BILL ANALYSIS �
SB 352
Page 1
Date of Hearing: June 25, 2013
ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER
PROTECTION
Richard S. Gordon, Chair
SB 352 (Pavley) - As Amended: June 19, 2013
SENATE VOTE : 36-2
SUBJECT : Medical assistants: supervision.
SUMMARY : Authorizes medical assistants (MAs) to perform
technical supportive services in any medical setting upon
specific authorization of a physician assistant (PA), nurse
practitioner (NP), or certified nurse-midwife (CNM) without a
physician on the premises. Specifically, this bill :
1)Expands the types of settings where MAs can provide technical
supportive services beyond community and free clinics to any
medical setting, with one exception.
2)Authorizes a physician or surgeon to authorize a NP, CNM, or
PA to supervise MAs following specific written instructions
provided by the physician or surgeon when the supervising
physician or surgeon is not onsite, if either:
a) The NP or CNM is functioning pursuant to standardized
procedures or protocols, including instructions for
specific authorizations, which shall be developed and
approved by the supervising physician and surgeon and the
NP or CNM; or,
b) The PA is functioning pursuant to existing requirements
for supervision and protocols, including instructions for
specific authorizations, and is authorized to do so by the
supervising physician and surgeon.
3)Specifies that the standards applied to MAs will be
established by the Medical Board of California (MBC).
4)Prohibits the MBC from adopting regulations that violate
existing statutory prohibitions on diagnosis or treatment.
5)Prohibits a MA from performing, or being authorized to
perform, any clinical laboratory test or examination for which
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the MA is not authorized under existing law.
6)Prohibits a MA from being employed for inpatient care in a
licensed general acute care hospital.
7)Prohibits a NP, CNM, or PA under this section from being a
laboratory director of a clinical laboratory.
8)Specifies that any authorization provided by a NP, CNM, or PA
for a MA to perform a prohibited procedure would be considered
unprofessional conduct.
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 and surgeon,
podiatrist, medical or podiatry corporation, PA, NP, CNM, or a
health care service plan; and specifies that an MA must be at
least 18 years of age, and have at least the minimum amount of
hours of appropriate training pursuant to standards
established by the MBC. (Business and Professions Code (BPC)
2069(b)(1))
2)Authorizes a MA to administer medication only by intradermal,
subcutaneous, or intramuscular injections and to perform skin
tests and additional technical supportive services with the
specific authorization and supervision of a licensed physician
and surgeon, or a podiatrist. (BPC 2069(a)(1))
3)Authorizes a MA to perform venipuncture or skin puncture for
the purposes of withdrawing blood upon specific authorization
and under the supervision of a licensed physician and surgeon,
podiatrist, PA, NP, or CNM. (BPC 2070)
4)Authorizes a MA to perform specified tasks and services in a
licensed community or free clinic upon the specific
authorization of a PA, NP, or CNM. (BPC 2069(a)(1))
5)Defines "specific authorization" as a specific written order
or standing order prepared by the supervising physician and
surgeon, podiatrist, PA, NP, or CNM authorizing the procedures
to be performed on a patient, and requires a notation of the
order be placed in the patient's medical record. (BPC
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2069(b)(2))
6)Defines "supervision" as the supervision of authorized
procedures by a physician and surgeon, podiatrist, PA, NP, or
CNM within the scope of their respective practices, who shall
be physically present in the treatment facility during the
performance of those procedures. (BPC 2069(b)(3))
7)Defines "technical supportive services" as the simple routine
medical tasks and procedures that may be safely performed by
an MA who has limited training and who functions under the
supervision of a licensed physician and surgeon, podiatrist,
PA, NP, or CNM. (BPC 2069(b)(4))
8)Authorizes the Board of Registered Nursing to take
disciplinary action against a certified or licensed nurse, or
deny an application for a certificate or license for
unprofessional conduct. (BPC 2761)
9)Authorizes the Physician Assistant Board to order the
suspension, revocation, or denial of a license, or order the
imposition of probationary conditions upon a PA license after
a hearing for unprofessional conduct. (BPC 3527)
10)Allows MBC to adopt and administer regulations that establish
standards for technical supportive services that may be
performed by a MA. (BPC 2071)
11)Provides that references to the "Division of Licensing" shall
be deemed to refer to the Medical Board of California. (BPC
2002)
FISCAL EFFECT : None. This bill is keyed non-fiscal by the
Legislative Counsel.
COMMENTS :
1)Purpose of this bill. Under existing law, PAs, NPs, and CNMs
are authorized to supervise MAs when the physician is not
physically present, but only in specified licensed community
or free clinics. This bill is intended to promote more
efficient coordinated care by allowing physicians to delegate
the task of MA supervision to PAs, NPs, and CNMs in all
medical settings, except licensed general acute care
hospitals. This bill is sponsored by the California Academy
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of Physician Assistants (CAPA).
2)Author's statement. According to the author's office, "The
implementation of the Patient Protection and Affordable Care
Act (ACA) in California will require the health care delivery
system(s) to accommodate an additional 4 to 6 million people.
The efficient use of existing health manpower resources will
become even more critical. California's primary care
infrastructure is already strained under current conditions,
leaving many patients waiting for long periods of time to
receive medical attention. One way to cut down on patient
wait-time is to improve to work distribution in medical
offices by allowing MAs to assist in basic medical tasks under
the supervision of a PA, NP, or CNM in outpatient facilities.
MAs already work under these conditions in free and community
clinics. By expanding this ability to all non-hospital,
out-patient facilities, MAs can better assist other medical
staff and promote overall efficiency."
3)Medical assistants. MAs are unlicensed medical personnel
trained to perform basic administrative, clerical and
technical supportive services in the office of a physician,
podiatrist or optometrist, and in clinic settings. These
services include taking blood pressure, charting height and
weight, administering medication, performing skin tests, and
withdrawing blood by venipuncture. According to the Bureau of
Labor and Statistics (BLS), in 2011 there were nearly 82,000
MAs employed in California. Nationally, BLS projects this
profession to grow by 34% over ten years, from 483,600 in
2008, to 647,500 by 2018.
4)Supervision requirements for MAs. MAs may currently be
supervised by licensed physicians and surgeons, podiatrists,
or optometrists. Before providing any technical services, MAs
must first receive a specific authorization in the form of a
written or standing order prepared by the supervising
physician and surgeon, podiatrist, or optometrist. This order
must specifically authorize the procedures to be performed by
the MA, and the MA must document all services performed in the
patient's record.
When working in a community or free clinic only, MAs may also
be supervised directly by a PA, NP, or CNM, if the supervising
physician or surgeon is not on site and has provided specific
written protocols for the activities the MA is authorized to
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perform. In these cases, the MA must document all services
performed in the patient's record, and also reference the
delegation of supervision from the physician and surgeon or
podiatrist to the PA, NP, or CNW.
With the exception of these clinics, MAs are limited to
performing only administrative and clerical duties when the
physician is not on the premises, and may not perform or
assist with technical supportive services. For example, if the
physician is making rounds at the hospital, out to lunch, or
absent from the clinic for any other reason, the MA may not
perform many of the tasks they are qualified for.
5)MA training and certification. Before performing any
services, an MA must receive training either 1) directly under
a licensed physician, podiatrist, registered nurse, licensed
vocational nurse, PA, or a MA qualified to train other MAs, as
specified, or 2) in a secondary, post-secondary, or adult
education program in a public school authorized by the
Department of Education, in a community college program
provided for in the Education Code, or a post-secondary
institution accredited or approved by the Bureau for Private
Postsecondary Education (BPPE) in the Department of Consumer
Affairs.
All MAs are regulated by the MBC and may become certified, but
are not licensed. The MA's employer may require that the he
or she be certified by a national or private association in
order to practice. MBC has approved three certifying
agencies: the American Association of Medical Assistants,
American Medical Technologists, and the California Certifying
Board of Medical Assistants.
6)Community or free clinics. A "community clinic" is a clinic
operated by a tax-exempt nonprofit corporation that is
supported and maintained in whole or in part by donations,
bequests, gifts, grants, government funds, or contributions,
that may be in the form of money, goods, or services. No
corporation other than a 501(c)(3) nonprofit corporation may
operate a community clinic. Any charges to the patient shall
be based on the patient's ability to pay, utilizing a sliding
fee scale.
A "free clinic" is defined as a clinic operated by a
tax-exempt, nonprofit corporation supported in whole or in
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part by voluntary donations, bequests, gifts, grants,
government funds or contributions, that may be in the form of
money, goods, or services. No corporation other than a
501(c)(3) nonprofit corporation shall operate a free clinic.
In a free clinic there shall be no charges directly to the
patient for services rendered, or for drugs, medicines,
appliances, or apparatuses furnished.
MAs are currently supervised directly by an NP, CNM, or PA
while working in these licensed community or free clinics,
which provides clinics with increased flexibility in staffing
and promotes better access to medical care in underserved
communities. SB 111 (Alpert) Chapter 358, Statues of 2001
originally established this practice, as clinics were
experiencing difficulty maintaining a supervising physician on
site at all times while the clinic is open and treating
patients.
7)Unprofessional conduct and MA authorization. This bill
specifies that a NP, CNM, or PA that authorizes a MA to
perform any clinical laboratory test or examination for which
the MA is not authorized, constitutes unprofessional conduct.
NPs and CNMs are licensed by the California Board of
Registered Nursing, while PAs are licensed by the California
Physician Assistant Board. Both entities have the authority
to take disciplinary action, including suspending and revoking
licenses, against a NP, CNM, or PA who is found to have
participated in unprofessional conduct.
This bill includes a specific clarification that a NP, CNM, or
PA would be subject to disciplinary action by their licensing
board for authorizing a MA to perform any clinical laboratory
test or examination for which the MA is not authorized in
order to increase patient safety. This is similar to existing
law for physicians, which prohibits the aiding and abetting of
unlicensed individuals engaging in the practice of medicine
8)Arguments in support . According to the sponsor of the bill,
the California Academy of Physician Assistants (CAPA), PAs
have been delegated the task of supervising MAs when the
physician is not physically present in specified licensed
community clinics for over a decade. As such, SB 352 proposes
to eliminate legal restrictions and barriers to efficient
coordinated care by allowing physicians to delegate the task
of MA supervision to a PA across almost all outpatient medical
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settings. This change is necessary if California hopes to
accommodate the dramatic increase in patients expected to
result from the ACA.
U.S. HealthWorks Medical Group states, "requiring a doctor to
be present while trained MAs perform routine technical
healthcare tasks is a wholly unnecessary and an inefficient
use of critical physician resources, which we all know are
only going to get scarcer as the reforms occasioned by the ACA
are implemented. PAs, NPs, and CNMs are highly trained and
licensed providers who are more than capable of providing
superior supervision to MAs handling their routine patient
care tasks. We know that this practice does not in any way
increase risk to patients and in fact, we believe overall
patient care is improved by allowing doctors to focus on the
more complex aspects of patient care."
The California Association for Nurse Practitioners states that
"allowing NPs to supervise MAs has enabled them to focus their
time and services on patient care by delegating some very
basic functions to an MA. Expanding this practice to all
settings will allow NPs 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 an MA or NP, but instead removes the
limitations in current law that do not permit this supervision
model in a non-clinic setting."
The California Optometric Association (COA) indicates that SB
352 will "deploy professionals in a team-based delivery model
where they work collaboratively with PAs, NPs, and CNMs." This
will "allow California to meet the demands placed on its
health care system created by a rapidly aging physician
population and expansion of health insurance coverage."
9)Arguments in opposition . The California Nurses Association
(CNA) believes that SB 352 "will contribute to the
fragmentation of primary care services, and, by consequently
expanding the use of MAs, will undermine the delivery of safe
health care services at a critical time in the expansion of
access to primary care under the ACA." CNA states that "MAs
are unlicensed, minimally trained healthcare assistive
personnel whose current role in physician offices, and
community and free clinic settings includes the administration
of medications, including administration by injection, as well
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as the administration of medication orally, sublingually,
topically, vaginally or rectally, or by providing a single
dose to a patient for immediate self-administration?
unlicensed MAs would likely become the substitute for licensed
practitioners, such as pharmacists and other advanced practice
clinicians for the administration of medication,
immunizations, and other practices."
Further, CNA argues that "there is no indication that the
impact of the ACA will necessitate a deskilling of healthcare
services in order to provide primary care provider access to
California consumers. CNA believes this bill will shift
licensed nursing functions onto less qualified employees in
order to shuttle patients through offices and clinics more
rapidly. CNA maintains its position that the expansion of
access to primary healthcare services does not require
existing providers to work more quickly, it simply requires a
greater number of those appropriately educated providers."
10)Previous legislation. SB 92 (Aanestad) of 2009 proposed many
changes to existing health care law, one of which would have
authorized MAs to perform treatment activities under the
authorization of an NP, a nurse-midwife, or a PA in any
setting. This bill failed passage in the Senate Health
Committee.
AB 1X 1 (N��ez) of 2008 would have authorized MAs to perform
treatment activities under the authorization of an NP, a
nurse-midwife, or a PA in any setting, among many other
changes to California's health care delivery system. This
bill failed passage in the Senate Health Committee.
AB 859 (Bass) of 2006 would have authorized MAs to perform
specified services under the supervision of a PA, NP, or CNM
without a physician on site in certain clinics exempt from
licensure, in addition to licensed free and community clinics.
This bill failed passage in the Assembly Committee on Business
and Professions.
SB 252 (Alpert) Chapter 234, Statutes of 2003, specified that
MAs are not authorized to perform a clinical laboratory test
or examination, and clarified that a NP, CNM, or PA is not
authorized to be a laboratory director of a clinical
laboratory.
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SB 111 (Alpert) Chapter 358, Statues of 2001, authorized a MA
to perform specified services in community and free clinics
under the supervision of a PA, NP, or CNM, if a physician or
surgeon provides specific written instructions regarding the
performance of tasks or duties by a medical assistant while
under the supervision of a PA, NP, or CNM when the supervising
physician and surgeon is not on site.
SB 1852 (Alpert) of 2000, would have authorized a MA to
perform specified tasks and services upon the authorization
and supervision, as specified, of a PA, NP, or CNM in a
licensed clinic that is enrolled by the State Department of
Health Services as a Medi-Cal provider in the Family Planning,
Access, Care, and Treatment Waiver Program. This bill died in
the Assembly Health Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
California Academy of Physician Assistants (sponsor)
Bay Area Council
California Academy of Family Physicians
California Association for Nurse Practitioners
California Optometric Association
Kaiser Permanente
Medical Board of California
U.S. HealthWorks Medical Group
United Nurses Associations of California/Union of Health Care
Professionals
1 individual
Opposition
California Nurses Association
Analysis Prepared by: Angela Pontes / B.,P. & C.P. / (916)
319-3301