The Nursing Practice Act provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing. The act authorizes a nurse practitioner to, among other things, furnish or order drugs or devices under specified circumstances subject to physician and surgeon supervision. The act prohibits a physician and surgeon from supervising more than 4 nurse practitioners at one time for purposes of furnishing drugs or devices.

Existing law authorizes the Board of Registered Nursing to issue a certificate to practice nurse-midwifery to any person licensed under the Nursing Practice Act that meets certain qualifications. Existing law authorizes a certified-nurse midwife certified nurse-midwife to, among other things, furnish or order drugs and devices under specified circumstances subject to physician and surgeon supervision. Existing law prohibits a physician and surgeon from supervising more than 4 certified-nurse midwives certified nurse-midwives at one time for purposes of furnishing or ordering drugs or devices.

The Physician Assistance Practice Act provides for the licensure and regulation of physician assistants by the Physician Assistant Board, which is within the jurisdiction of the Medical Board of California. The act authorizes a physician assistant licensed by the Physician Assistant Board to be eligible for employment or supervision by any physician and surgeon who is not subject to a disciplinary condition imposed by the Medical Board of California prohibiting that employment or supervision. The act prohibits a physician and surgeon from supervising more than 4 physician assistants at any one time, except as specified.

This bill would instead prohibit a physician and surgeon from supervising more than 18 12 nurse practitioners, certified-nurse midwives, certified nurse-midwives, and physician assistants at any one time. time, as specified.

The Nursing Practice Act provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing. The act authorizes a nurse practitioner to to, among other things, furnish or order drugs or devices under specified circumstances subject to physician and surgeon supervision. The act prohibits a physician and surgeon from supervising more than 4 nurse practitioners at one time for purposes of furnishing drugs or devices.

This bill would delete that cap on the number of nurse practitioners instead prohibit a physician and surgeon may supervise from supervising more than 18 nurse practitioners, certified-nurse midwives, and physician assistants at any one time for purposes of furnishing drugs or devices. time.

Existing law permits the Medical Board of California, the Dental Board of California, and the California State Board of Pharmacy to reproduce records that they have a duty to keep, if those records are destroyed by fire or public calamity.

This bill would make a nonsubstantive change to this provision.

 THIRD READING  

Bill No: AB 1560

Author:

:

Vote:

SENATE BUS., PROF. & ECON. DEV. COMMITTEE: 5-1, 7/10/17

AYES: Hill, Dodd, Galgiani, Hernandez, Wilk

NOES: Pan

NO VOTE RECORDED: Fuller, Glazer, Newman

ASSEMBLY FLOOR: 73-0, 5/15/17 - See last page for vote

SUBJECT:

SOURCE: California Association of Nurse Practitioners

DIGEST:

This bill allows a physician and surgeon to supervise up to 12 furnishing nurse practitioners, certified-nurse midwives, and physician assistants at any one time.

ANALYSIS:

Existing law:

1. Establishes the Board of Registered Nursing (BRN), within the Department of Consumer Affairs (DCA), and authorizes the BRN to license, certify and regulate nurses. (Business and Professions Code (BPC) §§ 2701; 2708.1)
2. Requires physician and surgeon supervision for nurse practitioners (NPs) who furnish drugs or devices, and limits supervision to four NPs at one time. (BPC § 2836.1 (e))
3. Defines “furnishing” as the ordering of a drug or device in accordance with standardized procedures or protocols (SPP) or transmitting an order of a supervising physician and surgeon. (BPC § 2836.1(h))
4. 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))
5. Authorizes a physician and surgeon to supervise no more than four CNMs at one time. (BPC § 2746.51 (a)(4))
6. Requires that the physician and surgeon supervision is not construed to require the physical presence of the physician, but does include collaboration to create the SPP, approval of the SPP and availability of the physician and surgeon to be contacted via telephone at the time of the patient examination by the NP and CNM. (BPC §§ 2836.1(d); 2746.51 (a)(4))
7. Establishes the Physician Assistant Board within DCA to administer the Physician Assistant Practice Act. (BPC §§ 3504; 3509)
8. Authorizes a physician assistant (PA) to perform those medical services as set forth by the regulations adopted by the Physician Assistant Board when the services are rendered under the supervision of a licensed physician and surgeon who is not subject to a disciplinary condition prohibiting that supervision or prohibiting the employment of a PA. (BPC § 3502 (a))
9. Requires the supervising physician and surgeon to be physically available to the PA for consultation when that assistance is rendered. (BPC § 3502 (b)(2))
10. Authorizes a physician and surgeon to supervise up to four PAs at any one time, except during war or times of emergency. (BPC §§ 3516 (b), 3502.5)

This bill authorizes a physician and surgeon to supervise up to, but no more than, a total of 12 furnishing NPs, CNMs, and PAs at any one time.

Background

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.

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 an SPP. There are 950 furnishing CNMs in California.

An NP is registered nurse who possesses additional preparation and skills in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary health care, and who has completed a NP program that conforms to BRN standards. NP programs are required to include 12 semester units or 18 quarter units of clinical practice (three hours of clinical practice each week equals one unit). NPs are required to have a Master’s degree, and many further pursue a doctorate in nursing. NPs may furnish dangerous drugs and devices pursuant to an SPP. There are currently 18,101 furnishing NPs licensed in California.

A PA performs many of the same diagnostic, preventative and health maintenance services as a physician, but PAs are limited in practice to those duties delegated by a supervising physician.

A PA must attend a specialized medical training program associated with a medical school that includes classroom studies and clinical experience. An academic degree and/or certificate is awarded upon graduation. Many PAs already have two- or four-year academic degrees before entering a PA training program. Most PA training programs require prior health care experience.

There are 10,764 California PA licensees.

Current law authorizes physicians and surgeons to supervise up to four furnishing NPs, four CNMs, and four PAs at any one time. This bill allows a physician and surgeon to supervise a total of 12 of any combination of these providers at a single time.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

SUPPORT: (Verified 7/11/17)

California Association for Nurse Practitioners (source)

Association of California Healthcare Districts

Bay Area Council

California Academy of Physician Assistants

California Council of Community Behavioral Health Agencies

California Health Advocates

OPPOSITION: (Verified 7/11/17)

California Chapter of the American College of Cardiology

Union of American Physicians and Dentists/AFSCME-Local 206

ARGUMENTS IN SUPPORT: According to the California Association for Nurse Practitioners, California is facing an ever-worsening issue of inadequate healthcare access that NPs are well suited to aide. They state that California’s medically underserved areas (MUAs) contain the populations most vulnerable to harm caused by inadequate healthcare access. Many NPs work in MUAs throughout California, putting them in a strategic position to make an especially positive impact on the state’s current and future healthcare access issues.

Supporters cite a University of California, San Francisco, Healthforce Center study, California’s Primary Care Workforce: Current Supply, Characteristics, and Pipeline of Trainees, 2017, which concluded that the NP workforce is growing at a rate 75 percent faster than that of California’s physician workforce. In addition to this finding, The Department of Healthcare Services has estimated that Medi-Cal enrollment for 2017-18 will increase to 14.3 million Californians from 13.4 million enrolled Californians from 2015-16. As a result, there are many clinic systems in California that are comprised of several different sites, yet contain only one medical director on staff. Consequently, the number of NPs who can care for patients is critically limited in these instances; which would be directly and instantly remedied by the implementation of AB 1560, making this legislation a measured and reasonable response to this pervasive and systemic issue.

The Bay Area Council writes in support, citing the 2014 report by the Bay Area Council Economic Institute, Full Practice Authority for Nurse Practitioner Increases Access and Controls Cost. According to the report, full effective use of NPs would result in a nearly 25 percent increase in California practitioners. Such a dramatic increase in number of practioners within the state would directly result in two million more preventative healthcare visits per year, which would consequently save the state a total of $1.8 billion dollars in 10 years’ time.

ARGUMENTS IN OPPOSITION: The Union of American Physicians and Dentists/AFSCME-Local 206 is concerned that there will be insufficient supervision with the proposed ratios.

ASSEMBLY FLOOR: 73-0, 5/15/17

AYES: Acosta, Aguiar-Curry, Arambula, Baker, Berman, Bloom, Bocanegra, Bonta, Brough, Burke, Caballero, Calderon, Cervantes, Chau, Chávez, Chen, Chiu, Chu, Cooley, Cooper, Cunningham, Dababneh, Daly, Eggman, Flora, Fong, Frazier, Friedman, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gomez, Gonzalez Fletcher, Gray, Grayson, Harper, Irwin, Jones-Sawyer, Kalra, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk, Quirk-Silva, Reyes, Ridley-Thomas, Rubio, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Voepel, Waldron, Weber, Wood, Rendon

NO VOTE RECORDED: Travis Allen, Bigelow, Choi, Dahle, Holden, Melendez, Rodriguez

Prepared by:

7/12/17 15:32:15

**** END ****

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2017 - 2018 Regular

Bill No: AB 1560 Hearing Date: July 10, 2017

Subject: Nurse practitioners: certified nurse-midwives: physician assistants: physician and surgeon supervision

SUMMARY:

Allows a physician and surgeon to supervise up to 12 furnishing nurse practitioners, certified-nurse midwives, and physician assistants at any one time.

Existing law:

1. Establishes the Board of Registered Nursing (BRN), within the Department of Consumer Affairs (DCA), and authorizes the BRN to license, certify and regulate nurses. (Business and Professions Code (BPC) §§ 2701; 2708.1)
2. Requires physician and surgeon supervision for NPs who furnish drugs or devices, and limits supervision to four NPs at one time. (BPC § 2836.1 (e))
3. Defines “furnishing” as the ordering of a drug or device in accordance with standardized procedures or protocols (SPP) or transmitting an order of a supervising physician and surgeon. (BPC § 2836.1(h))
4. 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))
5. Authorizes a physician and surgeon to supervise no more than four CNMs at one time. (BPC § 2746.51 (a)(4))
6. Requires that the physician and surgeon supervision is not construed to require the physical presence of the physician, but does include collaboration to create the SPP, approval of the SPP and availability of the physician and surgeon to be contacted via telephone at the time of the patient examination by the NP and CNM. (BPC §§ 2836.1(d); 2746.51 (a)(4))
7. Establishes the Physician Assistant Board within DCA to administer the Physician Assistant Practice Act. (BPC §§ 3504; 3509)
8. Authorizes a physician assistant (PA) to perform those medical services as set forth by the regulations adopted by the Physician Assistant Board when the services are rendered under the supervision of a licensed physician and surgeon who is not subject to a disciplinary condition prohibiting that supervision or prohibiting the employment of a physician assistant. (BPC § 3502 (a))
9. Requires the supervising physician and surgeon to be physically available to the PA for consultation when that assistance is rendered. (BPC § 3502 (b)(2))
10. Authorizes a physician and surgeon to supervise up to four PAs at any one time, except during war or times of emergency. (BPC §§ 3516 (b), 3502.5)

This bill authorizes a physician and surgeon to supervise up to, but no more than, a total of 12 furnishing NPs, CNMs, and PAs at any one time.

FISCAL EFFECT:

This bill is not keyed fiscal by the Legislative Counsel.

COMMENTS:

1. Purpose. This bill is sponsored by the California Association of Nurse Practioners. According to the Author’s office, “In many clinic systems where there are multiple clinic sites but only one medical director on staff, [current law] severely limits the number of NPs who can provide patient care. Additionally, as California law does not require physical or in-person supervision by a physician [for NPs or CNMs], this requirement is an antiquated barrier to care.”
2. Background. 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.

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 a SPP. There are 950 furnishing CNMs in California.

A NP is registered nurse who possesses additional preparation and skills in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary health care, and who has completed a NP program that conforms to BRN standards. NP programs are required to include 12 semester units or 18 quarter units of clinical practice (three hours of clinical practice each week equals one unit). NPs are required to have a Masters degree, and many further pursue a doctorate in nursing. NPs may furnish dangerous drugs and devices pursuant to a SPP. There are currently 18,101 furnishing NPs licensed in CA.

A PA performs many of the same diagnostic, preventative and health maintenance services as a physician, but PAs are limited in practice to those duties delegated by a supervising physician. These services may include, but are not limited to, the following:

• Taking health histories.
• Performing physical examinations.
• Ordering X-rays and laboratory tests.
• Ordering respiratory, occupational, or physical therapy treatments.
• Performing routine diagnostic tests.
• Establishing diagnoses.
• Treating and managing patient health problems.
• Administering immunizations and injections.
• Instructing and counseling patients.
• Providing continuing care to patients in the home, hospital, or extended care facility.
• Providing referrals within the health care system.
• Performing minor surgery.
• Providing preventative health care services.
• Acting as first or second assistants during surgery.
• Responding to life-threatening emergencies.

A PA must attend a specialized medical training program associated with a medical school that includes classroom studies and clinical experience. An academic degree and/or certificate is awarded upon graduation. Many PAs already have two- or four-year academic degrees before entering a PA training program. Most PA training programs require prior health care experience.

There are 10,764 California PA licensees.

Current law authorizes physicians and surgeons to supervise up to four furnishing NPs, four CNMs, and four PAs at any one time. This bill would allow a physician and surgeon to supervise a total of 12 of any combination of these providers at a single time.

1. Arguments in Support. According to the Sponsor, California Association for Nurse Practioners, California is facing an ever-worsening issue of inadequate healthcare access that NPs are well suited to aide.

California’s medically underserved areas (MUAs) contain the populations most vulnerable to harm caused by inadequate healthcare access. Many NPs work in MUAs throughout California, putting them in a strategic position to make an especially positive impact on the state’s current and future healthcare access issues.

Furthermore, the UCSF Healthforce Center conducted a study, California’s Primary Care Workforce: Current Supply, Characteristics, and Pipeline of Trainees, 2017, which concluded that the NP workforce is growing at a rate 75 percent faster than that of California’s physician workforce. In addition to this finding, The Department of Healthcare Services has estimated that Medi-Cal enrollment for 2017-18 will increase to 14.3 million Californians from 13.4 million enrolled Californians from 2015-16. As a result, there are many clinic systems in California that are comprised of several different sites, yet contain only one medical director on staff. Consequently, the number of NPs who can care for patients is critically limited in these instances; which would be directly and instantly remedied by the implementation of AB 1560, making this legislation a measured and reasonable response to this pervasive and systemic issue.

The Bay Area Council writes in support, citing the 2014 report by the Bay

Area Council Economic Institute, Full Practice Authority for Nurse Practitioner Increases Access and Controls Cost. According to the report, full effective use of NPs would result in a nearly 25 percent increase in California practitioners. Such a dramatic increase in number of practioners within the state would directly result in two million more preventative healthcare visits per year, which would consequently save the state a total of $1.8 billion dollars in 10 years’ time.

1. Arguments in Opposition. The Union of American Physicians and Dentists (UAPD)/AFSCME-Local 206 is concerned that there will be insufficient supervision with the ratios.
2. Related Legislation. AB 1612 (Burke) removes physician supervision for CNMs. (Status: This bill was held in the Assembly Committee on Appropriations.)
3. Prior Related Legislation. SB 1306 (Burke) of 2016 would have removed physician supervision for certified nurse midwives. (Status: This bill failed passage on the Assembly Floor.)

SB 323 (Hernandez) of 2015 would have authorized a nurse practitioner who holds a national certification to practice without physician supervision in specified settings. (Status: This bill was referred to the Assembly Committee on Business and Professions, but not heard at the request of the author.)

SB 491 (Hernandez) of 2013, would have permited a NP to practice independently after a period of physician supervision if the NP has national certification and liability insurance, and authorizes the NP to perform various other specified tasks related to the practice of nursing without protocols. (Status: This bill was held in the Assembly Appropriations Committee.)

SUPPORT AND OPPOSITION:

Support:

California Association for Nurse Practioners (Sponsor)

Association of California Healthcare Districts

Bay Area Council

California Academy of PAs

California Council of Community Behavioral Health Agencies

CaliforniaHealth Advocates

Opposition:

California Chapter of the American College of Cardiology

California Society of Plastic Surgeons

Union of American Physicians and Dentists

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1560

Author:(Friedman)

As Amended Ver:May 4, 2017

Majority vote

SUMMARY: Deletes the maximum number of nurse practitioners a physician and surgeon may supervise for purposes of furnishing or ordering drugs or devices under standardized procedures or protocols. Specifically, this bill:

Removes the requirement that a physician and surgeon shall supervise no more than four nurse practitioners at one time for purposes of furnishing or ordering drugs or devices.

FISCAL EFFECT: None

COMMENTS:

Purpose. This bill is sponsored by the California Association of Nurse Practitioners. According to the author, "AB 1560 eliminates the existing 1:4 supervision ratio for physicians and nurse practitioners with prescribing duties. Instead of complying with an arbitrary ratio that can limit a network of clinics' ability to provide care, physicians will be able to determine the appropriate level of supervision for their practice and/or care setting. This will increase essential healthcare availability, decrease costs, and improve efficiency, while maintaining patient quality and choice. With all of the challenges associated with our healthcare system, it is essential to ensure that all Californians have access to quality primary care."

Background. Estimates obtained from the Council on Graduate Medical Education (CGME) indicate that the number of primary care physicians actively practicing in California is far below the state's need. The distribution of these primary care physicians is also poor. In 2008, there were 69,460 actively practicing primary care physicians in California, of which only 35 % reported they actually practiced primary care. This equates to 63 active primary care physicians per 100,000 persons. However, according to the CGME, 60 to 80 primary care physicians are needed per 100,000 persons in order to adequately meet the needs of the population. When the same metric is applied regionally, only 16 of California's 58 counties fall within the needed supply range for primary care physicians. In other words, less than one third of Californians live in a community where they have access to adequate health care services. In addition, a 2013 study in Health Affairs found that the proportion of United States (U.S.) medical students choosing careers in primary care dropped from 60 % in 1998 to approximately 25 % in 2013. Some purport that the way to address this shortage is by expanding the role of nurse practitioners (NPs) and other allied healthcare professionals to provide primary care services.

NP Education and Training. There are over 19,000 NPs licensed by the Board of Registered Nursing (BRN). The BRN sets the educational standards for NP certification. A NP is a registered nurse (RN) who has earned a bachelors and postgraduate nursing degree such as a Master's or Doctorate degree. NPs possess advanced skill in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary health care, which occurs when a consumer makes contact with a health care provider who assumes responsibility and accountability for the continuity of health care regardless of the presence or absence of disease (Title 16 California Code of Regulations (CCR) Sections 1480(b); 1484). Examples of primary health care include: physical and mental assessment, disease prevention and restorative measures, performance of skin tests and immunization techniques, withdrawal of blood, and authority to initiate emergency procedures. Data from the Employment Developmental Department indicates that hospitals are the main employer of NPs.

NP Scope and SPPs. A NP does not have an additional scope of practice beyond the RNs scope and must rely on standardized procedures and protocols (SPPs) for authorization to perform medical functions which overlap with those conducted by a physician (16 CCR Section 1485). According to the BRN, "SPPs are the legal mechanism for registered nurses, nurse practitioners to perform functions which would otherwise be considered the practice of medicine." Examples of these functions include: diagnosing mental and physical conditions, using drugs in or upon human beings, severing or penetrating the tissue of human beings, and using other methods in the treatment of diseases, injuries, deformities or other physical or mental conditions.

SPPs must be developed collaboratively with NPs, physicians, and administration of the organized health care system where they will be utilized. Because of this interdisciplinary collaboration, there is accountability on several levels for the activities to be performed by the NP. Importantly, a NP must provide the organized health system with satisfactory evidence that the NP meets the experience, training and/or education requirements to perform the functions. If a NP undertakes a procedure without the competence to do so, such an act may constitute gross negligence and be subject to discipline by the BRN.

Full Practice Authority. The American Association of Nurse Practitioners defines full practice authority as, "The collection of state practice and licensure laws that allow for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments, including prescribe medications, under the exclusive licensure authority of the state board of nursing." Under full practice authority, NPs are still required to meet educational and practice requirements for licensure, maintain national certification and remain accountable to the public and the state board of nursing.

Over the past 50 years, several organizations and research institutions have examined the feasibility of full practice authority for NPs. The Institute of Medicine (IOM) of the National Academies of Science released a 2010 report titled, The Future of Nursing: Leading Change, Advancing Health, in which the IOM wrote, "Remove scope of practice barriers. [NPs] should be able to practice to the full extent of their education and training…the current conflicts between what [NPs] can do based on their education and training and what they may do according to state federal regulations must be resolved so that they are better able to provide seamless, affordable and quality care." In a 2011 report, the IOM noted that three to 14 NPs can be educated for the same cost as one physician. A report by the National Governor's Association, The Role of Nurse Practitioners in Meeting Increased Demand for Primary Care noted, "In light of research evidence, states might consider changing scope of practice restrictions and assuring adequate reimbursement for their services as a way of encouraging and incentivizing greater NP involvement in the provision of primary health care."

Despite these arguments, some physician groups, including the American Medical Association (AMA) assert that granting full practice authority for NPs may put patients' health at risk. They cite the difference in educational attainment noting that physicians are required to complete four years of medical school plus three years of residency compared to the four years of nursing school and two years of graduate school required for NPs. The President of the AMA, Dr. Robert M. Wah, was quoted in a 2015 New York Times article, "[…nurses practicing independently] would further compartmentalize and fragment health care [which should be] collaborative with the physician at the head of the team."

Ratios. Current law indicates that physicians may supervise no more than four physician assistants for any purpose, except during emergencies, and four nurse practitioners or four certified nurse midwives for purposes of furnishing drugs. These practitioners work under direct supervision or indirect supervision. In the case of indirect supervision, oftentimes, SPPs or delegated service agreements (DSAs) are drafted. The SPPs and DSAs are written agreements that govern the activities that practitioners can engage in while under indirect supervision of a physician.

Other States. Many other states have recognized the ability for NPs to play a more efficient role in the delivery of health care services and have updated their practice acts to align with NPs training and education. For example, at least 20 states have adopted full practice authority for NPs. The AMA contends that many of the NPs that practice independently in these states do not deliver care to underserved areas.

Please see the policy committee analysis for a full discussion of this bill.

Analysis Prepared by: Le Ondra Clark Harvey, Ph.D. / B. & P. /(906) 319-3301 FN: 0000274

Date of Hearing: May 2, 2017

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Evan Low, Chair

ABPCA Bill Id:AB 1560

Author:(Friedman) – As Amended Ver:March 21, 2017

SUBJECT: Nurse practitioners: supervision.

SUMMARY: Deletes the maximum number of nurse practitioners a physician and surgeon may supervise for purposes of furnishing or ordering drugs or devices under standardized procedures or protocols.

EXISTING LAW:

1. Establishes the Board of Registered Nursing (BRN), within the Department of Consumer Affairs (DCA), and authorizes the BRN to license, certify and regulate nurses. (Business and Professions Code (BPC) §§ 2701; 2708.1)
2. Clarifies that there are various and conflicting definitions of “nurse practitioner” and “registered nurse” (RN) that are used within California and finds the public interest is served by determining the legitimate and consistent use of the title “nurse practitioner” established by the BRN. (BPC § 2834)
3. Requires applicants for licensure as a NP to meet specified educational requirements including: (BPC § 2835.5)
   1. Holding a valid and active registered nursing license;
   2. Possessing a Master’s degree in nursing, a Master’s degree in a clinical field related to nursing, or a graduate degree in nursing; and,
   3. Completing a NP program authorized by the BRN.
4. Recognizes the existence of overlapping functions between physicians and NPs and permits additional sharing of functions within organized health care systems that provide for collaboration between physicians and NPs. (BPC § 2725; Health and Safety Code (HSC) § 1250)
5. Defines "health facility" as any facility, place, or building that is organized, maintained and operated for the diagnosis, care, prevention, and treatment of physical or mental human illness including convalescence, rehabilitation, care during and after pregnancy, or for any one or more of these purposes, for which one or more persons are admitted for a 24-hour stay or longer. (HSC § 1250)
6. Authorizes a NP to do the following, pursuant to standardized procedures and protocols (SPPs) created by a physician or surgeon, or in consultation with a physician or surgeon: (BPC § 2835.7)
   1. Order durable medical equipment;
   2. Certify disability claims; and,
   3. Approve, sign, modify or add information to a plan of treatment for individuals receiving home health services.
7. Defines “furnishing” as the ordering of a drug or device in accordance with SPPs or transmitting an order of a supervising physician and surgeon. (BPC § 2836.1(h))
8. Defines “drug order” or “order” as an order for medication which is dispensed to or for an ultimate user and issued by a NP. (BPC § 2836.1(i))
9. Specifies that a NP is not prohibited from furnishing or ordering drugs or devices if the following apply:
   1. The furnishing and ordering of drugs or devices by NPs is done in accordance with the SPP developed by the supervising physician and surgeon, NP and the facility administrator or designee and shall be consistent with the NPs educational preparation and/or established and maintained clinical competency. (BPC § 2836.1(a))
   2. The NP is functioning pursuant to a SPP. The SPP shall be developed and approved by the supervising physician and surgeon, the nurse practitioner, and the facility administrator or the designee. (BPC § 2836.1(b))
   3. Specifies that the SPP must list which NPs may furnish or order drugs or devices. (BPC § 2836.1(c)(1))
   4. Indicates that for Schedule II controlled substances, the SPP must address the diagnosis of the illness, injury or condition for which the controlled substance is to be furnished. (BPC § 2836.1(c)(2))
   5. Indicates a physician and surgeon may determine the extent of supervision necessary in the furnishing or ordering or drugs and devices. (BPC § 2836.1(g)(2))
   6. Permits a NP to furnish or order Schedule II through Schedule V controlled substances and specifies that a copy of the SPP shall be provided upon request to any licensed pharmacist when there is uncertainty about the NP furnishing the order. (BPC § 2836.1(f)(1)(2); HSC §§ 11000; 11055; 11056).
   7. Requires that a NP has completed a course in pharmacology covering the drugs or devices to be furnished or ordered. (BPC § 2836.1(g)(1))
   8. States that a NP must hold an active furnishing number, register with the United States Drug Enforcement Administration and take a continuing education course in Schedule II controlled substances. (BPC § 2836.1(f)(3))
   9. Specifies that the physician and surgeon supervision shall not be construed to require the physical presence of the physician, but does include collaboration to create the SPP, approval of the SPP and availability of the physician and surgeon to be contacted via telephone at the time of the patient examination by the NP. (BPC § 2836.1(d))
   10. Limits the physician and surgeon to supervise no more than four NPs at one time.
       (BPC § 2836.1(e))
10. Authorizes the BRN to issue a number to NPs who dispense drugs or devices and revoke, suspend or deny issuance of the number for incompetence or gross negligence.
    (BPC § 2836.2)

THIS BILL:

1. Removes the requirement that a physician and surgeon shall supervise no more than four nurse practitioners at one time for purposes of furnishing or ordering drugs or devices.

FISCAL EFFECT: None. This bill is keyed non-fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the California Association of Nurse Practitioners. According to the author, “AB 1560 eliminates the existing 1:4 supervision ratio for physicians and nurse practitioners with prescribing duties. Instead of complying with an arbitrary ratio that can limit a network of clinics’ ability to provide care, physicians will be able to determine the appropriate level of supervision for their practice and/or care setting. This will increase essential healthcare availability, decrease costs, and improve efficiency, while maintaining patient quality and choice. With all of the challenges associated with our healthcare system, it is essential to ensure that all Californians have access to quality primary care.”

Background. Estimates obtained from the Council on Graduate Medical Education (CGME) indicate that the number of primary care physicians actively practicing in California is far below the state's need. The distribution of these primary care physicians is also poor. In 2008, there were 69,460 actively practicing primary care physicians in California, of which only 35 percent reported they actually practiced primary care. This equates to 63 active primary care physicians per 100,000 persons. However, according to the CGME, 60 to 80 primary care physicians are needed per 100,000 persons in order to adequately meet the needs of the population. When the same metric is applied regionally, only 16 of California’s 58 counties fall within the needed supply range for primary care physicians. In other words, less than one third of Californians live in a community where they have access to adequate health care services. In addition, a 2013 study in Health Affairs found that the proportion of U.S. medical students choosing careers in primary care dropped from 60 percent in 1998 to approximately 25 percent in 2013. Some purport that the way to address this shortage is by expanding the role of NPs and other allied healthcare professionals to provide primary care services.

NP Education and Training. There are over 19,000 NPs licensed by the BRN. The BRN sets the educational standards for NP certification. A NP is a registered nurse (RN) who has earned a bachelors and postgraduate nursing degree such as a Master’s or Doctorate degree. NPs possess advanced skill in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary health care, which occurs when a consumer makes contact with a health care provider who assumes responsibility and accountability for the continuity of health care regardless of the presence or absence of disease (Title 16 California Code of Regulations (CCR) §§ 1480(b); 1484). Examples of primary health care include: physical and mental assessment, disease prevention and restorative measures, performance of skin tests and immunization techniques, withdrawal of blood, and authority to initiate emergency procedures. Data from the Employment Developmental Department indicates that hospitals are the main employer of NPs.

NP Scope and SPPs. A NP does not have an additional scope of practice beyond the RNs scope and must rely on SPPs for authorization to perform medical functions which overlap with those conducted by a physician (16 CCR § 1485). According to the BRN, “SPPs are the legal mechanism for registered nurses, nurse practitioners to perform functions which would otherwise be considered the practice of medicine.” Examples of these functions include: diagnosing mental and physical conditions, using drugs in or upon human beings, severing or penetrating the tissue of human beings, and using other methods in the treatment of diseases, injuries, deformities or other physical or mental conditions.

SPPs must be developed collaboratively with NPs, physicians, and administration of the organized health care system where they will be utilized. Because of this interdisciplinary collaboration, there is accountability on several levels for the activities to be performed by the NP. Importantly, a NP must provide the organized health system with satisfactory evidence that the NP meets the experience, training and/or education requirements to perform the functions. If a NP undertakes a procedure without the competence to do so, such an act may constitute gross negligence and be subject to discipline by the BRN.

The BRN and the Medical Board of California (MBC) jointly promulgated the following guidelines for SPPs: (BRN, 16 CCR § 1474; MBC, 16 CCR § 1379)

“SPPs shall include a written description of the method used in developing and approving them and any revision thereof. Each SPP shall:

1) Be in writing, dated and signed by the organized health care system personnel authorized to approve it.

2) Specify which SPP functions registered nurses may perform and under what circumstances.

3) State any specific requirements which are to be followed by NPs in performing particular SPP functions.

4) Specify any experience, training, and/or education requirements for performance of SPP functions.

5) Establish a method for initial and continuing evaluation of the competence of those NPs authorized to perform SPP functions.

6) Provide for a method of maintaining a written record of those persons authorized to perform SPP functions.

7) Specify the scope of supervision required for performance of SPP functions, for example, telephone contact with the physician.

8) Set forth any specialized circumstances under which the NP is to immediately communicate with a patient's physician concerning the patient's condition.

9) State the limitations on settings, if any, in which SPP functions may be performed.

10) Specify patient record-keeping requirements.

11) Provide for a method of periodic review of the SPP.”

Nurse-Managed Health Clinics. Nurse-managed health clinics, of which many are Federally Qualified Heath Centers (FQHC) and independent non-profit clinics, are safety net clinics that provide primary care, health promotion, and disease prevention services to patients who are least likely to receive ongoing health care. Unlike other FQHC and independent non-profits, these clinics are solely operated by NPs. The Patient Protections and Affordable Care Act (ACA) defines a nurse-managed health clinic as, “…a nurse practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent non-profit health or social services agency.” (42 U.S.C. § 330A–1 (2010))

According to the National Nursing Centers Consortium, nurse-managed health clinics have doubled in their presence since 2013. To date, there are over 500 nurse-managed health clinics most of which are located in the East Coast. A small percentage of these have been chosen for funding through a federal expansion initiative. One such clinic, GLIDE Health Services, is a FQHC located in San Francisco, California and provides primary and urgent care, preventative services and psychiatric treatment to an urban population.

• Physician Supervision. In many of the nurse-managed health clinics, the physician to NP supervision relationship is quite flexible. A supervising physician may be present for a very limited amount of time to perform perfunctory tasks such as signing off on equipment orders, and reviewing and signing medical records. The physician may also elect to make himself/herself available for telephonic consult. For example, at GLIDE, the supervising physician is physically on site 1-2 days a week to sign off on orders such as wheel chairs, walkers and commodes and review medications that have been prescribed and furnished by NPs. According to Patricia Dennehy, a NP and director of GLIDE, “Though we value our MD colleagues and consult with them for complex care issues, currently there are administrative barriers to care delivery and access that are not practical.”
• Clinical Training Sites. In addition to providing care to patients, nurse-managed health clinics also play an important role in health professions education. More than 85 of the nation's leading nursing schools operate nurse-managed health clinics that serve as clinical education and practice sites for nursing students and faculty. Many, such as GLIDE, have partnerships with other academic programs and provide learning opportunities for medical, pharmacy, social work, public health, and other students.

Full Practice Authority. The American Association of Nurse Practitioners defines full practice authority as, “The collection of state practice and licensure laws that allow for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments, including prescribe medications, under the exclusive licensure authority of the state board of nursing.” Under full practice authority, NPs are still required to meet educational and practice requirements for licensure, maintain national certification and remain accountable to the public and the state board of nursing.

Over the past 50 years, several organizations and research institutions have examined the feasibility of full practice authority for NPs. The Institute of Medicine (IOM) of the National Academies of Science released a 2010 report titled, The Future of Nursing: Leading Change, Advancing Health, in which the IOM wrote, “Remove scope of practice barriers. [NPs] should be able to practice to the full extent of their education and training…the current conflicts between what [NPs] can do based on their education and training and what they may do according to state federal regulations must be resolved so that they are better able to provide seamless, affordable and quality care.” In a 2011 report, the IOM noted that three to 14 NPs can be educated for the same cost as one physician. A report by the National Governor’s Association, The Role of Nurse Practitioners in Meeting Increased Demand for Primary Care noted, “In light of research evidence, states might consider changing scope of practice restrictions and assuring adequate reimbursement for their services as a way of encouraging and incentivizing greater NP involvement in the provision of primary health care.”

Despite these arguments, some physician groups, including the American Medical Association (AMA) assert that granting full practice authority for NPs may put patients’ health at risk. They cite the difference in educational attainment noting that physicians are required to complete four years of medical school plus three years of residency compared to the four years of nursing school and two years of graduate school required for NPs. The President of the AMA, Dr. Robert M. Wah, was quoted in a 2015 New York Times article, “[…nurses practicing independently] would further compartmentalize and fragment health care [which should be] collaborative with the physician at the head of the team.”

Financial Implications. Over the past 40 years, there have been a number of studies on the cost-effectiveness of NP practice. Results show NPs provide equivalent or improved medical care at a lower cost than their physician counterparts (citation). After insurance reform in Massachusetts, the state demonstrated that they could gain a cost savings of $4.2 to $8.4 billion, over a 10 year period, from the increased use of NPs (Eibner, E. et al. 2009, Controlling Health Care Spending in Massachusetts: An Analysis of Options. RAND Health).

Though the ACA encourages the creation of nurse-managed practices, by requiring insurers to pay NPs the same rates paid to physicians for identical services rendered, Medicare will not provide equal reimbursement. Presently, Medicare pays NPs 85 percent of the physician rate for the same services. The Medicare Payment Advisory Commission, the federal agency that advises Congress on Medicare issues, found that there was no analytical foundation for this difference. Despite this fact, revising payment methodology would require Congress to change the Medicare law. A report by the IOM titled “The Future of Nursing, Leading Change, Advancing Health,” recommended that the Medicare program be expanded to include coverage of advanced practice registered nurse services just as physician services are covered. The report also recommended that Medicaid reimbursement rates for primary care physicians be extended to advanced practice registered nurses providing similar primary care services.

Additionally, health insurance plans have significant discretion to determine what services they cover and which providers they recognize. Not all plans cover NPs. Further, many managed care plans require enrollees to designate a primary care provider but do not always recognize NPs. A 2009 survey conducted by the National Nursing Centers Consortium found that nearly half of the major managed care organizations did not credential NPs as primary care providers (www.healthaffairs.org/healthpolicybriefs/brief.php). If NPs were granted full practice authority, efforts may need to be undertaken in order for NPs to be recognized as primary care providers by insurance companies.

Ratios. Current law indicates that physicians may supervise no more than four physician assistants for any purpose, except during emergencies, and four nurse practitioners or four certified nurse midwives for purposes of furnishing drugs. These practitioners work under direct supervision or indirect supervision. In the case of indirect supervision, oftentimes, SPPs or delegated service agreements (DSAs) are drafted. The SPPs and DSAs are written agreements that govern the activities that practitioners can engage in while under indirect supervision of a physician.

DSAs are specific to physician assistants. They are detailed agreements between a physician and the physician assistant that delegate certain tasks and authority to perform procedures to physician assistants. DSAs include patient case reviews and other types of meetings between the physician and physician assistant. Physicians are limited by law to supervising four physician assistants by way of DSA for any purpose.

SPPs are operating procedures developed through collaboration between health professionals, including a nurse and a physician, and the administration in authorized health facilities. SPPs are protocols for performing procedures ordinarily outside of one's legal scope of practice. The SPPs authorize procedures that the supervising physician and administrators have determined are safe to perform given a practitioner's training and competence. For most situations, there is no default statutory supervision requirement or limit on the number of practitioners under a given SPP or supervisor (although the SPPs themselves can require any level of supervision the collaborators felt necessary given the procedures included). However, NPs and certified nurse practitioners have special limitations for the furnishing or ordering of drugs and devices, including supervision and limits.

Other States. Many other states have recognized the ability for NPs to play a more efficient role in the delivery of health care services and have updated their practice acts to align with NPs training and education. For example, at least 20 states have adopted full practice authority for NPs. The AMA contends that many of the NPs that practice independently in these states do not deliver care to underserved areas.

Current Related Legislation. AB 1612 (Burke) of the current Legislative Session removes physician supervision for certified nurse midwives. STATUS: This bill is pending in the Assembly Committee on Appropriations.

Prior Related Legislation. SB 1306 (Burke) of 2016 would have removed physician supervision for certified nurse midwives. NOTE: This bill failed passage on the Assembly Floor.

SB 323 (Hernandez) of 2015 would have authorized a nurse practitioner who holds a national certification to practice without physician supervision in specified settings. NOTE: This bill was referred to the Assembly Committee on Business and Professions, but not heard at the request of the author.

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.

AMENDMENTS:

In recognition of the need to increase access to services, but also recognizing concerns about removing physician supervision for NPs completely, the author should amend the bill to increase the number of physician assistants a physician can supervise. Additionally, the bill should be amended to increase the supervision ratio for nurses and certified nurse midwives for purposes of ordering or furnishing drugs or devices. The supervision ratio should be amended to allow one physician to supervise up to 18 of any combination of these providers.

REGISTERED SUPPORT:

California Association of Nurse Practitioners (sponsor)

REGISTERED OPPOSITION:

Union of American Physicians and Dentists

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

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Evan Low, Chair

ABPCA Bill Id:AB 1560

Author:(Friedman) – As Amended Ver:March 21, 2017

SUBJECT: Nurse practitioners: supervision.

SUMMARY: Deletes the maximum number of nurse practitioners a physician and surgeon may supervise for purposes of furnishing or ordering drugs or devices under standardized procedures or protocols.

EXISTING LAW:

1. Establishes the Board of Registered Nursing (BRN), within the Department of Consumer Affairs (DCA), and authorizes the BRN to license, certify and regulate nurses. (Business and Professions Code (BPC) §§ 2701; 2708.1)
2. Clarifies that there are various and conflicting definitions of “nurse practitioner” and “registered nurse” (RN) that are used within California and finds the public interest is served by determining the legitimate and consistent use of the title “nurse practitioner” established by the BRN. (BPC § 2834)
3. Requires applicants for licensure as a NP to meet specified educational requirements including: (BPC § 2835.5)
   1. Holding a valid and active registered nursing license;
   2. Possessing a Master’s degree in nursing, a Master’s degree in a clinical field related to nursing, or a graduate degree in nursing; and,
   3. Completing a NP program authorized by the BRN.
4. Recognizes the existence of overlapping functions between physicians and NPs and permits additional sharing of functions within organized health care systems that provide for collaboration between physicians and NPs. (BPC § 2725; Health and Safety Code (HSC) § 1250)
5. Defines "health facility" as any facility, place, or building that is organized, maintained and operated for the diagnosis, care, prevention, and treatment of physical or mental human illness including convalescence, rehabilitation, care during and after pregnancy, or for any one or more of these purposes, for which one or more persons are admitted for a 24-hour stay or longer. (HSC § 1250)
6. Authorizes a NP to do the following, pursuant to standardized procedures and protocols (SPPs) created by a physician or surgeon, or in consultation with a physician or surgeon: (BPC § 2835.7)
   1. Order durable medical equipment;
   2. Certify disability claims; and,
   3. Approve, sign, modify or add information to a plan of treatment for individuals receiving home health services.
7. Defines “furnishing” as the ordering of a drug or device in accordance with SPPs or transmitting an order of a supervising physician and surgeon. (BPC § 2836.1(h))
8. Defines “drug order” or “order” as an order for medication which is dispensed to or for an ultimate user and issued by a NP. (BPC § 2836.1(i))
9. Specifies that a NP is not prohibited from furnishing or ordering drugs or devices if the following apply:
   1. The furnishing and ordering of drugs or devices by NPs is done in accordance with the SPP developed by the supervising physician and surgeon, NP and the facility administrator or designee and shall be consistent with the NPs educational preparation and/or established and maintained clinical competency. (BPC § 2836.1(a))
   2. The NP is functioning pursuant to a SPP. The SPP shall be developed and approved by the supervising physician and surgeon, the nurse practitioner, and the facility administrator or the designee. (BPC § 2836.1(b))
   3. Specifies that the SPP must list which NPs may furnish or order drugs or devices. (BPC § 2836.1(c)(1))
   4. Indicates that for Schedule II controlled substances, the SPP must address the diagnosis of the illness, injury or condition for which the controlled substance is to be furnished. (BPC § 2836.1(c)(2))
   5. Indicates a physician and surgeon may determine the extent of supervision necessary in the furnishing or ordering or drugs and devices. (BPC § 2836.1(g)(2))
   6. Permits a NP to furnish or order Schedule II through Schedule V controlled substances and specifies that a copy of the SPP shall be provided upon request to any licensed pharmacist when there is uncertainty about the NP furnishing the order. (BPC § 2836.1(f)(1)(2); HSC §§ 11000; 11055; 11056).
   7. Requires that a NP has completed a course in pharmacology covering the drugs or devices to be furnished or ordered. (BPC § 2836.1(g)(1))
   8. States that a NP must hold an active furnishing number, register with the United States Drug Enforcement Administration and take a continuing education course in Schedule II controlled substances. (BPC § 2836.1(f)(3))
   9. Specifies that the physician and surgeon supervision shall not be construed to require the physical presence of the physician, but does include collaboration to create the SPP, approval of the SPP and availability of the physician and surgeon to be contacted via telephone at the time of the patient examination by the NP. (BPC § 2836.1(d))
   10. Limits the physician and surgeon to supervise no more than four NPs at one time.
       (BPC § 2836.1(e))
10. Authorizes the BRN to issue a number to NPs who dispense drugs or devices and revoke, suspend or deny issuance of the number for incompetence or gross negligence.
    (BPC § 2836.2)

THIS BILL:

1. Removes the requirement that a physician and surgeon shall supervise no more than four nurse practitioners at one time for purposes of furnishing or ordering drugs or devices.

FISCAL EFFECT: None. This bill is keyed non-fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the California Association of Nurse Practitioners. According to the author, “AB 1560 eliminates the existing 1:4 supervision ratio for physicians and nurse practitioners with prescribing duties. Instead of complying with an arbitrary ratio that can limit a network of clinics’ ability to provide care, physicians will be able to determine the appropriate level of supervision for their practice and/or care setting. This will increase essential healthcare availability, decrease costs, and improve efficiency, while maintaining patient quality and choice. With all of the challenges associated with our healthcare system, it is essential to ensure that all Californians have access to quality primary care.”

Background. Estimates obtained from the Council on Graduate Medical Education (CGME) indicate that the number of primary care physicians actively practicing in California is far below the state's need. The distribution of these primary care physicians is also poor. In 2008, there were 69,460 actively practicing primary care physicians in California, of which only 35 percent reported they actually practiced primary care. This equates to 63 active primary care physicians per 100,000 persons. However, according to the CGME, 60 to 80 primary care physicians are needed per 100,000 persons in order to adequately meet the needs of the population. When the same metric is applied regionally, only 16 of California’s 58 counties fall within the needed supply range for primary care physicians. In other words, less than one third of Californians live in a community where they have access to adequate health care services. In addition, a 2013 study in Health Affairs found that the proportion of U.S. medical students choosing careers in primary care dropped from 60 percent in 1998 to approximately 25 percent in 2013. Some purport that the way to address this shortage is by expanding the role of NPs and other allied healthcare professionals to provide primary care services.

NP Education and Training. There are over 19,000 NPs licensed by the BRN. The BRN sets the educational standards for NP certification. A NP is a registered nurse (RN) who has earned a bachelors and postgraduate nursing degree such as a Master’s or Doctorate degree. NPs possess advanced skill in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary health care, which occurs when a consumer makes contact with a health care provider who assumes responsibility and accountability for the continuity of health care regardless of the presence or absence of disease (Title 16 California Code of Regulations (CCR) §§ 1480(b); 1484). Examples of primary health care include: physical and mental assessment, disease prevention and restorative measures, performance of skin tests and immunization techniques, withdrawal of blood, and authority to initiate emergency procedures. Data from the Employment Developmental Department indicates that hospitals are the main employer of NPs.

NP Scope and SPPs. A NP does not have an additional scope of practice beyond the RNs scope and must rely on SPPs for authorization to perform medical functions which overlap with those conducted by a physician (16 CCR § 1485). According to the BRN, “SPPs are the legal mechanism for registered nurses, nurse practitioners to perform functions which would otherwise be considered the practice of medicine.” Examples of these functions include: diagnosing mental and physical conditions, using drugs in or upon human beings, severing or penetrating the tissue of human beings, and using other methods in the treatment of diseases, injuries, deformities or other physical or mental conditions.

SPPs must be developed collaboratively with NPs, physicians, and administration of the organized health care system where they will be utilized. Because of this interdisciplinary collaboration, there is accountability on several levels for the activities to be performed by the NP. Importantly, a NP must provide the organized health system with satisfactory evidence that the NP meets the experience, training and/or education requirements to perform the functions. If a NP undertakes a procedure without the competence to do so, such an act may constitute gross negligence and be subject to discipline by the BRN.

The BRN and the Medical Board of California (MBC) jointly promulgated the following guidelines for SPPs: (BRN, 16 CCR § 1474; MBC, 16 CCR § 1379)

“SPPs shall include a written description of the method used in developing and approving them and any revision thereof. Each SPP shall:

1) Be in writing, dated and signed by the organized health care system personnel authorized to approve it.

2) Specify which SPP functions registered nurses may perform and under what circumstances.

3) State any specific requirements which are to be followed by NPs in performing particular SPP functions.

4) Specify any experience, training, and/or education requirements for performance of SPP functions.

5) Establish a method for initial and continuing evaluation of the competence of those NPs authorized to perform SPP functions.

6) Provide for a method of maintaining a written record of those persons authorized to perform SPP functions.

7) Specify the scope of supervision required for performance of SPP functions, for example, telephone contact with the physician.

8) Set forth any specialized circumstances under which the NP is to immediately communicate with a patient's physician concerning the patient's condition.

9) State the limitations on settings, if any, in which SPP functions may be performed.

10) Specify patient record-keeping requirements.

11) Provide for a method of periodic review of the SPP.”

Nurse-Managed Health Clinics. Nurse-managed health clinics, of which many are Federally Qualified Heath Centers (FQHC) and independent non-profit clinics, are safety net clinics that provide primary care, health promotion, and disease prevention services to patients who are least likely to receive ongoing health care. Unlike other FQHC and independent non-profits, these clinics are solely operated by NPs. The Patient Protections and Affordable Care Act (ACA) defines a nurse-managed health clinic as, “…a nurse practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent non-profit health or social services agency.” (42 U.S.C. § 330A–1 (2010))

According to the National Nursing Centers Consortium, nurse-managed health clinics have doubled in their presence since 2013. To date, there are over 500 nurse-managed health clinics most of which are located in the East Coast. A small percentage of these have been chosen for funding through a federal expansion initiative. One such clinic, GLIDE Health Services, is a FQHC located in San Francisco, California and provides primary and urgent care, preventative services and psychiatric treatment to an urban population.

• Physician Supervision. In many of the nurse-managed health clinics, the physician to NP supervision relationship is quite flexible. A supervising physician may be present for a very limited amount of time to perform perfunctory tasks such as signing off on equipment orders, and reviewing and signing medical records. The physician may also elect to make himself/herself available for telephonic consult. For example, at GLIDE, the supervising physician is physically on site 1-2 days a week to sign off on orders such as wheel chairs, walkers and commodes and review medications that have been prescribed and furnished by NPs. According to Patricia Dennehy, a NP and director of GLIDE, “Though we value our MD colleagues and consult with them for complex care issues, currently there are administrative barriers to care delivery and access that are not practical.”
• Clinical Training Sites. In addition to providing care to patients, nurse-managed health clinics also play an important role in health professions education. More than 85 of the nation's leading nursing schools operate nurse-managed health clinics that serve as clinical education and practice sites for nursing students and faculty. Many, such as GLIDE, have partnerships with other academic programs and provide learning opportunities for medical, pharmacy, social work, public health, and other students.

Full Practice Authority. This bill is an incremental step towards determining the full extent of NP practice competence. The American Association of Nurse Practitioners defines full practice authority as, “The collection of state practice and licensure laws that allow for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments, including prescribe medications, under the exclusive licensure authority of the state board of nursing.” Similar to the changes to statute proposed in this legislation, under full practice authority, “certified NPs” are still required to meet educational and practice requirements for licensure, maintain national certification and remain accountable to the public and the state board of nursing. Under this model, “certified NPs” would continue to consult with and refer patients to other health care providers according to the patient’s needs.

Over the past 50 years, several organizations and research institutions have examined the feasibility of full practice authority for NPs. The Institute of Medicine (IOM) of the National Academies of Science released a 2010 report titled, The Future of Nursing: Leading Change, Advancing Health, in which the IOM wrote, “Remove scope of practice barriers. [NPs] should be able to practice to the full extent of their education and training…the current conflicts between what [NPs] can do based on their education and training and what they may do according to state federal regulations must be resolved so that they are better able to provide seamless, affordable and quality care.” In a 2011 report, the IOM noted that three to 14 NPs can be educated for the same cost as one physician. A report by the National Governor’s Association, The Role of Nurse Practitioners in Meeting Increased Demand for Primary Care noted, “In light of research evidence, states might consider changing scope of practice restrictions and assuring adequate reimbursement for their services as a way of encouraging and incentivizing greater NP involvement in the provision of primary health care.”

Despite these arguments, some physician groups, including the American Medical Association (AMA) assert that granting full practice authority for NPs may put patients’ health at risk. They cite the difference in educational attainment noting that physicians are required to complete four years of medical school plus three years of residency compared to the four years of nursing school and two years of graduate school required for NPs. The President of the AMA, Dr. Robert M. Wah, was quoted in a 2015 New York Times article, “[…nurses practicing independently] would further compartmentalize and fragment health care [which should be] collaborative with the physician at the head of the team.”

Financial Implications. Over the past 40 years, there have been a number of studies on the cost-effectiveness of NP practice. Results show NPs provide equivalent or improved medical care at a lower cost than their physician counterparts (citation). After insurance reform in Massachusetts, the state demonstrated that they could gain a cost savings of $4.2 to $8.4 billion, over a 10 year period, from the increased use of NPs (Eibner, E. et al. 2009, Controlling Health Care Spending in Massachusetts: An Analysis of Options. RAND Health).

Though the ACA encourages the creation of nurse-managed practices, by requiring insurers to pay NPs the same rates paid to physicians for identical services rendered, Medicare will not provide equal reimbursement. Presently, Medicare pays NPs 85 percent of the physician rate for the same services. The Medicare Payment Advisory Commission, the federal agency that advises Congress on Medicare issues, found that there was no analytical foundation for this difference. Despite this fact, revising payment methodology would require Congress to change the Medicare law. A report by the IOM titled “The Future of Nursing, Leading Change, Advancing Health,” recommended that the Medicare program be expanded to include coverage of advanced practice registered nurse services just as physician services are covered. The report also recommended that Medicaid reimbursement rates for primary care physicians be extended to advanced practice registered nurses providing similar primary care services.

Additionally, health insurance plans have significant discretion to determine what services they cover and which providers they recognize. Not all plans cover NPs. Further, many managed care plans require enrollees to designate a primary care provider but do not always recognize NPs. A 2009 survey conducted by the National Nursing Centers Consortium found that nearly half of the major managed care organizations did not credential NPs as primary care providers (www.healthaffairs.org/healthpolicybriefs/brief.php). If NPs were granted full practice authority, efforts may need to be undertaken in order for NPs to be recognized as primary care providers by insurance companies.

Ratios. Current law indicates that physicians may supervise no more than four physician assistants for any purpose, except during emergencies, and four nurse practitioners or four certified nurse midwives for purposes of furnishing drugs. These practitioners work under direct supervision or indirect supervision. In the case of indirect supervision, oftentimes, SPPs or delegated service agreements (DSAs) are drafted. The SPPs and DSAs are written agreements that govern the activities that practitioners can engage in while under indirect supervision of a physician.

DSAs are specific to physician assistants. They are detailed agreements between a physician and the physician assistant that delegate certain tasks and authority to perform procedures to physician assistants. DSAs include patient case reviews and other types of meetings between the physician and physician assistant. Physicians are limited by law to supervising four physician assistants by way of DSA for any purpose.

SPPs are operating procedures developed through collaboration between health professionals, including a nurse and a physician, and the administration in authorized health facilities. SPPs are protocols for performing procedures ordinarily outside of one's legal scope of practice. The SPPs authorize procedures that the supervising physician and administrators have determined are safe to perform given a practitioner's training and competence. For most situations, there is no default statutory supervision requirement or limit on the number of practitioners under a given SPP or supervisor (although the SPPs themselves can require any level of supervision the collaborators felt necessary given the procedures included). However, NPs and certified nurse practitioners have special limitations for the furnishing or ordering of drugs and devices, including supervision and limits.

Other States. Many other states have recognized the ability for NPs to play a more efficient role in the delivery of health care services and have updated their practice acts to align with NPs training and education. For example, at least 20 states have adopted full practice authority for NPs. The AMA contends that many of the NPs that practice independently in these states do not deliver care to underserved areas.

Current Related Legislation. AB 1612 (Burke) of the current Legislative Session removes physician supervision for certified nurse midwives. STATUS: This bill is pending in the Assembly Committee on Appropriations.

Prior Related Legislation. SB 1306 (Burke) of 2016 would have removed physician supervision for certified nurse midwives. NOTE: This bill failed passage on the Assembly Floor.

SB 323 (Hernandez) of 2015 would have authorized a nurse practitioner who holds a national certification to practice without physician supervision in specified settings. NOTE: This bill was referred to the Assembly Committee on Business and Professions, but not heard at the request of the author.

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.

AMENDMENTS:

In recognition of the need to increase access to services, but also recognizing concerns about removing physician supervision for NPs completely, the author should amend the bill to increase the number of physician assistants a physician can supervise. Additionally, the bill should be amended to increase the supervision ratio for nurses and certified nurse midwives for purposes of ordering or furnishing drugs or devices. The supervision ratio should be amended to allow one physician to supervise up to 18 of any combination of these providers.

REGISTERED SUPPORT:

California Association of Nurse Practitioners (sponsor)

REGISTERED OPPOSITION:

Union of American Physicians and Dentists

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