BILL ANALYSIS Ó AB 1308 Page 1 Date of Hearing: April 23, 2013 ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER PROTECTION Richard S. Gordon, Chair AB 1308 (Bonilla) - As Amended: March 21, 2013 SUBJECT : Midwifery SUMMARY : Authorizes a midwife to directly obtain supplies, order testing, and receive reports that are necessary to his or her practice of midwifery; requires the Medical Board of California (MBC) to revise and adopt regulations defining the supervision requirements between a physician and a midwife; and requires a midwife to disclose his or her arrangements for the referral of complications to a physician. Specifically, this bill : 1)Authorizes a midwife to directly obtain supplies, order testing, and receive reports that are necessary to his or her practice of midwifery and consistent with his or her scope of practice. 2)Requires the MBC, by July 1, 2015, to revise and adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery and identifying complications necessitating referral to a physician and surgeon. 3)Expands the existing oral and written disclosures required of a licensed midwife to a prospective client to include the specific arrangements for the referral of complications to a physician and surgeon. 4)Makes Legislative findings and declarations. 5)States that no reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. AB 1308 Page 2 EXISTING LAW : 1)Establishes the Licensed Midwifery Practice Act of 1993, which provides for the licensure of midwives by the MBC. (Business and Professions Code (BPC) Section 2505 et seq.) 2)Creates the Midwifery Advisory Council (MAC) which is required to make recommendations on matters specified by MBC. (BPC 2509) 3)Defines the practice of midwifery as the furthering or undertaking by any licensed midwife, under the supervision of a licensed physician who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. (BPC 2507) 4)Required MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery by July 1, 2003. (BPC 2507 (f)) 5)Permits a licensed midwife 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 under the supervision of a licensed physician and surgeon. (BPC 2507 (a)) 6)Requires a licensed midwife to disclose orally and in writing: a) The scope of a midwife's practice, as specified; b) Whether the licensed midwife has liability coverage; c) The specific arrangements for the transfer of care during the prenatal period, hospital transfer during the intrapartum and postpartum periods, and access to appropriate emergency medical services for mother and baby, if necessary; and, d) The procedure for reporting complaints to MBC. (BPC 2508) FISCAL EFFECT : Unknown AB 1308 Page 3 COMMENTS : 1)Purpose of this bill . This bill would enact multiple changes to clarify and facilitate the practice of midwifery: permitting a midwife to directly obtain supplies, order testing, and receive reports that are necessary to his or her practice; requiring MBC to revise and adopt regulations defining supervision requirements between a physician and a midwife; and requiring a midwife to disclose his or her arrangements for the referral of complications to a physician. This bill is sponsored by the American Congress of Obstetricians and Gynecologists. 2)Author's statement . According to the author, "Midwives were first licensed in 1993. MBC was charged with crafting regulations to implement the licensing, reporting, and other facets of this policy change. Unfortunately, there are some issues that MBC has not been able to address?. AB 1308 endeavors to address some of these issues. "Specifically, this bill authorizes midwives to order supplies, drugs, tests, and devices without an ordering physician listed. Currently, this is included in the scope of practice for licensed midwives, however, in the field many times they are unable to get access to supplies, drugs, and tests because the supplier requires listing of an ordering physician. This authority should help provide clarity to what should already be permissible. "The bill also requires MBC to revise regulations regarding licensed midwives before July 1, 2015. With the advent of this legislation, regulations may need to be modified to account for any changes. By pushing back the deadline by when the Medical Board must draft regulations, we allow for this revision to occur. "Amendments also clarify that the regulations should identify complications necessitating referral to a physician or surgeon. As medicine advances and we learn more about underlying health conditions and risk factors, it is important that the Medical Board continue to explore this topic." 3)Long-standing problems with clarifying physician supervision requirements . A licensed midwife is an individual who has AB 1308 Page 4 been issued a license to practice midwifery by MBC. The practice of midwifery authorizes the licensee, under the supervision of a licensed physician, to attend cases of normal childbirth, in a home, birthing clinic, or hospital environment. According to a 2013 report by the California Senate Business, Professions, and Economic Development (BPED) Committee, physician supervision is essentially unavailable to licensed midwives performing home births because California physicians are generally prohibited by their malpractice insurance companies from providing supervision of licensed midwives who perform home births. Existing law previously required MBC to adopt regulations by July 1, 2003 defining both the appropriate standard of care and the level of supervision required for the practice of midwifery. Due to its inability to reach a consensus on the supervision issue, the MBC bifurcated this requirement, and in 2006 adopted the Standards of Care for Midwifery. BPED reported that three previous attempts to resolve the physician supervision issue through legislation and/or regulation have been unsuccessful due to the widely divergent opinions of interested parties. The MBC, through its Midwifery Advisory Council, has held many meetings regarding physician supervision of licensed midwives and has attempted to create regulations to address this issue. The concepts of collaboration, such as required consultation, referral, transfer of care, and physician liability have been discussed among the interested parties with little success. Despite midwives' inability to obtain physician supervision, midwives are currently performing midwifery without sanction by MBC because administrative courts have determined that it is unfair to enforce the physician supervision requirement because physician supervision is practically unobtainable. This bill aims to restart those discussions by creating a deadline for MBC to establish supervision guidelines. And in light of the current imperfections with the supervision guidelines, this bill also requires midwives to explicitly disclose to the patient his or her arrangements for the referral of complications to a physician AB 1308 Page 5 4)Supplies, testing, and results . According to the author, some licensed midwives are impeded by the supervision requirement because many drug, testing, and device suppliers require the name of an ordering physician to fulfill requests, thereby delaying or blocking midwives' ability to obtain supplies, order tests, and receive results. Licensed midwives who are unable to establish an account with a local medical supply company may have to order drugs and supplies from out of state at significantly increased expense, or obtain them from another licensed midwife. Continuity of care becomes an important patient issue in areas where licensed midwives are unable to establish laboratory accounts or refer patients for ultrasounds because patients then have to see a different provider. This may increase costs and cause delay for patients, and can affect time-sensitive testing windows, such as for the genetic screening done in early pregnancy. According to the author, in some cases patients refuse to seek out these laboratory tests when they would have consented to them had they been available through their licensed midwife. This bill would explicitly authorize midwives to order the tools necessary and appropriate to their practice without naming a supervising physician. 5)Arguments in support . The American Congress of Obstetricians and Gynecologists write, "For the twenty years licensed midwives have been authorized to practice in California, there never has been a workable system where licensed midwives and medical professionals can work together. This system failure is bad for licensed midwives, physicians, MBC (whom is responsible for regulating licensed midwives), hospitals, hospital staff and most importantly, the pregnant woman, her pregnancy and family?[T]he American Congress of Obstetricians and Gynecologists, District IX, who has been working with the Medical Board and licensed midwives for years to develop workable regulations, without success, is concerned the issue of licensed midwifery might not get the attention it needs and deserves. Given this situation, ACOG-IX decided to sponsor a bill by Assemblymember Bonilla. "We do not yet know how we will be able to redefine the relationship to a more workable one due to the many factors to AB 1308 Page 6 be considered. So, we are starting with the very practical issues which impede the licensed midwives' ability to practice, including the ability to obtain needed supplies and tests within their scope of practice, without the need for a named physician supervisor." 6)Previous legislation . SB 1638 (Figueroa), Chapter 536, Statutes of 2006. SB 1638 required MBC to create and appoint the MAC, and required licensed midwives to make annual reports to the Office of Statewide Health Planning and Development containing specified information regarding the births the midwife assisted in delivering during the prior year. SB 1950 (Figueroa), Chapter 1085, Statutes of 2002, required MBC to adopt regulations by July 1, 2003, defining the appropriate standard of care and level of supervision required for the practice of midwifery. SB 1479 (Figueroa), Chapter 303, Statutes of 2000, revised and expanded the information a licensed midwife is required to disclose to prospective clients. REGISTERED SUPPORT / OPPOSITION : Support American Congress of Obstetricians and Gynecologists (sponsor) Opposition None on file Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916) 319-3301