BILL ANALYSIS Ó AB 2348 Page 1 Date of Hearing: April 24, 2012 ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER PROTECTION Mary Hayashi, Chair AB 2348 (Mitchell) - As Amended: March 29, 2012 SUBJECT : Registered nurses: dispensation of drugs. SUMMARY : Allows registered nurses (RNs) to dispense hormonal contraceptives in primary care clinics. Specifically, this bill : 1)Allows RNs to dispense drugs or devices upon an order by a certified nurse-midwife (CNM), nurse practitioner (NP), or physician assistant (PA) if the RN is functioning within a licensed primary care clinic, as specified. 2)Allows RNs to dispense hormonal contraceptives pursuant to standardized procedures, developed in compliance with current law defining standardized procedures that RN's may implement, if the RN is functioning within a licensed primary care clinic, as specified. EXISTING LAW 1)Regulates and licenses physicians and surgeons and PAs via the Medical Board of California (MBC). 2)Regulates and licenses RNs, including advanced practice nurses in the categories of CNM or NP, via the Board of Registered Nursing (BRN). 3)Allows RNs to dispense drugs or other devices upon an order by a physician and surgeon if the RN is functioning within a licensed primary care clinic, as specified. 4)Defines "standardized procedures," as it pertains to RN's scope of practice, to mean policies and protocols developed by an organized health care system or a health facility licensed by DPH, as specified, through collaboration among administrators and health professionals, including physicians and nurses. These policies and protocols shall be subject to any guidelines for standardized procedures that the Division of Licensing of the MBC and the BRN may jointly promulgate. AB 2348 Page 2 If promulgated, the guidelines shall be administered by the BRN. FISCAL EFFECT : Unknown. This bill is keyed non-fiscal. COMMENTS : Purpose of this bill . According to the author, "Across California, many women lack access to birth control, leaving them at significant risk of unintended pregnancy. In some parts of the state, patients of community health clinics cannot access hormonal contraceptives because of the limited supply of prescribers and others who are legally authorized to order or furnish these medications. Lack of enough appropriate staff can result in health centers closing or reducing hours, compounding many communities' unmet family planning needs. For a woman in need of birth control these types of shortages can mean waiting long periods of time to schedule a health center appointment, sitting in a waiting room for hours before being seen, or driving long distances to see a provider. All of these barriers place her at greater risk of unintended pregnancy." Background . The BRN regulates California RNs. There are more than 300,000 RNs in California providing health care services in a variety of settings. RNs use a number of titles in their practice, including certified nurse anesthetist, CNM, clinical nurse specialist, critical care nurse, NP, and public health nurse. Existing law allows RNs working in primary care clinics to dispense drugs or other devices only upon an order by a physician and surgeon. This bill expands the number of practitioners under whose orders an RN may dispense medications to include CNMs, NPs, and PAs. This bill also allows RNs to dispense hormonal contraceptives pursuant to standardized procedures as that term is defined in existing law governing RN's scope of practice. Support . Planned Parenthood Affiliates of California, the sponsor of this measure, writes, "Access to birth control is a critical public health issue and an essential component of women's health care. Unfortunately, there are thousands of women in California who lack access to contraception, leaving them at significant risk of unintended pregnancy. In fact, AB 2348 Page 3 according to data from the Family PACT program evaluation, only 71% of women in need of publicly funded family planning services are actually able to access care. "In some parts of the state, this lack of access is due to shortages of doctors and health care professionals authorized to order or furnish these medications. For example, Planned Parenthood health centers in the Central Valley have ongoing staff vacancies, which, if filled, would result in 13,000 more patients receiving basic reproductive care each month. "Contraceptives are among the safest and most widely studied of all drugs. Due to this safety and the importance of timely access, medical standards and guidelines currently recommend that birth control be provided based on a self-reported medical history and blood pressure check, delinking requirements for annual pelvic examinations and PAP smear tests. These updated guidelines establish the current standard for care and expand access to comprehensive reproductive care. While preventive screenings and well-woman visits are key to the quality reproductive health care provided by Planned Parenthood, there is no medical reason to delay providing access to birth control until a woman has undergone them." Opposition . The California Association for Nurse Practitioners states, "AB 2348 would remove NPs from the medical examination and assessment of patients prior to the dispensation of hormonal contraceptives. However, under the regulatory scenario proposed in (this) bill, NPs would be held ultimately responsible for the decisions made by the RN?we believe that AB 2348 would put the NP in the middle of a legal relationship between a physician, an RN, and a patient, without having seen the patient. "While many forms of hormonal contraception are very safe, all patients should undergo a medical assessment with a provider who is able to review their potential risk factors, family history, and other medical factors and then make an informed determination as to a medication they may be taking. To perform this type of assessment is beyond the current scope of practice of an RN?Should complications arise, it is unclear to us what options the patient would have to maintain an ongoing relationship with her provider. "RNs are not currently authorized to furnish or prescribe. Again, it concerns us that the intent of AB 2348 is for an NP to AB 2348 Page 4 delegate his or her authority to dispense, and perhaps furnish, to an RN who does not have this authority under existing law. AB 2348 would allow for all types of hormonal contraceptives to be dispensed by an RN, encompassing a very broad category of drugs and devices, all of which require a prescription. "Lastly, our NPs who have reviewed the bill believe that AB 2348 is unnecessary. Under current law, an RN may work under standardized procedures. Thus, the medical director could set up these procedures and delegate authority directly to an RN to dispense hormonal contraceptives." The California Nurses Association states, "Understanding the difference between 'furnish' and 'dispense' is central to understanding part of CNA's strong objections to this legislation. Under current law, RNs are allowed in primary, community and free clinics to 'dispense' medications. Dispense means to hand to a patient for future use, medication prescribed by a physician. Under current law, NPs 'furnish' medications under a professional protocol that is called 'standardized procedure.' Medication that is ordered for patients under standardized procedures is referred to as 'furnishing' because it is prescriptive authority that is delegated by physicians under these special procedures/protocols. NPs have advanced training and an advanced degree to provide primary health care and to 'furnish' medications. NPs must have furnishing numbers in order to verify that they have completed statutorily required education to furnish medications under California law and that furnish number must be printed on the order for medication that is to be filled by a pharmacist. "This legislation refers to the new authority as the 'dispensing' of hormonal contraceptives but in actuality the RN alone performs a nursing assessment and then under the mechanism of a standardized procedure decides what contraceptive is appropriate. The RN then gives the patient the contraceptive when the patient leaves the clinic. There would be no examination performed by a physician or a NP. The 'dispensing' of hormonal contraceptive is in actuality limited 'furnishing' authority. The only difference is that the patient does not get a written order that can be filled at a pharmacy. Instead, the patient is handed the supply of medications that has been determined by the RN to be appropriate for a particular patient." AB 2348 Page 5 REGISTERED SUPPORT / OPPOSITION : Support California Family Health Council (sponsor) Planned Parenthood Affiliates of California (sponsor) Planned Parenthood Mar Monte (sponsor) Planned Parenthood of Santa Barbara, Ventura and San Luis Obispo Counties, Inc. (sponsor) Planned Parenthood Pasadena and San Gabriel Valley (sponsor) Planned Parenthood Shasta Pacific Action Fund (sponsor) Six Rivers Planned Parenthood (sponsor) ACCESS Women's Health Justice California Latinas for Reproductive Justice Forward Together Ibis Reproductive Health Law Students for Reproductive Justice Maternal and Child Health Access National Center for Youth Law National Council of Jewish Women Nevada County Citizens for Choice Physicians for Reproductive Choice and Health United Nurses Associations of California/Union of Health Care Professionals Women's Community Clinic Opposition California Association for Nurse Practitioners California Nurses Association Analysis Prepared by : Angela Mapp / B.,P. & C.P. / (916) 319-3301