitioner, consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care, reasonably believes impairs the health care practitioner’s ability to provide appropriate health care to his or her patients.”

These and similar provisions make the uneven doctrine of CPM largely unnecessary.

5. Arguments in Support. Writing in support of the bill, the California Association of Midwives, Maternal and Child Health Access (MCHA), Black Women for Wellness, the County of Santa Cruz Board of Supervisors, South Coast Midwifery & Women’s Healthcare, Inc., Beach Cities Midwifery & Women’s Health Care, Beachside Birth Center, the American Association of Birth Centers, AARP, the California Association of Nurse Anesthetists, Inland Midwife Service, and the Center on Reproductive Rights and Justice at the University of California, Berkley School of Law state, AB 1306 separates the practice of nurse-midwives from physician practice, creating an opportunity for expansion of women’s health care services within their current scope of practice.  These organizations state that “California is one of six remaining states to include physician supervision language, language which contradicts national and international standards.  AB 1306 will not change the high quality of care provided by nurse-midwives nor the way that nurse-midwives currently practice.  Removing state-mandated supervision would allow the nurse-midwife to partner collaboratively with physicians, expanding options beyond working as a physician’s employee.  AB 1306 would directly and positively affect the California health care system by providing for improved physician and nurse-midwife collaboration and greater innovation in health care delivery.”

The American College of Nurse-Midwives (ACNM) states, “California nurse-midwives are highly trained providers who earn graduate degrees and are trained in the disciplines of midwifery and nursing.  AB 1306 would require all nurse-midwives to pass a national certification examination to demonstrate mastery of ACNM’s core competencies, which meet or exceed national recommendations for midwifery care, as a condition of licensure.  Safe, quality health care can best be provided to women and their infants when policymakers permit CNMs to provide independent midwifery care within their scope of practice.”

The American Nurses Association/California, the California Association for Nurse Practitioners, the United Nurses Associations of California/Union of Health Care Professionals, and the California Nurse Midwife Association (CNMA) state that a CNM is an advanced practice nurse who is educated in Master’s Degree programs accredited by the American Commission on Midwifery Education through the US Department of Education and have a higher level of education and training than Licensed Midwives.  According to these organizations, “with the increasing number of Californians insured under Covered California and the Affordable Care Act, there is a growing shortage of providers to meet the demand for primary care services.  This bill untethers CNMs from physician supervision requirements to promote the expansion of primary health care access for thousands of women.  In addition, the bill eliminated barriers that physicians encounter from malpractice carriers that prohibit them from supervising CNMs due to fears of vicarious liability.”

5. Arguments in Opposition. The California Hospital Association, Ridgecrest Regional Hospital, Henry Mayo Newhall Hospital, San Gorgonio Memorial Hospital, San Benito Health Care District, Community Hospital of the Monterey Peninsula, Lompoc Valley Medical Center, Sutter Health, Sharp Healthcare, Watsonville Community Hospital, Natividad Medical Center, St. Helena Hospital Napa Valley, Mammoth Hospital, Coalinga Regional Medical Center, Ceders-Sinai, Lodi Health, El Camino Hospital, Adventist Health, and Loma Linda University Health state that their opposition is in response to the amendment that subjects CNMs to the ban on the corporate practice of medicine.  These organizations state, “This corporate practice ban would prevent CNMs from being employed by hospitals, professional corporations, and most other employers that would like to make CNMs available to their patient population.  The current ban in AB 1306 is more restrictive than provisions that exist for physicians.  This restriction is an unnecessary and unreasonable barrier for employment of CNMs and hinders access to care for California women.”

The Medical Board of California has taken an oppose unless amended position, stating, “This bill does not have the same clear guidance and restrictions on what types of patients that [CNMs] can accept and does not clearly delineate when a patient should be transferred to a physician or require a physician consult for higher risk patients.  Because this bill does not currently include parameters on independent CNM practice that would ensure consumer protection, the Board is opposed to this bill unless it is amended to address these concerns.”

5. Related Legislation This Year. SB 323 (Hernandez) of 2015, would authorize a nurse practitioner who holds a national certification to practice without physician supervision in specified settings. (Status: This bill is pending reconsideration in the Assembly Business and Professions Committee).

5. Prior Related Legislation. SB 1308 (Bonilla, Chapter 665, Statutes of 2013) authorized a midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing and receive reports that are necessary to his/her practice of midwifery and consistent with his/her scope of practice; expanded the disclosures required to be made by a midwife to a prospective client to include the specific procedures that warrant consultation with a physician and surgeon; and made other correcting and conforming changes. This bill included no CPM provisions.

SB 1950 (Figueroa, Chapter 1085, Statutes of 2002) required the MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery.

SB 1479 (Figueroa, Chapter 303, Statutes of 2000) expanded the disclosures required to be given by licensed midwives and also required midwives to register birth certificates for home births.

SB 350 (Killea, Chapter 1280, Statutes of 1993) enacted the Licensed Midwifery Practice Act of 1993 to provide for the licensing and regulation of non-nurse and non-physician assistant midwives by the MBC.

13. Suggested Amendments.

1. Strike references to the ban on CPM. The ban on CPM has outlived its usefulness and extending it to another class of healthcare professionals does not further the interests of California consumers or CNMs.

On page 14, strike lines 3 -34.

To provide additional protections against any corporate influence on medical judgment, insert the following on page 16, after line 21:

“(c) No entity in (b) shall interfere with, control, or otherwise direct the professional judgment of a certified nurse midwife in a manner prohibited by Section 510 or of any other provision of law.”

2. Remove references to the Medical Board of California. This bill deletes the authorization for the BRN to appoint a Nurse-Midwifery Committee, and instead requires the BRN to create and appoint a Nurse-Midwifery Advisory Council, at least two members of which would be qualified physicians appointed by the MBC, including an obstetrician that has experience working with nurse-midwives.

There is no precedent for DCA boards to have appointment authority over the composition of another board’s committee. BRN is capable of appointing physician members to the Council proposed in this bill and as such, language referencing a MBC appointment should be removed.

On page 13, line 36, strike “appointed by the Medical Board of California”

3. Amendments regarding home birth conditions. The following language would provide greater semantic clarity to the circumstances in which a CNM may attend a home birth.

On page 15, line 39, strike “likely” and add “with the potential”

On page 15, line 40, add “or birth” after pregnancy.

On page 16, line 1, after “from” add “or during,” strike “likely” and add “with the potential”

On page 16, line 2, strike “significant”

On page 16, line 6, after “is” add “equal to or” and replace “370/7” with “37/7”

On page 16, line 7, add a space between “42” and “0/7”

SUPPORT AND OPPOSITION:

Support:

California Nurse Midwives Association (Sponsor)

AARP

American Association of Birth Centers

American College of Nurse-Midwives

American Nurses Association/California

Beach Cities Midwifery & Women’s Health Care

Beachside Birth Center

Black Women for Wellness

California Association of Midwives

California Association of Nurse Anesthetists

California Association for Nurse Practitioners

Center on Reproductive Rights and Justice at the University of California, Berkley School of Law

County of Santa Cruz Board of Supervisors

Inland Midwife Service

Maternal and Child Health Access

South Coast Midwifery & Women’s Healthcare, Inc.

United Nurses Associations of California/Union of Health Care Professionals

Numerous individuals

Opposition:

Adventist Health

California Hospital Association

Ceders-Sinai

Coalinga Regional Medical Center

Community Hospital of the Monterey Peninsula

El Camino Hospital

Henry Mayo Newhall Hospital

Lodi Health

Loma Linda University Health

Lompoc Valley Medical Center

Mammoth Hospital

Medical Board of California

Natividad Medical Center

Ridgecrest Regional Hospital

San Benito Health Care District

San Gorgonio Memorial Hospital

Sharp Healthcare

St. Helena Hospital Napa Valley

Sutter Health

Watsonville Community Hospital

-- END --

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2015 - 2016 Regular

Bill No: AB 1306 Hearing Date: July 6, 2015

Subject: Healing arts: certified nurse-midwives: scope of practice

SUMMARY:

Removes physician supervision requirements for a Certified Nurse Midwife (CNM), increases educational requirements, establishes a Nurse-Midwifery Advisory Council within the Board of Registered Nursing (BRN), and subjects CNMs to the ban on the corporate practice of medicine, among other changes.

Existing law:

1. The Nursing Practice Act, provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing (BRN), within the Department of Consumer Affairs (DCA), and authorizes the BRN to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the BRN or the equivalent of those educational standards. (Business and Professions Code (BPC) §§ 2700 et seq.)

2. Authorizes a CNM, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. (BPC § 2746.5 (a))

3. Provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. (BPC § 2746.5 (b))

4. States that physician “supervision” shall not be construed to require the physical presence of the supervising physician. (BPC § 2746.5 (c))

5. Authorizes a CNM to furnish and order drugs or devices incidentally to the provision of family planning services, routine health care or perinatal care, and care rendered consistently with the CNM's educational preparation in specified facilities and clinics, and only in accordance with standardized procedures and protocols, as specified. (BPC § 2746.51 et seq.)

6. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center, if certain requirements are met, including, but not limited to, that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon. (BPC § 2746.52)

7. Authorizes the BRN to appoint a Nurse-Midwifery Committee of qualified physicians and nurses, including, but not limited to, obstetricians and nurse-midwives, to develop the necessary standards relating to educational requirements, ratios of nurse-midwives to supervising physicians, and associated matters. (BPC § 2746.2)

8. Authorizes a CNM to furnish or order drugs or devices, including Schedule II-V controlled substances, pursuant to physician supervision, standardized procedures and protocols, and other conditions, as specified. (BPC § 2746.51)

9. Prohibits a physician from referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the physician or his or her immediate family has a financial interest with the person or in the entity that receives the referral. (BPC § 650.01)

10. Requires a physician and surgeon’s certificate to practice medicine. (BPC § 2052)

11. States that corporations and other artificial legal entities shall have no professional rights, privileges, or powers. Provides that the Medical Board of California (MBC) may in its discretion, after such investigation and review of such documentary evidence as it may require, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for professional services rendered patients is made by any such institution, foundation, or clinic. (BPC § 2400)

12. Establishes exceptions to the ban on the corporate practice medicine, thereby allowing certain types of facilities to employ physicians. (BPC § 2401)

13. Establishes the following protections against retaliation for health care practitioners who advocate for appropriate health care for their patients pursuant to Wickline v. State of California (192 Cal. App. 3d 1630):

    1. It is the public policy of the State of California that a health care practitioner be encouraged to advocate for appropriate health care for his or her patients. For purposes of this section, “to advocate for appropriate health care” means to appeal a payer’s decision to deny payment for a service pursuant to the reasonable grievance or appeal procedure established by a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer, or to protest a decision, policy, or practice that the health care practitioner, consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care, reasonably believes impairs the health care practitioner’s ability to provide appropriate health care to his or her patients.

    2. The application and rendering by any individual, partnership, corporation, or other organization of a decision to terminate an employment or other contractual relationship with or otherwise penalize a health care practitioner principally for advocating for appropriate health care consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care violates the public policy of this state.

    3. This law shall not be construed to prohibit a payer from making a determination not to pay for a particular medical treatment or service, or the services of a type of health care practitioner, or to prohibit a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff, hospital governing body, or payer from enforcing reasonable peer review or utilization review protocols or determining whether a health care practitioner has complied with those protocols. (BPC § 510)

This bill:

1. Subjects CNMs to the prohibition on referring a person for laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy, or diagnostic imaging goods or services if the CNM or his or her immediate family has a financial interest with the person or in the entity that receives the referral.

2. States that, notwithstanding the prohibition on referrals, a CNM may refer a person to a licensed alternative birth center or to a nationally accredited alternative birth center, among other facilities.

3. Requires an applicant to acquire an advanced level national certification by a certifying body that meets standards established and approved by the BRN for certification as a nurse midwife.

4. Deletes the authorization for the BRN to appoint a Nurse-Midwifery Committee, and instead requires the BRN to create and appoint, with assistance from the MBC, a Nurse-Midwifery Advisory Council (Council). States that the Council shall make recommendations to the BRN on all matters related to nurse-midwifery practice, education, and other matters as specified by the BRN.

5. Requires the Council to meet regularly, but at least twice a year.

6. Specifies that the Council shall consist of:

1. Majority of CNMs in good standing with experience in hospital settings, alternative birth center settings, and home settings.

2. A nurse-midwife educator who has demonstrated familiarity with educational standards in the delivery of maternal-child health care.

3. A consumer of midwifery care.

4. At least two qualified physicians appointed by the MBC, including an obstetrician that has experience working with nurse-midwives.

7. Prohibits corporations and other artificial legal entities from having any professional rights, privileges, or powers. However, the BRN may in its discretion, after such investigation and review of such documentary evidence as it may require, and under regulations adopted by it, grant approval of the employment of licensees on a salary basis by licensed charitable institutions, foundations, or clinics, if no charge for professional services rendered patients is made by any such institution, foundation, or clinic.

8. Permits the following entities to employ a CNM and charge for professional services rendered by a CNM; however, the entity shall not interfere with, control, or otherwise direct the professional judgment of a certified nurse-midwife:

1. A nonprofit clinic.

2. A hospital owned and operated by a health care district.

3. A clinic operated primarily for the purpose of medical education or nursing education by a public or private nonprofit university medical school, which is approved by the MBC the Osteopathic Medical Board of California, provided the CNM holds an academic appointment on the faculty of the university, including, but not limited to, the University of California medical schools and hospitals.

4. A licensed alternative birth center, as specified, or a nationally accredited alternative birth center owned or operated by a nursing corporation, as specified.

9. Deletes references in current law to supervision by a physician and surgeon.

10. Authorizes a CNM to manage a full range of primary gynecological and obstetric care services for women from adolescence to beyond menopause, consistent with the Core Competencies for Basic Midwifery practice promulgated by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the BRN. These services include, but are not limited to, primary health care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth, and the postpartum period, and treatment of male partners for sexually transmitted infections, utilizing consultation, collaboration, or referral to appropriate levels of health care services, as indicated.

11. Authorizes permissible settings in which a CNM may practice, including the home, but only when the following conditions apply:

1. There is the absence of all of the following:

1. Any preexisting maternal disease or condition likely to complicate the pregnancy.

2. Disease arising from the pregnancy likely to cause significant maternal and/or fetal compromise.

3. Prior caesarean delivery.

2. There is a singleton fetus.

3. There is cephalic presentation at the onset of labor.

4. The gestational age of the fetus is greater than 370/7 weeks and less than 420/7 completed weeks of pregnancy at the onset of labor.

5. Labor is spontaneous or induced in an outpatient setting.

12. States that if a potential CNM client meets the conditions specified in clauses (b) – (e) above, but fails to meet the conditions specified in (a) and the woman still desires to be a client of the CNM, the CNM shall consult with a physician and surgeon trained in obstetrics and gynecology. A CNM may assist the woman in pregnancy and childbirth only if a physician and surgeon trained in obstetrics and gynecology is consulted and the physician and surgeon who performed the consultation determines that the risk factors presented by her disease or condition are not likely to significantly affect the course of pregnancy and childbirth.

13. States that the practice of nurse-midwifery within a health care system provides for consultation, collaboration, or referral as indicated by the health status of the patient and the resources and medical personnel available in the setting of care. It also emphasizes informed consent, preventive care, and early detection and referral of complications to physicians and surgeons. While practicing in a hospital setting, the certified nurse-midwife shall collaboratively care for women with more complex health needs.

14. Requires a CNM to be subject to all credentialing and quality standards held by the facility in which he or she practices. The peer review body shall include nurse-midwives as part of the peer review body that reviews nurse-midwives. The peer review body of that facility shall impose standards that assure quality and patient safety in their facility. The standards shall be approved by the relevant governing body unless found by a court to be arbitrary and capricious.

15. Requires any regulations promulgated by a state department that affect the scope of practice of a CNM to be developed in consultation with the Council.

16. Deletes references to standardized procedures and protocols and physician supervision for the furnishing of drugs and devices by CNMs, except that, in a nonhospital setting, a Schedule II controlled substance shall be furnished by a CNM only during labor and delivery and only after a consultation with a physician and surgeon.

17. Authorizes a CNM to furnish or order drugs or devices related to the provision of care rendered in a home, as specified.

18. Authorizes a CNM to directly procure supplies and devices, to order, obtain, and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice as a CNM and consistent with nurse-midwifery education preparation.

19. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second-degree lacerations of the perineum in a home, as specified.

20. States that a consultative relationship between a CNM and a physician and surgeon shall not, by itself, provide the basis for finding a physician and surgeon liable for any act or omission of the CNM.

21. Makes clarifying and technical amendments.

FISCAL EFFECT:

This bill has been keyed “fiscal” by Legislative Counsel. According to the Assembly Appropriations Committee analysis dated May 13, 2015, this bill will result in minor costs to the BRN Fund for advisory council meetings. The analysis notes that the potential impact on BRN enforcement costs resulting from the bill is unclear, but will likely be minor, as removing the requirement for supervision does not significantly change the practice of midwifery.

COMMENTS:

1. Purpose. This bill is sponsored by the California Nurse Midwives Association. According to the Author’s office, “Approximately 1,200 CNMs are licensed in California by the BRN to practice midwifery – the care of childbearing women during pregnancy, labor and birth, and during the postpartum period. While most states allow CNMs to practice independently, California is one of only six states that require physician supervision of CNMs.

“California law requires a CNM to practice under the supervision of a physician, but specifies that the supervision requirement shall not be construed to require the physical presence of the physician. Although the supervision requirement tethers CNMs to practice only where a physician can supervise, it does not consist of actual oversight of health care delivery, inspection or review of charts, co-signatures on prescriptions, direct care of the patient, or evaluation of CNM patients at any point during pregnancy or well-woman care. In communities without obstetricians/gynecologists, the supervision requirement limits access to care for women, even when a CNM is available to provide care.

“In 2013, the Legislature removed physician supervision of licensed midwives (LMs) (AB 1308, Bonilla, Chapter 665, Statutes of 2013). CNMs are required to have a higher level of education and training than LMs in order to qualify for licensure (licensed as a registered nurse and graduate of a Board-approved nurse-midwifery program), and yet are still subject to physician supervision to practice.

“AB 1306 allows CNMs to practice to the full extent of the education and training, without physician supervision. The bill keeps their existing scope of practice in place and aligns their education and practice requirements with national standards. In addition, the bill includes consumer protections to guard against kickbacks and self-referrals, as well as additional structure for CNMs serving patients in home and birth center settings.”

2. CNMs. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth, as well as immediate care for the newborn. Current law requires CNM be licensed as a registered nurse and graduate from an approved program in nurse-midwifery. There are 1,271 CNMs in California.

A CNM may furnish drugs and devices after certification that he or she has completed at least six months of physician and surgeon supervised experience in the furnishing of drugs and devices and a course in pharmacology. “Furnishing” is the ordering of a drug or device in accordance with standardized procedure or protocol.

Standardized procedures are defined as policies and protocols developed by a health facility or organized health care system, with input from administrators and health professionals, which establish parameters for medical care. Protocols are a part of standardized procedures and are designed to describe the steps of medical care for given patient situations. Protocols are developed in consultation with a supervising physician. “Supervision” requires telephonic availability but not the physical presence of the physician.

This bill would remove the requirements of physician supervision and largely remove the restrictions on the independent furnishing of drugs and devices by CNMs.

2. CNMs as Independent Practitioners. According to the U.S. Library of Medicine, CNMs are well positioned as independent primary care practitioners. “[CNMs] have improved primary health care services for women in rural and inner-city areas. The National Institute of Medicine has recommended that [CNMs] be given a larger role in delivering women's health care.

“Many studies over the past 20 to 30 years have shown that [CNMs] can manage most perinatal (including prenatal, delivery, and postpartum) care. They are also qualified to deliver most family planning and gynecological needs of women of all ages. Some may check and manage common adult illnesses, as well.”

In addition, a 2015 article in the peer-reviewed Journal of Midwifery & Women’s Health, “Midwives as Primary Care Providers for Women,” conclude that “Midwives certified by the American Midwifery Certification Board are prepared to provide primary care to women from menarche across the lifespan and to well newborns to 28 days using consultation, collaboration, and referral to other providers as needed.”

2. Ban on the Corporate Practice of Medicine (CPM). This bill subjects CNMs to the ban on CPM, which previously has only been applied to physicians. The corporate practice of medicine (CPM) is usually referred to in the context of a prohibition, banning hospitals from employing physicians. The ban on CPM evolved in the early 20^th century when mining companies had to hire physicians directly to provide care for their employees in remote areas. However, problems arose when physicians' loyalty to the mining companies conflicted with patients' needs. Eventually, physicians, courts, and legislatures prohibited CPM in an effort to preserve physicians' autonomy and improve patient care.

Over the years, various state and federal statutes have left the CPM prohibition substantially weakened and largely nonsensical. According to a 2007 report issued by the California Research Bureau, “California’s CPM doctrine has been defined largely through lawsuits and Attorney General opinions over decades, and then riddled by HMO and other legislation; its power and meaning are now inconsistent…. Although some non-profit clinics may employ physicians, California applies the CPM doctrine to most other entities. Non-profit associations may employ physicians under specific circumstances and non-profit corporations may employ physicians in clinics meeting specific requirements. Teaching hospitals may employ physicians, but other hospitals, including most public and non-profit hospitals, may not employ physicians.  Professional medical corporations are expressly permitted to engage in the practice of medicine, and may employ physicians. [However, t]hese medical corporations may operate on a for-profit basis, although the profit motive was one of the original rationales of the CPM prohibition.” Indeed, the greatest cost pressures typically come from health insurers, and not the facilities themselves.

The following entities may currently employ physicians:

• A clinic operated primarily of the purpose of medical education by a public or private nonprofit university medical school.

• A clinic operated by a nonprofit corporation as an entity organized and operated exclusively for scientific and charitable purposes.

• A narcotic treatment program.

• A hospital owned and operated by a health care district.

• A hospital owned and operated by a licensed charitable organization, that offers only pediatric subspecialty care, as specified.

California is one of only five remaining states that adhere to some form of the ban. The American Medical Association, historically the driving force behind the CPM prohibition, no longer views physician employment per se as a violation of medical ethics and has removed the doctrine from its ethical code.

5. The Changing Healthcare Employment Landscape. California’s ban on CPM is becoming a hindrance to efficiency and the state’s competitiveness in a rapidly changing healthcare environment. Extending an outdated ban on employment to an expanding and vital class of health care providers will not benefit consumers or the professionals themselves. According to a 2011 survey from the consulting firm Accenture:

“U.S. physicians continue to sell their private practices and seek employment with healthcare systems, according to a new survey from Accenture.  As physicians migrate from private practice to larger health systems, the new landscape will require healthcare information technology (IT), medical device manufacturers, pharmaceutical companies and payers to revise their business models and offerings.  At the same time, hospitals will need to determine how to retain and recruit the correct mix of physicians, especially in high-growth service lines, including cardiovascular care, orthopedics, cancer care and radiology.  Patients will increasingly move to large health systems, as opposed to the current trend of visiting doctors in private, small practice settings.

“The rate of independent physicians being employed by health systems will grow by an annual five percent over three years. By 2013, less than one-third of physicians are expected to remain truly independent. 

“’Health reform is challenging the entire system to deliver improved care through insight driven health,’ said Kristin Ficery, senior executive, Accenture Health.  ‘We see an increasing number of physicians leaving private practice to join hospital systems, which will force all stakeholders to revise and refine their business models, product offerings and service strategies.’ 

“According to the survey, physicians are increasingly attracted to the benefits offered by hospital-based employment opportunities.  These benefits include: 

• Relief from administrative responsibilities.

• Greater access to leading-edge healthcare IT tools, facilities and equipment.

• A more manageable work week.

• Stability in a business environment made uncertain by developments such as payment reforms.”

These realities are the same facing CNMs, who are currently employed by hospitals and other facilities. CNMs would be unable to continue to realize the benefits of employment should this measure pass.

5. Health Care Access. The potential impact of the ban on CPM for CNMs is not only on those currently employed; it will affect future employment opportunities that will be lost as the result of it.

The elimination of the physician supervision requirement for CNMs, standing on its own, would likely result in the increased employment by hospitals and clinics of CNMs, given their versatility: CNMs can provide a wide range of services in a variety of settings, and hospitals would no longer have to struggle to find physicians willing to supervise them. Particularly for rural hospitals and other areas where it is challenging to attract physicians, employing CNMs would be a desirable option for expanding hospitals’ and clinics’ ability to meet basic community needs.

5. California’s CPM Equality Argument. Supporters of the CPM ban argue that it is necessary for equity in the workforce to subject any profession that becomes independent of physician supervision to be subject to the same business constraints as physicians. This is not a valid argument because the professions are not on equal footing.

1. Physicians and CNMs have very different practice scopes. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care, including interconception care and family planning. The nurse - midwifery certificate also authorizes the CNM to attend cases of normal childbirth on his or her own responsibility, as well as immediate care for the newborn. CNM care includes preventative measures and the detection of abnormal conditions in mother and child, but CNMs cannot assist childbirth by any artificial, forcible, or mechanical means. CNMs are not authorized to perform surgery, although this bill will allow them to perform and repair episiotomies and first-degree and second-degree lacerations of the perineum in a home, as specified.

Obstetrician-gynecologists (OB/GYN) are physicians who possess special knowledge, skills and professional capability in the medical and surgical care of the female reproductive system and associated disorders. OB/GYNs are necessary for abnormal cases of pregnancy, advanced conditions, and surgeries. Resident education in obstetrics-gynecology must include four years of accredited, clinically-oriented graduate medical education, which must be focused on reproductive health care and ambulatory primary health care for women, including health maintenance, disease prevention, diagnosis, treatment, consultation, and referral.

There will always be a need for OB/GYNs, and while there will be some practice overlap, the professions are not, nor will they be according to the terms of this bill, interchangeable.

2. Physicians still have control of medical staffing decisions at hospitals and may not have incentives to hire physician extenders like CNMs.

Current law requires that hospitals have a dual structure – an administrative governing body, which oversees the hospital operations, and a medical staff, which provides medical services and is generally responsible for ensuring that its members provide appropriate medical care to patients at the hospital.

In order to practice at a hospital, a physician must be granted privileges by the medical staff. To the extent that CNMs may provide some overlapping functions with OB/GYNs, hospitals may prefer to hire some CNMs in addition to OB/GYNs to handle cases of normal childbirth and provision of primary care. Because this bill would revoke employment by hospitals by CNMs, CNMs would have to apply for staff privileges from physicians. Given the nature of their overlapping scopes, it is likely that medical staff would be reluctant to replace or supplement OB/GYNs with CNMs.

5. Additional Means of Protecting Medical Decision Making. In tandem with the exceptions made to the ban on CPM, California has enacted legislation sharply limiting actual and potential corporate control over physicians.

The Knox-Keene Act, which regulates health maintenance organizations (HMOs), subjects HMOs to the following requirements:

• Capitated payment agreements or shared-risk arrangements must not be tied to specific medical decisions.

• Health plans must furnish medical services in a manner providing continuity of care.

• Health plans must provide ready referral to other providers when good professional practice requires it.

• All services must be readily available, and to the extent feasible, readily accessible, to all enrollees.

• Health plans must assure that medical decisions are made by qualified medical providers, without influence of fiscal or administrative management.

Multiple sections in California statute and regulation ensure the primacy of an individual’s professional medical decision-making, including this broad statute contained in BPC § 501:

“It is the public policy of the State of California that a health care practitioner be encouraged to advocate for appropriate health care for his or her patients. For purposes of this section, ‘to advocate for appropriate health care’ means to appeal a payer’s decision to deny payment for a service pursuant to the reasonable grievance or appeal procedure established by a medical group, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer, or to protest a decision, policy, or practice that the health care practitioner, consistent with that degree of learning and skill ordinarily possessed by reputable health care practitioners with the same license or certification and practicing according to the applicable legal standard of care, reasonably believes impairs the health care practitioner’s ability to provide appropriate health care to his or her patients.”

These and similar provisions make the uneven doctrine of CPM largely unnecessary.

5. Arguments in Support. Writing in support of the bill, the California Association of Midwives, Maternal and Child Health Access (MCHA), Black Women for Wellness, the County of Santa Cruz Board of Supervisors, South Coast Midwifery & Women’s Healthcare, Inc., Beach Cities Midwifery & Women’s Health Care, Beachside Birth Center, the American Association of Birth Centers, AARP, the California Association of Nurse Anesthetists, Inland Midwife Service, and the Center on Reproductive Rights and Justice at the University of California, Berkley School of Law state, AB 1306 separates the practice of nurse-midwives from physician practice, creating an opportunity for expansion of women’s health care services within their current scope of practice.  These organizations state that “California is one of six remaining states to include physician supervision language, language which contradicts national and international standards.  AB 1306 will not change the high quality of care provided by nurse-midwives nor the way that nurse-midwives currently practice.  Removing state-mandated supervision would allow the nurse-midwife to partner collaboratively with physicians, expanding options beyond working as a physician’s employee.  AB 1306 would directly and positively affect the California health care system by providing for improved physician and nurse-midwife collaboration and greater innovation in health care delivery.”

The American College of Nurse-Midwives (ACNM) states, “California nurse-midwives are highly trained providers who earn graduate degrees and are trained in the disciplines of midwifery and nursing.  AB 1306 would require all nurse-midwives to pass a national certification examination to demonstrate mastery of ACNM’s core competencies, which meet or exceed national recommendations for midwifery care, as a condition of licensure.  Safe, quality health care can best be provided to women and their infants when policymakers permit CNMs to provide independent midwifery care within their scope of practice.”

The American Nurses Association/California, the California Association for Nurse Practitioners, the United Nurses Associations of California/Union of Health Care Professionals, and the California Nurse Midwife Association (CNMA) state that a CNM is an advanced practice nurse who is educated in Master’s Degree programs accredited by the American Commission on Midwifery Education through the US Department of Education and have a higher level of education and training than Licensed Midwives.  According to these organizations, “with the increasing number of Californians insured under Covered California and the Affordable Care Act, there is a growing shortage of providers to meet the demand for primary care services.  This bill untethers CNMs from physician supervision requirements to promote the expansion of primary health care access for thousands of women.  In addition, the bill eliminated barriers that physicians encounter from malpractice carriers that prohibit them from supervising CNMs due to fears of vicarious liability.”

5. Arguments in Opposition. The California Hospital Association, Ridgecrest Regional Hospital, Henry Mayo Newhall Hospital, San Gorgonio Memorial Hospital, San Benito Health Care District, Community Hospital of the Monterey Peninsula, Lompoc Valley Medical Center, Sutter Health, Sharp Healthcare, Watsonville Community Hospital, Natividad Medical Center, St. Helena Hospital Napa Valley, Mammoth Hospital, Coalinga Regional Medical Center, Ceders-Sinai, Lodi Health, El Camino Hospital, Adventist Health, and Loma Linda University Health state that their opposition is in response to the amendment that subjects CNMs to the ban on the corporate practice of medicine.  These organizations state, “This corporate practice ban would prevent CNMs from being employed by hospitals, professional corporations, and most other employers that would like to make CNMs available to their patient population.  The current ban in AB 1306 is more restrictive than provisions that exist for physicians.  This restriction is an unnecessary and unreasonable barrier for employment of CNMs and hinders access to care for California women.”

The Medical Board of California has taken an oppose unless amended position, stating, “This bill does not have the same clear guidance and restrictions on what types of patients that [CNMs] can accept and does not clearly delineate when a patient should be transferred to a physician or require a physician consult for higher risk patients.  Because this bill does not currently include parameters on independent CNM practice that would ensure consumer protection, the Board is opposed to this bill unless it is amended to address these concerns.”

5. Related Legislation This Year. SB 323 (Hernandez) of 2015, would authorize a nurse practitioner who holds a national certification to practice without physician supervision in specified settings. (Status: This bill is pending reconsideration in the Assembly Business and Professions Committee).

5. Prior Related Legislation. SB 1308 (Bonilla, Chapter 665, Statutes of 2013) authorized a midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing and receive reports that are necessary to his/her practice of midwifery and consistent with his/her scope of practice; expanded the disclosures required to be made by a midwife to a prospective client to include the specific procedures that warrant consultation with a physician and surgeon; and made other correcting and conforming changes. This bill included no CPM provisions.

SB 1950 (Figueroa, Chapter 1085, Statutes of 2002) required the MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery.

SB 1479 (Figueroa, Chapter 303, Statutes of 2000) expanded the disclosures required to be given by licensed midwives and also required midwives to register birth certificates for home births.

SB 350 (Killea, Chapter 1280, Statutes of 1993) enacted the Licensed Midwifery Practice Act of 1993 to provide for the licensing and regulation of non-nurse and non-physician assistant midwives by the MBC.

13. Suggested Amendments.

1. Strike references to the ban on CPM. The ban on CPM has outlived its usefulness and extending it to another class of healthcare professionals does not further the interests of California consumers or CNMs.

On page 14, strike lines 3 -34.

To provide additional protections against any corporate influence on medical judgment, insert the following on page 16, after line 21:

“(c) No entity in (b) shall interfere with, control, or otherwise direct the professional judgment of a certified nurse midwife in a manner prohibited by Section 510 or of any other provision of law.”

2. Remove references to the Medical Board of California. This bill deletes the authorization for the BRN to appoint a Nurse-Midwifery Committee, and instead requires the BRN to create and appoint a Nurse-Midwifery Advisory Council, at least two members of which would be qualified physicians appointed by the MBC, including an obstetrician that has experience working with nurse-midwives.

There is no precedent for DCA boards to have appointment authority over the composition of another board’s committee. BRN is capable of appointing physician members to the Council proposed in this bill and as such, language referencing a MBC appointment should be removed.

On page 13, line 36, strike “appointed by the Medical Board of California”

3. Amendments regarding home birth conditions. The following language would provide greater semantic clarity to the circumstances in which a CNM may attend a home birth.

On page 15, line 39, strike “likely” and add “with the potential”

On page 15, line 40, add “or birth” after pregnancy.

On page 16, line 1, after “from” add “or during,” strike “likely” and add “with the potential”

On page 16, line 2, strike “significant”

On page 16, line 6, after “is” add “equal to or” and replace “370/7” with “37/7”

On page 16, line 7, add a space between “42” and “0/7”

SUPPORT AND OPPOSITION:

Support:

California Nurse Midwives Association (Sponsor)

AARP

American Association of Birth Centers