BILL ANALYSIS                                                                                                                                                                                                    Ó


          |SENATE RULES COMMITTEE            |                        SB 352|
          |Office of Senate Floor Analyses   |                              |
          |1020 N Street, Suite 524          |                              |
          |(916) 651-1520         Fax: (916) |                              |
          |327-4478                          |                              |
                                 UNFINISHED BUSINESS

          Bill No:  SB 352
          Author:   Pavley (D), et al.
          Amended:  6/19/13
          Vote:     21

           SENATE BUSINESS, PROF. & ECON. DEV. COMM.  :  9-1, 4/8/13
          AYES:  Price, Emmerson, Block, Corbett, Galgiani, Hernandez,  
            Hill, Padilla, Wyland
          NOES:  Yee

           SENATE FLOOR  :  36-2, 4/22/13
          AYES:  Anderson, Beall, Berryhill, Block, Calderon, Cannella,  
            Corbett, Correa, De León, DeSaulnier, Emmerson, Evans, Fuller,  
            Gaines, Galgiani, Hernandez, Hill, Hueso, Huff, Jackson,  
            Knight, Lara, Leno, Lieu, Liu, Monning, Nielsen, Padilla,  
            Pavley, Price, Roth, Steinberg, Walters, Wolk, Wright, Wyland
          NOES:  Hancock, Yee
          NO VOTE RECORDED:  Vacancy, Vacancy

           ASSEMBLY FLOOR  :  69-0, 8/8/13 - See last page for vote

           SUBJECT  :    Medical assistants:  supervision

           SOURCE  :     California Academy of Physician Assistants
                      California Association of Physician Groups

           DIGEST :    This bill allows medical assistants (MAs) to perform  
          technical supportive services, in doctor's offices and all  
          medical clinics, under the supervision of a physician assistant  
          (PA), nurse practitioner (NP) or certified nurse-midwife (CNM)  


                                                                     SB 352

          without a physician on the premises; and makes other clarifying,  
          conforming, technical, and nonsubstantive changes.

           Assembly Amendments  prohibit an NP, CNM, or PA from authorizing  
          an MA to perform any clinical laboratory test or exam for which  
          the MA is not authorized, as specified; and make technical  

           ANALYSIS  :    

          Existing law:

          1. Authorizes an MA, as defined, to perform specified services  
             relating to the administration of medication and performance  
             of skin tests and simple routine medical tasks and procedures  
             upon specific authorization from and under the supervision of  
             a licensed physician and surgeon or podiatrist, or in a  
             specified clinic upon specific authorization of a PA, NP, or  

          2. Defines "specific authorization" as a specific written order  
             prepared by the supervising physician, surgeon, podiatrist,  
             NP or nurse-midwife authorizing the procedures to be  
             performed on a patient.  

          3. Requires the Board of Registered Nursing to issue a  
             certificate to practice nurse-midwifery to a qualifying  
             applicant who is licensed pursuant to the Nursing Practice  

          4. Authorizes MAs to perform additional technical supportive  
             services, as specified.

          This bill:

          1. Expands the types of settings where MAs can provide technical  
             supportive services from community and free clinics to any  
             medical setting.  

          2. Authorizes a physician or surgeon to authorize an NP, CNM, or  
             PA to provide supervision of MAs as they follow written  
             instructions provided by the physician when the physician is  
             not on site, if either:  



                                                                     SB 352

             A.    The NP or CNM is functioning pursuant to standardized  
                procedures, as defined by Business and Professions Code  
                (BPC) Section 2725, or protocol.  The standardized  
                procedures or protocol, including instructions for  
                specific authorizations, shall be developed and approved  
                by the supervising physician and surgeon and the NP or  

             B.    The PA is functioning pursuant to regulated services  
                defined in BPC Section 3502, including instructions for  
                specific authorizations, and is approved to do so by the  
                supervising physician and surgeon.

          3. Specifies that the standards established for MAs 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 MAs shall not perform any tests or  
             examinations for which he/she is not authorized. 

          5. Prohibits an NP, CNM, or PA to be a laboratory director of a  
             clinical laboratory.

          6. Prohibits an NP, CNM, or PA from authorizing an MA to perform  
             any clinical laboratory test or examination for which the MA  
             is not authorized, as specified, a violation of which  
             constitutes unprofessional conduct.

           MAs 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 MAs  
          will grow by 34%, from 483,600 in 2008, to 647,500 by 2018.   
          California employs nearly 82,000 MAs.  MAs are unlicensed  
          personnel who work in physician, podiatrist or optometrist  
          offices and clinics.  MAs may not work for inpatient care in  
          licensed general acute care hospitals.  MAs can perform basic  
          administrative, clerical and technical supportive services when  
          conditions regarding supervision, training, specific  
          authorization and records are met. 



                                                                     SB 352

           Training  .  An MA must receive training either directly from a  
          physician, surgeon, podiatrist, registered nurse, licensed  
          vocational nurse, PA or a qualified MA.  Alternatively, an MA  
          may receive training from a secondary, postsecondary or adult  
          education program in a public school authorized by the  
          California Department of Education, in a community college  
          program, or a postsecondary institution accredited by an  
          accreditation agency recognized by the U.S. Department of  
          Education or approved by the Bureau for Private Postsecondary  

           Certification  .  MAs are regulated by the MBC and may be  
          certified.  There are two MA certifying agencies that are  
          recognized by the National Commission for Certifying Agencies   
          the American Association of Medical Assistants who provide  
          Certified Medical Assistant certification, and the American  
          Medical Technologists who provide Registered Medical Assistant  

           Supervision  .  MAs can be supervised by physicians, surgeons,  
          podiatrists or optometrists.  Additionally, if an MA is working  
          in a community or free clinic, they may work under the direct  
          supervision of a PA, NP 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  

           Authorization  .  MAs 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  .  MAs 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 PA, NP  
          or nurse-midwife, the delegation of supervision from the  
          physician, surgeon or podiatrist to the PA, NP or nurse-midwife,  
          must be documented in a written standard protocol. 

           Community and free clinics  .  In response to California's growing  
          population and ensuing need to provide health care services, SB  
          111 (Alpert, Chapter 358, Statutes of 2000) permitted MAs to  



                                                                     SB 352

          perform technical supportive services in community and free  
          clinics under the direct supervision of a PA, NP or  

          There are four types of licensed community clinics in  
          California:  (1) Federally Qualified Health Center sites (FQHC);  
          (2) FQHC look-alike sites; (3) free clinic sites; and (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 Section 330 of the Public Health Service Act  
          (PHSA).  Only FQHC clinics receive PHSA Section 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  
          Section 330 operating grant and are supported largely by private  

          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 PAs, NPs or  
          nurse-midwifes supervising MAs in community and free clinics. 

          According to the author's office, existing laws require that a  
          physician must be present at the practice site to supervise an  
          MA.  However, MAs can work under the supervision of a PA, NP or  
          nurse-midwife in licensed community and free clinics.  With the  
          exception of these clinics, MAs 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.

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  No   Local:  



                                                                     SB 352

           SUPPORT :   (Verified  8/12/13)

          California Academy of Physician Assistants (co-source)
          California Association of Physician Groups (co-source)
          California Academy of Family Physicians
          California Association for Nurse Practitioners
          California Optometric Association
          United Nurses Associations of California/Union of Health Care  

           OPPOSITION  :    (Verified  8/12/13)

          Board of Registered Nursing
          California Nurses Association
          National Nurses United

           ARGUMENTS IN SUPPORT  :    According to this bill's sponsor, 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, CAPA 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 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 (ACA).  

          The California Association for Nurse Practitioners indicates  
          that this bill will expand the current practice that occurs in  
          community clinics of allowing NPs and PAs to supervise MAs to  
          all settings.  This model has been in place for over 10 years  
          with no complications.  Allowing NPs to supervise MAs in this  
          way has enabled them to focus their time and services on patient  
          care, 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.  This bill makes no  
          changes to the scope of practice of either an MA or a 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 believes this bill will  



                                                                     SB 352

          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 indicates that with the implementation of the  
          ACA, 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.

           ARGUMENTS IN OPPOSITION  :    According to the California Nurses  
          Association (CNA), "this bill 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 Affordable Care Act.?  This  
          bill is premature since there is no indication that the impact  
          of the Affordable Care Act 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 far less qualified  
          employees in order to shuttle patients through offices and  
          clinics more rapidly.  Quantity care is not quality care and 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."

          The Board of Registered Nursing writes that they are concerned  
          that "the increase in venues where medical assistants could  
          function in a technical role could decrease the availability of  
          licensed professionals thus possible having a negative impact on  
          public safety and health."



                                                                     SB 352

           ASSEMBLY FLOOR  : 69-0, 08/08/13
          AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Bigelow, Bloom,  
            Bocanegra, Bonilla, Bonta, Bradford, Buchanan, Ian Calderon,  
            Chau, Chesbro, Conway, Cooley, Dahle, Daly, Donnelly, Eggman,  
            Fong, Fox, Beth Gaines, Gatto, Gomez, Gonzalez, Gordon,  
            Gorell, Gray, Grove, Hagman, Hall, Harkey, Roger Hernández,  
            Holden, Jones, Jones-Sawyer, Levine, Linder, Logue, Lowenthal,  
            Maienschein, Mansoor, Medina, Melendez, Mitchell, Morrell,  
            Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan, Patterson,  
            Perea, V. Manuel Pérez, Quirk-Silva, Rendon, Salas, Skinner,  
            Stone, Ting, Wagner, Waldron, Weber, Wilk, Williams, John A.  
          NO VOTE RECORDED: Brown, Campos, Chávez, Dickinson, Frazier,  
            Garcia, Quirk, Wieckowski, Yamada, Vacancy, Vacancy

          MW:k  8/12/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

                                   ****  END  ****