BILL ANALYSIS Ó
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|Hearing Date:June 23, 2014 |Bill No:AB |
| |1841 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Ted W. Lieu, Chair
Bill No: AB 1841Author:Mullin
As Amended: June 2, 2014Fiscal: No
SUBJECT: Medical assistants.
SUMMARY: Authorizes a medical assistant to hand out properly labeled
and prepackaged prescription drugs to patients as part of their
existing authorization to provide "technical supportive services."
Existing law:
1)Establishes the Medical Practice Act (Act) which licenses and
regulates physicians and surgeons as well as regulating medical
assistants (MAs) by the Medical Board of California (MBC) within the
Department of Consumer Affairs (DCA). (Business and Professions
Code (BPC) § 2000 et seq.)
2)Defines a MA as a person who may be unlicensed, who performs basic
administrative, clerical, and technical supportive services, as
specified, for a licensed physician and surgeon or a licensed
podiatrist, a physician or podiatrist group, a medical or podiatry
corporation, a physician assistant, a nurse practitioner, a
certified nurse-midwife or for a health care service plan. (BPC §
2069 (b) (1))
3)Requires a MA to be at least 18 years of age and have at least the
minimum amount of hours of appropriate training pursuant to
standards established MBC, and further requires a MA to have a
certificate by the training institution or instructor indicating
satisfactory completion of the required training, and for each
employer to retain a copy of this certificate.
(BPC § 2069 (b) (1))
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4)Authorizes a MA to administer medication only by intradermal,
subcutaneous, or intramuscular injections and perform skin tests and
additional technical supportive services upon the specific
authorization and supervision of a licensed physician and surgeon or
podiatrist. A MA may also perform all these tasks and services upon
the specific authorization of a physician assistant, nurse
practitioner, or certified nurse-midwife. (BPC § 2069 (a) (1))
5)Permits a supervising physician and surgeon to provide written
instructions to be followed by a MA in performing tasks or
supportive services. The written instructions may delegate the
supervision of the MA in performing the tasks or services to a nurse
practitioner, certified nurse-midwife, or physician assistant within
the standardized procedures or protocols.
(BPC § 2069 (a) (2)
6)Defines "technical supportive services" as simple routine medical
tasks and procedures that may be safely performed by a MA who has
limited training and who functions under the supervision of a
licensed physician and surgeon, podiatrist, physician assistant,
nurse practitioner or a certified nurse-midwife, as specified. (BPC
§ 2069 (b) (4))
7)Permits a MA to perform venipuncture or skin puncture for the
purposes of withdrawing blood upon specific authorization and
supervision of a licensed physician and surgeon, podiatrist,
physician assistant, nurse practitioner or nurse-midwife if the MA
has met minimum training requirements established by MBC. (BPC §
2070)
8)Establishes the Pharmacy Law which provides for the licensure and
regulation of pharmacies, pharmacists and wholesalers of dangerous
drugs or devices by the Board of Pharmacy (BOP) within the DCA.
9)Governs the prescribing, dispensing, or furnishing of dangerous drugs
by prescribers, defined to include a physician and surgeon,
podiatrist and certified nurse-midwife, as specified.
(BPC § 4170).
10)Authorizes a pharmacy to employ a non-licensed person to type a
prescription label or otherwise enter prescription information into
a computer record system, but the responsibility for the accuracy of
the prescription information and the prescription as dispensed lies
with the registered pharmacist who initials the prescription or
prescription record. At the direction of the registered pharmacist,
a non-licensed person may also request and receive refill
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authorization. (California Code of Regulations, Title 16, Division
17, Article 11, Section 1793.3 (a))
11)Authorizes a licensed nonprofit community clinic or free clinic, a
county owned or operated primary care clinic, a clinic operated by a
federally recognized Indian tribe or tribal organization, a clinic
operated by primary care community or free clinic, a student health
center, a nonprofit multispecialty clinic, as specified, to be
licensed by the BOP to purchase drugs at wholesale for
administration or dispensing, under the direction of a physician and
surgeon, to patients registered for care at the clinic, as
specified. (BPC § 4180)
12)Authorizes a surgical clinic, as specified, to be licensed by the
BOP to purchase drugs to purchase drugs at wholesale for
administration or dispensing, under the direction of a physician and
surgeon, to patients registered for care at the clinic, as
specified. (BPC § 4190)
This bill:
1)Expands the definition of "technical supportive services" carried out
by a MA in a clinic described in Items 11 and 12 above, other than a
facility operated by the state, to include the following:
a) Handing a patient a properly labeled and prepackaged
prescription drug, excluding a controlled substance, ordered by a
licensed physician and surgeon, podiatrist, physician assistant,
nurse practitioner or certified nurse-midwife, as specified.
b) Requires that prior to a MA handing the medication to a
patient, a licensed physician and surgeon, podiatrist, physician
assistant, nurse practitioner, or certified nurse-midwife shall
verify that the medication and dosage for that specific patient
is correct, that the patient's name is affixed to the package and
shall provide the appropriate patient consultation regarding the
use of the drug.
FISCAL EFFECT: This bill has been keyed "non-fiscal" by Legislative
Counsel.
COMMENTS:
1.Purpose. This bill is sponsored by Planned Parenthood Affiliates of
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California to increase patient access to care by specifying medical
assistants' ability to include handing to a patient medication that
has already been packaged and labeled by the dispensing provider.
This authority is limited to facilities that are licensed by the
State Board of Pharmacy, excluding those operated by the state. The
bill also excludes controlled substances, and requires the
medication be properly labeled by the ordering provider who has
appropriately counseled the patient on the medication.
2.Background. According to the Author, "Medical Assistants are
currently allowed to provide a range of supportive and medical
services like administer medication (including narcotics) orally,
topically, or through injection; perform skin tests; apply bandages,
remove casts and stitches, perform simple lab/ screening tests; and
perform technical supportive services upon training and
authorization of a licensed physician and surgeon. MAs cannot
dispense and are not allowed to hand over medication of any kind to
patients."
The Author further states that current practice in community health
centers relies on the use of MAs to support physicians and
clinicians (nurse practitioners, certified nurse-midwives, and
physician assistants). Since MAs are not permitted to hand
medication to a patient, that administrative task must be done by
the physician or clinician, taking their time away from seeing more
patients and focusing on the care they have been trained to provide.
The Author states, "After examining a patient, diagnosing them,
discussing options and providing education on any recommended
medication, the clinician must go back to the locked pharmacy closet
to select, package and label the appropriate medication and then
returns to the patient exam room to physically hand the patient the
medication. This bill would allow a MA to take the medication,
after it has been pulled, packaged, and labeled, and physically hand
it to the patient."
The Author indicates that although this takes only several minutes for
each patient, it adds up significantly over time ultimately limiting
patient access. "This minor increase in MAs ability to hand over
medication will free up other providers to see additional patients.
More fully utilizing the abilities of [MAs] will increase efficiency
in health facilities like community health centers and by seeing
more patients, health facilities will be able to reduce waiting
times and expand patient access to care.
With millions of Californians newly enrolled in health care coverage
under the ACA [Affordable Care Act] and millions more eligible for
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coverage, expanding access to care is essential to ensuring that
these individuals have meaningful coverage. California needs to
utilize all health care professionals and those that assist them to
the fullest extent of their abilities and potential to increase
access, improving our health care delivery system to better serve
the newly enrolled population and providing coverage for the
remaining uninsured."
3.Medical Assistants. MAs are unlicensed, but certificated,
individuals. MAs must have a high school diploma or GED equivalent
and take a certificate course at an approved school. Prior to
performing technical supportive services, a medical assistant must
receive training, as necessary, and it is the responsibility of the
supervising physician, podiatrist or instructor to assure the MA's
competence in performing that service at the appropriate standard of
care.
The MBC regulations establish the requirements which allow certifying
organizations to certify medical assistants. According to the MBC,
the training may be administered under a licensed physician,
podiatrist, registered nurse, licensed vocational nurse, physician
assistant or qualified medical assistant, or in a secondary,
post-secondary, or adult education program in a public school
authorized by the Department of Education, in a community college
program, or a post-secondary institution accredited or approved by
the Bureau for Private Postsecondary Education. To administer
medications by intramuscular, subcutaneous and intradermal
injections, perform skin tests, perform venipuncture or skin
puncture to withdraw blood, a MA must complete specified training
prescribed by the MBC regulations.
MA's may perform specific functions as part of "technical supportive"
services in addition to administrative functions, including:
a) Administer medications orally, sublingually, topically,
vaginally or rectally, or by providing a single dose to a patient
for immediate self-administration;
b) Administer medication by inhalation;
c) Perform electrocardiogram, electroencephalogram, or
plethysmography tests;
d) Apply and remove bandages and dressings;
e) Remove sutures or staples from superficial incisions or
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lacerations;
f) Collect by non-invasive techniques and preserve specimens for
testing, including urine, sputum, semen and stool;
g) Prepare patients for and assist the physician, podiatrist,
physician assistant or registered nurse in examinations or
procedures including positioning, draping, shaving and
disinfecting treatment sites, and prepare a patient for gait
analysis testing;
h) As authorized by the physician or podiatrist, provide patient
information and instructions;
i) Collect and record patient data including height, weight,
temperature, pulse, respiration rate and blood pressure, and
basic information about the presenting and previous conditions;
j) Perform simple laboratory and screening tests customarily
performed in a medical office.
This bill clarifies that MAs may hand out properly labeled and
prepackaged prescription drugs to patients as part of "technical
supportive services" in specified types of clinics. Based upon
currently authorized abilities, this appears to be well within a
MA's scope of practice.
4.Related Legislation. SB 352 (Pavley, Chapter 352, Statutes of 2013)
authorized MAs to perform technical supportive services in any
medical setting upon specific authorization of a physician
assistant, nurse practitioner, or certified nurse-midwife without a
physician on the premises. This bill removed the requirement that a
MA be supervised by a physician assistant, nurse practitioner, or
certified nurse-midwife only in specified community clinics.
SB 1852 (Alpert, 2000) would have allowed MAs to perform specified
tasks and services which they were only permitted to perform upon
the specific authorization and under the direct supervision of a
physician or podiatrist upon the specific authorization of a
physician's assistant, a nurse practitioner or a nurse-midwife in a
licensed clinic, as specified, that is enrolled as a Medi-Cal
provider in the Family Planning, Access, Care, and Treatment Waiver
Program. ( Status : SB 1852 died in Assembly Health Committee.)
SB 252 (Alpert, Chapter 234, Statutes of 2003) specified that MAs are
not authorized to perform a clinical laboratory test or examination
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and does not authorize a nurse practitioner, nurse-midwife or
physician assistant to be a laboratory director of a clinical
laboratory. ( Note : This bill originally included a provision for
MAs to provide technical supportive services under the supervision
of a physician assistant, nurse practitioner or nurse midwife, but
those provisions were removed from the bill in response to
opposition.)
SB 111 (Alpert, Chapter 358, Statues of 2001) authorized a medical
assistant to perform specified services in community and free
clinics under the supervision of a physician assistant, nurse
practitioner or nurse-midwife. This bill authorized a physician and
surgeon in these specified clinics to provide written instructions
for MAs, regarding the performance of tasks or duties, while under
the supervision of a physician assistant, nurse practitioner or
nurse midwife when the supervising physician and surgeon was not on
site.
5.Arguments in Support. In sponsoring the bill, Planned Parenthood
Affiliates of California writes that this minor expansion of MA
duties will increase access to care in health care settings,
including Planned Parenthood, by reducing waiting times caused, in
part, by clinicians who must package the medications and then
themselves hand it to the patient. "Authorizing MAs to hand over
pre-packaged/pre-labeled medication is consistent with (if not less
complicated than) the level and complexity and range of medical and
technical support services they are already authorized to perform,
including administering narcotics and giving injections." Finally,
Planned Parenthood argues that authorizing MAs to hand over
medication frees up the clinician from this administrative duty and
allows them to see more patients and spend more time with each
patient answering questions.
Medical Board of California (MBC) believes the bill will help further
the Board's mission of increasing access to care, and writes in
support that allowing MAs to hand over properly labeled,
pre-packaged medication is a minor increase in the MAs duties, and
one that does not compromise consumer protection, since the
physician would have to label the medication for the patient,
package the medication, and provide the appropriate consultation.
California Association for Nurse Practitioners (CANP) states that with
millions of Californians entering the health care system due to ACA
implementation, healthcare providers' ability to deliver care as
efficiently as possible is essential to meet the often pent-up
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demand for services of these newly eligible individuals. The
already strained delivery system is experiencing increased pressure,
particularly in underserved areas, where NPs play a critical role in
providing care. AB 1841 will assist with this problem by allowing
medical assistants to furnish patients with pre-labeled,
pre-packaged medication, only after the medication has been selected
and packaged by a physician or advanced practice clinician, such as
an NP. This will allow primary care practitioners, including NPs, to
dedicate more time to providing patient care.
The Association of California Healthcare Districts (ACHD) states that
millions of Californians rely on public health facilities and
programs for vital health care services. Additionally, many of our
Community Based Healthcare Districts specialize in promoting
community health care, focusing on prevention, food access, and
disease management. In many parts of California, Healthcare
Districts act as the sole provider of health care services in their
communities. ACHD states: "As more Californians are now eligible
for care, it is important that health care staff is utilized
efficiently to accommodate patients as they seek care and medical
services. AB 1841 creates greater staffing efficiency by utilizing
medical assistants to assist with handing patients a pre-packaged
and pre-authorized prescription. By allowing medical assistants to
assist in this responsibility, doctors, nurses and other medical
staff can focus on other patient needs"
6.Oppose Unless Amended. California Society of Health-System
Pharmacists (CSHP) opposes this bill unless it is amended, stating,
"we support the intent of the bill to reduce waiting times, expand
access, and improve patient care and satisfaction in community
clinics, and we appreciate the recent amendments to specify patient
education, we are still concerned by the language, especially as it
lacks recognition of pharmacists as providers in community clinics."
CSHP indicates that with the passage of SB 493 (Hernandez, Chapter
469, Statutes of 2013) pharmacists are recognized as providers and
may offer certain services that are often provided telephonically
and collaboratively with physicians in clinic settings. CSHP has
indicated a willingness to work with the Author in his efforts to
expand access and improve patient care.
7.Arguments in Opposition. California Right to Life Committee, Inc.
argues that allowing unlicensed healthcare professionals to hand a
patient "a properly labeled and prepackaged prescription drug,"
creates a completely unnecessary barrier to Doctor/ patient
communication.
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"Even the most educated Medical Assistants with the highest
certifications do not receive pharmacy training, neither are Medical
Assistants allowed to diagnose or to perform any task that requires
assessment - including commenting on the safety and/or efficacy of a
prescribed drug. This bill makes it much harder for a patient to
obtain a consultation with a professional qualified to address their
questions and assess their health needs."
Committee staff notes that the bill explicitly requires the licensed
physician and surgeon, podiatrist, physician assistant, nurse
practitioner, or certified nurse-midwife to provide the appropriate
patient consultation regarding the use of the drug prior to the MA
handing it to the patient.
SUPPORT AND OPPOSITION:
Support:
Planned Parenthood Affiliates of California (Sponsor)
Association of California Healthcare Districts
California Association for Nurse Practitioners
Medical Board of California
Oppose Unless Amended:
California Society of Health-System Pharmacists
Opposition:
California Right to Life Committee, Inc.
Consultant:G. V. Ayers