BILL ANALYSIS �
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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 Le�n, 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)
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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
changes.
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
nurse-midwife.
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
Act.
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:
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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
CNM.
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.
Background
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.
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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
Education.
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
certification.
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
MA.
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
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perform technical supportive services in community and free
clinics under the direct supervision of a PA, NP or
nurse-midwife.
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
donations.
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.
Comments
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:
No
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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
Professionals
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
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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."
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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 Hern�ndez,
Holden, Jones, Jones-Sawyer, Levine, Linder, Logue, Lowenthal,
Maienschein, Mansoor, Medina, Melendez, Mitchell, Morrell,
Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan, Patterson,
Perea, V. Manuel P�rez, Quirk-Silva, Rendon, Salas, Skinner,
Stone, Ting, Wagner, Waldron, Weber, Wilk, Williams, John A.
P�rez
NO VOTE RECORDED: Brown, Campos, Ch�vez, Dickinson, Frazier,
Garcia, Quirk, Wieckowski, Yamada, Vacancy, Vacancy
MW:k 8/12/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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