BILL ANALYSIS �
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|Hearing Date:April 8, 2013 |Bill No:SB |
| |352 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Curren D. Price, Jr., Chair
Bill No: SB 352Author:Pavley
As Introduced: February 20, 2013 Fiscal: No
SUBJECT: Medical assistants: supervision.
SUMMARY: Allows medical assistants to perform technical supportive
services, in doctor's offices and all medical clinics, under the
supervision of a physician assistant, nurse practitioner or nurse
midwife without a physician on the premises.
Existing law:
1) Defines "medical assistant" as a person who may be unlicensed, who
performs basic administrative, clerical and technical supportive
services for a licensed physician, surgeon, podiatrist, a medical
or podiatry corporation, physician assistant, nurse practitioner,
nurse midwife or health care service plan. (Business and
Professions Code (BPC) � 2069(b)(1))
2) Specifies that a medical assistant is at least 18 years of age and
has had at least the minimum amount of hours of appropriate
training pursuant to standards established by the Division of
Licensing. (BPC � 2069(b)(1))
3) Establishes the requirements which allow certifying organizations
to certify medical assistants (California Code of Regulations (CCR)
Title 16 � 1366.31)
4) Requires a medical assistant to receive their training from either
of the two (CCR Title 16 � 1366.3(a)):
a) A secondary, postsecondary or adult education
program in a public school authorized by the Department of
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Education, in a community college program, or a
postsecondary institution accredited by an accreditation
agency recognized by the United States Department of
Education or approved by the Bureau for Private
Postsecondary Education.
b) A physician, podiatrist, registered nurse, licensed
vocational nurse, physician assistant or a qualified medical
assistant.
5) Requires a "qualified medical assistant" to meet one of three
criteria:
(CCR Title 16 � 1366.3(c))
a) Certified by a medical assistant certifying
organization approved by the division.
b) Holds a credential to teach in a medical assistant
training program at a community college.
c) Is authorized to teach medical assistants in a
private postsecondary institution accredited by an
accreditation agency recognized by the United States
Department of Education or approved by the Bureau for
Private Postsecondary Education.
6) Specifies that a qualified medical assistant cannot train other
medical assistants to administer medication by inhalation. (CCR
Title 16 �1366.3)
7) Defines "technical supportive services" as simple routine medical
tasks and procedures that may be safely performed by a medical
assistant who has limited training and who functions under the
supervision of a licensed physician, surgeon, podiatrist, physician
assistant, nurse practitioner or nurse midwife. (BPC � 2070(4))
8) Allows the Division of Licensing to adopt and administer
regulations that establish standards for technical supportive
services that may be performed by a medical assistant.
(BPC � 2071)
9) Defines "specific authorization" as a specific written order
prepared by the supervising physician, surgeon, podiatrist, nurse
practitioner or nurse midwife authorizing the procedures to be
performed on a patient. (BPC � 2069(b)(2))
10)Authorizes medical assistants to administer medication only by
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intradermal, subcutaneous or intramuscular injection and to perform
skin tests under the specific authorization and supervision of a
licensed physician, surgeon or podiatrist. (BPC � 2069(a)(1))
11)Authorizes medical assistants to perform venipuncture or skin
puncture for the purposes of withdrawing blood upon specific
authorization and under the supervision of a licensed physician,
surgeon, podiatrist, physician assistant, nurse practitioner or
nurse midwife.
(BPC � 2070)
12)Authorizes medical assistants to perform the following additional
technical supportive services (CCR Title 16 � 1366(b)):
a) Administer medication 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, except full body plethysmography;
d) Apply and remove bandages and dressings;
e) Apply orthopedic appliances such as knee
immobilizers, envelope slings, orthotics and similar
devices;
f) Remove casts, splints and other external devices;
g) Obtain impressions for orthotics, padding and custom
molded shoes;
h) Select and adjust crutches to patient and instruct
patient in proper use of crutches;
i) Remove sutures or staples from superficial incisions
or lacerations;
j) Perform ear lavage to remove impacted cerumen;
aa) Collect, by non-invasive techniques, and preserve
specimens for testing including urine, sputum, semen and
stool;
bb) Assist patients in ambulation and transfers;
cc) 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;
dd) Prepare a patient for gait analysis testing;
ee) as authorized by the physician or podiatrist,
provide patient information and instructions;
ff) Collect and record patient data including height,
weight, temperature, pulse, respiration rate and blood
pressure, and basic information about the presenting and
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previous conditions;
gg) Perform simple laboratory and screening tests
customarily performed in a medical office;
hh) Cut the nails of otherwise healthy patients; and
ii) Fit prescription lenses or use any optical device in
connection with ocular exercises, visual training, vision
training or orthoptics.
13)Authorizes medical assistants to practice in any setting where
optometry or ophthalmology is practiced under the direct
responsibility and supervision of a physician, surgeon or
optometrist to do the following tasks (BPC � 2544):
a) Prepare patients for examination;
b) Collect preliminary patient data, including taking a
patient history;
c) Perform simple non-invasive testing of visual
acuity, pupils and ocular motility;
d) Perform automated visual field testing;
e) Perform ophthalmic photography and digital imaging;
f) Perform tonometry;
g) Perform lensometry;
h) Perform non-subjective auto refraction in connection
with subjective refraction procedures performed by an
ophthalmologist or optometrist;
i) Administer cycloplegiacs, mydriatics and topical
anesthetics that are not controlled substances, for
ophthalmic purposes; and
j) Perform pachymetry, keratometry, A scans, B scans
and electrodiagnostic testing.
14)Permits a physician or surgeon at a community or free clinic to
authorize a nurse practitioner, nurse midwife or physician
assistant to provide supervision of medical assistants as they
follow written instructions provided by the physician when the
physician is not on site.
(BPC � 2069(a); Health and Safety Code (HSC) � 1204))
This bill:
1) Expands the types of settings where medical assistants can provide
technical supportive services from community and free clinics to
any medical setting.
2) Authorizes a physician or surgeon, in any medical setting, to
authorize a nurse practitioner, nurse midwife or physician
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assistant to provide supervision of medical assistants as they
follow written instructions provided by the physician when the
physician is not on site.
3) Specifies that the standards established for medical assistants
will be established by the Medical Board of California (MBC), and
specifies that the MBC shall not adopt regulations that violate
prohibitions on diagnosis or treatment.
4) Specifies that medical assistants shall not perform any tests or
examinations for which he or she is not authorized.
5) Prohibits a nurse practitioner, nurse midwife or physician
assistant to be a laboratory director of a clinical laboratory.
FISCAL EFFECT: Unknown. This bill has been keyed "non-fiscal" by
Legislative Counsel.
COMMENTS:
1. Purpose. This bill is sponsored by the California Academy of
Physician Assistants . According to the author, current laws require
that a physician must be present at the practice site to supervise
a medical assistant. However, medical assistants can work under
the supervision of a physician assistant, nurse practitioner or
nurse midwife in licensed community and free clinics. With the
exception of these clinics, medical assistants are limited to
performing administrative and clerical duties and therefore may not
perform or assist with even the simplest technical supportive
services if the physician is not on the premises.
2. Background.
Medical Assistants and Their Scope of Practice. According to the
United States Bureau of Labor and Statistics (BLS), the medical
assisting professions continue to be some of the fastest growing
employment categories. The BLS projects that the number of medical
assistants will grow by 34%, from 483,600 in 2008, to 647,500 by
2018. California employs nearly 82,000 medical assistants.
Medical assistants are unlicensed personnel who work in physician,
podiatrist or optometrist offices and clinics. Medical assistants
may not work for inpatient care in licensed general acute care
hospitals. Medical assistants can perform basic administrative,
clerical and technical supportive services when conditions
regarding supervision, training, specific authorization and records
are met.
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Training. A medical assistant must receive training either
directly from a physician, surgeon, podiatrist, registered nurse,
licensed vocational nurse, physician assistant or a qualified
medical assistant. Alternatively, a medical assistant may receive
training from a secondary, postsecondary or adult education program
in a public school authorized by the Department of Education, in a
community college program, or a postsecondary institution
accredited by an accreditation agency recognized by the United
States Department of Education or approved by the Bureau for
Private Postsecondary Education.
Certification. Medical assistants are regulated by the Medical
Board of California and may be certified. There are two medical
assistant certifying agencies that are recognized by the National
Commission for Certifying Agencies. These include: 1) the American
Association of Medical Assistants, who provide Certified Medical
Assistant certification and 2) the American Medical Technologists
who provide Registered Medical Assistant certification.
Supervision. Medical assistants can be supervised by physicians,
surgeons, podiatrists or optometrists. Additionally, if a medical
assistant is working in a community or free clinic, they may work
under the direct supervision of a physician assistant, nurse
practitioner or nurse midwife when the supervising physician or
surgeon is not on site, only if the physician or surgeon has
created a written protocol for the activities of the medical
assistant.
Authorization. Medical assistants must receive specific
authorization before providing any technical services. This
authorization may be in the form of a specific written order or
standing order prepared by the supervising physician, surgeon or
podiatrist. The order must include an authorization for the
procedure to be performed and it must be noted in the patient's
medical record.
Records. Medical assistants are required to document all technical
supportive services in the patient's record. In addition, when
practicing in a community or free clinic under the supervision of a
physician assistant, nurse practitioner or nurse midwife, the
delegation of supervision from the physician, surgeon or podiatrist
to the physician assistant, nurse practitioner or nurse midwife,
must be documented in a written standard protocol.
Community and Free Clinics. In response to California's growing
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population and ensuing need to provide health care services, SB 111
was passed in 2001. SB 111 permitted medical assistants to perform
technical supportive services in community and free clinics under
the direct supervision of a physician assistant, nurse practitioner
or nurse midwife.
There are four types of licensed community clinics in California:
1) Federally Qualified Health Center sites (FQHC)
2) Federally Qualified Health Center look-alike sites
3) Free clinic sites
4) Other independent, non-profit clinic sites
A key distinction among these different designations is the type of
public funding support
each clinic receives. FQHC sites and FQHC look-alike sites both
meet eligibility requirements for two critical sources of funding
support: 1) enhanced Medi-Cal reimbursement rates and, 2) a federal
operating grant made available by Public Health Service Act (PHSA)
� 330. Only FQHC clinics receive PHSA � 330 operating grants,
which are nationally competitive. Conversely, FQHC look-alike
clinics have a non-competitive grant process.
Free clinics are statutorily required to not directly charge
patients for receipt of treatment. Further, free clinics are not
supported by enhanced Medi-Cal reimbursements or a PHSA � 330
operating grant and are supported largely by private donations.
(HSC Division 2, Chapter 1, Article 1 � 1204;
http://www.chcf.org/topics/almanac/inde.cfm?itemId=133890)
Since the passage of SB 111, neither the Physician Assistant
Committee nor the Board of Registered Nursing of the Department of
Consumer Affairs have received any patient safety complaints or
enacted any disciplinary action related to physician assistants,
nurse practitioners or nurse midwifes supervising medical
assistants in community and free clinics.
Though this bill does not propose an expansion of duties for
medical assistants, in the wake of the Patient Protection and
Affordable Care Act, the growing demand for health care services
and utilization of health information technology (HIT) to track
medical data, it is important to note the discomfort that other
allied health professionals have and may experience with
supervising medical assistants or embracing them and their expanded
role (utilization of HIT mechanisms such as inputting data in
electronic health records) as part of a medical team. A study
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published in 2010 examined the expanded role of medical assistants
as they worked in community and free clinics. According to the
study, respondents were asked about the challenges the clinics
faced in creating innovative or expanded roles for medical
assistants. Clinic managers and medical directors cited the lack
of resources available to provide the extra training needed for
medical assistants to learn new roles as the most significant
challenge. Another challenge was the acceptance of the role of
the medical assistants by the rest of the primary care team.
Concurrently, there existed consensus that these types of
challenges were generally overcome with time. Staff reported
enthusiasm when they observed how the medical assistants' functions
made a difference in patient flow and the overall quality of
patient care. Thus, despite initial trepidation, health
professionals who supervised medical assistants came to value the
role of the medical assistant as they worked within community and
free clinic settings.
(http://futurehealth.ucsf.edu/Public/PublicationsandResources/Conten
t.aspx?topic=Medical_Assistants_in_Community_Clinics:__Perspectives_
on_Innovation_in_Role_Development)
1. Arguments in Support. According to the Sponsor , physician
assistants have been delegated the task of supervising medical
assistants when the physician is not physically present in
specified licensed community clinics for over a decade. As such,
CAPA proposes to eliminate legal restrictions and barriers to
efficient coordinated care by allowing physicians to delegate the
task of medical assistant supervision to a physician assistant
across all outpatient medical settings. This change is necessary
if California hopes to accommodate the dramatic increase in
patients expected to result from the Patient Protection and
Affordable Care Act.
The California Association for Nurse Practitioners supports the
bill. They indicate SB 352 will expand the current practice that
occurs in community clinics of allowing nurse practitioners and
physician assistants to supervise medical assistants to all
settings. This model has been in place for over ten years with no
complications. Allowing nurse practitioners to supervise medical
assistants in this way has enabled them to focus their time and
services on patient care, delegating some very basic functions to a
medical assistant. Expanding this practice to all settings will
allow nurse practitioners to increase the number of patients they
will be able to see, providing much needed increased access to
health care. SB 352 makes no changes to the scope of practice of
either a medical assistant or a nurse practitioner but instead
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removes the limitations in current law that do not permit this
supervision model in a non-clinic setting.
The California Optometric Association supports the bill because
they believe it will expand access and allow more patients to
receive care. They state, "?deploying these professionals in a
team-based delivery model where they work collaboratively with
physician assistants, nurse practitioners or midwives will allow
California to meet the demands placed on its health care systems
created by a rapidly aging physician population and expansion of
health insurance coverage."
The United Nurses Associations of California/Union of Health Care
Professionals supports the bill. They indicate that with the
implementation of the Patient Protection and Affordable Care Act,
change is necessary in California in order to accommodate the
dramatic increase in patients expected to result from health care
reform.
The California Academy of Family Physicians indicates with the
large influx of newly insured individuals in California nearing, it
is necessary to continue to find more efficient ways of ensuring
adequacy in the delivery of primary care. The Academy applauds
efforts that streamline delivery of quality care while preserving
the team based approach that is best for patients.
4. Related Legislation. SB 1852 (Alpert, 2000) would have allowed
medical assistants 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. ( Note : This bill died in Assembly Health
Committee after opposition from the California Nurses Association
and the California Association for Medical Laboratory Technology.)
SB 252 (Alpert, Chapter 234, Statutes of 2003) specified medical
assistants are not authorized to perform a clinical laboratory test
or examination 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 medical assistants to provide technical supportive
services under the supervision of a physician assistant, nurse
practitioner or nurse midwife, but those provisions were removed
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from the bill in response to opposition.)
SB 111 (Alpert, Chapter 358, Statues of 2001) amended the Medical
Practice Act to authorize a medical assistant to perform specified
services in community and free clinics under the supervision of a
physician assistant, nurse practitioner or nurse-midwife. The bill
authorized a physician and surgeon in these specified clinics to
provide written instructions for medical assistants, 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. Suggested Technical Amendments.
The Board of Registered Nursing requires that all nurse midwives be
certified. As such, the following are recommended technical and
conforming changes:
Page 2, line 8, before "nurse-midwife" insert: certified
Page 2, line 11, before "nurse-midwife" insert: certified
Page 2, line 16, before "nurse-midwife" insert: certified
Page 2, line 20, before "nurse-midwife" insert: certified
Page 2, line 24, before "nurse-midwife" insert: certified
Page 2, line 36, before "nurse-midwife" insert: certified
Page 3, line 8, before "nurse-midwife" insert: certified
Page 3, line 13, before "nurse-midwife" insert: certified
Page 3, line 24, before "nurse-midwife" insert: certified
Page 3, line 31, before "nurse-midwife" insert: certified
Page 4, line 5, before "nurse-midwife" insert: certified
Page 4, line 17, before "nurse-midwife" insert: certified
SUPPORT AND OPPOSITION:
Support:
California Academy of Physician Assistants (Sponsor)
California Association for Nurse Practitioners
California Optometric Association
United Nurses Associations of California/Union of Health Care
Professionals
California Academy of Family Physicians
Opposition:
California Nurses Association (As of April 3, 2013.)
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Consultant: Le Ondra Clark, Ph.D.