BILL ANALYSIS Ó
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|Hearing Date:April 22, 2013 |Bill No:SB |
| |491 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Curren D. Price, Jr., Chair
Bill No: SB 491Author:Hernandez
As Amended:April 16, 2013 Fiscal: Yes
SUBJECT: Nurse practitioners.
SUMMARY: Deletes the requirement that nurse practitioners perform
certain tasks pursuant to standardized procedures and/or consultation
with a physician or surgeon and authorizes a nurse practitioner to
perform those tasks independently. Also requires, after July 1, 2016,
that nurse practitioners possess a certificate from a national
certifying body in order to practice.
Existing law:
1) Establishes the Board of Registered Nursing (BRN), within the
Department of Consumer Affairs (DCA), and authorizes the BRN to
license, certify and regulate nurses. (Business and Professions
Code (BPC) §§ 2701; 2708.1)
2) Clarifies that there are various and conflicting definitions of
"nurse practitioner" (NP) and "registered nurse" (RN) that are used
within California and finds the public interest is served by
determining the legitimate and consistent use of the title "nurse
practitioner" established by the BRN. (BPC § 2834)
3) Requires applicants for licensure as a NP to meet specified
educational requirements including: (BPC § 2835.5)
a) Possessing a Master's degree in nursing, and/or a Master's
degree in a clinical field related to nursing;
b) A graduate degree in nursing; and
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c) Completion of a registered nursing program authorized by the
BRN.
4) Recognizes the existence of overlapping functions between
physicians and NPs and permits additional sharing of functions
within organized health care systems that provide for collaboration
between physician and NPs. (BPC § 2725; Health and Safety Code
(HSC) § 1250)
5) Defines "health facility" as any facility, place, or building that
is organized, maintained, and operated for the diagnosis, care,
prevention and treatment of physical or mental human illness
including convalescence, rehabilitation, care during and after
pregnancy, or for any one or more of these purposes, for which one
or more persons are admitted for a 24-hour stay or longer. (HSC §
1250)
6) Authorizes a NP to do the following, pursuant to standardized
procedures created by a physician or surgeon, or in consultation
with a physician or surgeon: (BPC § 2835.7)
a) Order durable medical equipment;
b) Certify disability claims; and
c) Approve, sign, modify or add information to a plan of
treatment for individuals receiving home health services.
7) Defines "furnishing" as the ordering of a drug or device in
accordance with standardized procedures or protocols (SPP) or
transmitting an order of a supervising physician and surgeon. (BPC
§ 2836.1(h))
8) Defines "drug order" or "order" as an order for medication which is
dispensed to or for an ultimate user and issued by a NP. (BPC §
2836.1(i))
9) Establishes that the furnishing and ordering of drugs or devices by
NPs is done in accordance with the SPP developed by the supervising
physician and surgeon, NP and the facility administrator or
designee, and shall be consistent with the NPs educational
preparation and/or established and maintained clinical competency.
(BPC § 2836.1)
10)Indicates a physician and surgeon may determine the extent of
supervision necessary in the furnishing or ordering or drugs and
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devices. (BPC § 2836.1(g)(2))
11)Permits a NP to furnish or order Schedule II through Schedule V
controlled substances and specifies that a copy of the SPP shall be
provided upon request to any licensed pharmacist who or devices
when there is uncertainty about the NP furnishing the order.
(BPC § 2836.1(f)(1)(2); HSC §§ 11000; 11055; 11056).
12)Indicates that for Schedule II controlled substances, the SPP must
address the diagnosis of the illness, injury or condition for which
the controlled substance is to be furnished.
(BPC § 2836.1(2))
13)Requires that a NP has completed a course in pharmacology covering
the drugs or devices to be furnished or ordered. (BPC §
2836.1(g)(1))
14)States a NP must hold an active furnishing number, register with
the United States Drug Enforcement Administration and take a
continuing education course in Schedule II controlled substances.
(BPC § 2836.1(3))
15)Specifies the SPP must list which nurse practitioners may furnish
or order drugs or devices. (BPC § 2836.1(c)(1))
16)Requires that the physician and surgeon supervision shall not be
construed to require the physical presence of the physician, but
does include collaboration to create the SPP, approval of the SPP
and availability of the physician and surgeon to be contacted via
telephone at the time of the patient examination by the NP. (BPC §
2836.1(d))
17)Limits the physician and surgeon to supervise no more than four NPs
at one time.
(BPC § 2836.1(e))
18)Authorizes the BRN to issue a number to NPs who dispense drugs or
devices and revoke, suspend or deny issuance of the number for
incompetence or gross negligence.
(BPC § 2836.2)
This bill:
1) Makes findings and declarations of the Legislature regarding the
vital, safe and effective role of NPs and notes the important role
of NPs addressing the primary care shortage anticipated as a result
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of the implementation of the federal Patient Protection and
Affordable Care Act (ACA).
2) Indicates that a person who has been found to be qualified by the
BRN to use the title "nurse practitioner" prior to January 1, 2005,
is not required to submit additional information to the BRN.
3) Requires after July 1, 2016, an applicant for certification as a NP
must hold a national certification from a national certifying body
recognized by the BRN.
4) Removes the requirement that NPs must do the following tasks only
if there are SPP authorized by a physician:
a) Order durable medical equipment;
b) Certify disability claims; and
c) Approve, sign, modify or add information to a plan of
treatment for individuals receiving home health services.
5) Adds the following to the list of tasks NPs can perform
independently and without a SPP authorized by a physician:
a) Assess patients, synthesize and analyze data and apply
principles of health care;
b) Manage patients' physical and psychosocial health status;
c) Analyze data to identify the nature of a health care problem
and select, implement and evaluate appropriate treatment;
d) Examine a patient and establish a medical diagnosis;
e) Order, furnish or prescribe drugs or devices;
f) Refer a patient to another health care provider and consult
with the other health care provider if the situation or condition
is beyond the NPs knowledge and experience;
g) Delegate duties to a medical assistant;
h) Order hospice care; and
i) Maintain medical malpractice insurance.
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6) Specifies that drugs or devices furnished, ordered or prescribed
independently by a NP shall be consistent with the NPs educational
preparation or level of competency.
7) Indicates that a NP shall not furnish, order or prescribe a
dangerous drug without an appropriate examination and a medical
indication except in certain circumstances.
8) Permits NPs to prescribe controlled substances and register with
the United States Drug Enforcement Administration.
FISCAL EFFECT: Unknown. This bill has been keyed "fiscal" by
Legislative Counsel.
COMMENTS:
1. Purpose. The bill is sponsored by the Author. The Author
indicates SB 491 will establish full practice authority for NPs
enabling them to perform all tasks and functions consistent with
their education and training, and in collaboration with physicians
and other health care providers. The Author believes SB 491 is an
answer to the anticipated health workforce shortages due to the
implementation of the Patient Protections and Affordable Care Act
in 2014. The Author notes, "?many newly insured Californians will
cause additional pressure on the already strained health care
system, particularly in medically underserved areas."
2. Background.
a) The Patient Protections and Affordable Care Act. On
March 23, 2010, President Obama signed the Patient Protection
and Affordable Care Act (ACA) into federal statute. The ACA,
which states will begin implementing in 2014, represents one
of the most significant government expansions and regulatory
overhauls of the United States health care system since the
passage of Medicare and Medicaid in 1965. The ACA is aimed at
increasing the rate of health insurance coverage for Americans
and reducing the overall costs of health care. It provides a
number of mechanisms including mandates, subsidies and tax
credits to employers and individuals in order to increase the
coverage rate. Additional reforms aim to improve health care
outcomes and streamline the delivery of health care. One
salient provision is the requirement for insurance companies
to cover all applicants and offer the same rates regardless of
pre-existing medical conditions.
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Opponents of the ACA turned to the federal courts to challenge
its constitutionality. On June 28, 2012, the United States
Supreme Court upheld the constitutionality of most of ACA in
the case of National Federation of Independent Business versus
Sebelius. Specifically, the Supreme Court upheld the mandate
for individuals to purchase health insurance if not covered by
their employers on the basis that it is a tax rather than
protection under the Commerce Clause. However, the Supreme
Court determined that states could not be forced to
participate in the expansion of Medicaid. As such, all
provisions of the ACA will continue in effect or will take
effect as scheduled subject to states determination on
Medicaid expansion. In California, efforts are well underway
to implement the ACA including Medicaid expansion, also
referred to as "Medi-Cal" in California, by 2014.
b) Primary Care Workforce Shortage. As a result of
implementation of the ACA, about 4.7 million additional
Californians will be eligible for health insurance beginning
in 2014. It is anticipated that the newly insured will
increase demand for health care on an already strained system.
For example, according to estimates obtained from the Council
on Graduate Medical Education (CGME), the number of primary
care physicians actively practicing in California is far below
the state's need. The distribution of these primary care
physicians is also poor. In 2008, there were 69,460 actively
practicing primary care physicians in California, of which
only 35 percent reported they actually practiced primary care.
This equates to 63 active primary care physicians per 100,000
persons. However, according to the CGME, 60 to 80 primary
care physicians are needed per 100,000 persons in order to
adequately meet the needs of the population. When the same
metric is applied regionally, only 16 of California's 58
counties fall within the needed supply range for primary care
physicians. In other words, less than one third of
Californians live in a community where they have access to
adequate health care services.
c) Nurse Practitioner Education, Training and Scope.
Education and Training. The BRN sets the educational standards
for NP certification. A NP is a registered nurse (RN) who has
earned a bachelors and postgraduate nursing degree such as a
Master's or Doctorate degree. NPs possess advanced skill in
physical diagnosis, psycho-social assessment and management of
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health-illness needs in primary health care, which occurs when
a consumer makes contact with a health care provider who
assumes responsibility and accountability for the continuity
of health care regardless of the presence or absence of
disease (CCR §§ 1480(b); 1484). Examples of primary health
care include: physical and mental assessment, disease
prevention and restorative measures, performance of skin tests
and immunization techniques, withdrawal of blood and authority
to initiate emergency procedures.
Scope/ Standardized Procedures (SPPs). A NP does not have an
additional scope of practice beyond the RNs scope and must
rely on SPPs for authorization to perform medical functions
which overlap with those conducted by a physician (CCR §
1485). Examples of these functions include: diagnosing
mental and physical conditions, using drugs in or upon human
beings, severing or penetrating the tissue of human beings and
using other methods in the treatment of diseases, injuries,
deformities or other physical or mental conditions.
Standardized procedures and protocols must be developed
collaboratively with NPs, physicians and administration of the
organized health care system where they will be utilized.
Because of this interdisciplinary collaboration, there is
accountability on several levels for the activities to be
performed by the NP. Importantly, a NP must provide the
organized health system with satisfactory evidence that the
nurse meets the experience, training and/or education
requirements to perform the functions. If a NP undertakes a
procedure without the competence to do so, such an act may
constitute gross negligence and be subject to discipline by
the BRN.
The BRN and the Medical Board of California (MBC) jointly
promulgated the following guidelines for SPPs: (Board of
Registered Nursing, Title 16, California Code of Regulations
(CCR) section 1474; Medical Board of California, Title 16, CCR
Section 1379.)
Standardized procedures and protocols shall include a written
description of the method used in developing and approving
them and any revision thereof. Each SPP shall:
1) Be in writing, dated and signed by the
organized health care system personnel authorized to
approve it;
2) Specify which SPP functions registered
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nurses may perform and under what circumstances;
3) State any specific requirements which are
to be followed by NPs in performing particular SPP
functions;
4) Specify any experience, training, and/or
education requirements for performance of SPP
functions;
5) Establish a method for initial and
continuing evaluation of the competence of those NPs
authorized to perform SPP functions;
6) Provide for a method of maintaining a
written record of those persons authorized to perform
SPP functions;
7) Specify the scope of supervision required
for performance of SPP functions, for example,
telephone contact with the physician;
8) Set forth any specialized circumstances
under which the NP is to immediately communicate with a
patient's physician concerning the patient's condition;
9) State the limitations on settings, if any,
in which SPP functions may be performed;
10) Specify patient record-keeping
requirements; and
11) Provide for a method of periodic review
of the SPP.
d) Nurse Practitioners in Medically Underserved Areas.
Supervision of Medical Assistants. In response to California's
growing population and ensuing need to provide health care
services, SB 111 was passed in 2001. SB 111 permits NPs and
other specified allied health professionals to supervise
medical assistants (MAs) without a physician present and
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according to SPPs established by the physician.
This supervision model is currently only permitted in free and
community clinics such as Federally Qualified Health Centers
(FQHC) and independent non-profit clinics. These clinics are
typically in medically underserved areas and are statutorily
prohibited from directly charging patients for receipt of
treatment. They are not supported by enhanced Medi-Cal, but
are largely supported by private donations. Since the passage
of SB 111, the BRN within the DCA has not received any patient
safety complaints or enacted any disciplinary action related
to NPs supervising MAs in free and community clinics.
( http://www.chcf.org/topics/almanac/inde.cfm?itemId=133890 ;HSC
Division 2, Chapter 1, Article 1 § 1204)
Nurse-Managed Health Clinics. Nurse-managed health clinics,
of which many are FQHCs and independent non-profit clinics,
are safety net clinics that provide primary care, health
promotion and disease prevention services to patients who are
least likely to receive ongoing health care. This population
includes people of all ages who are uninsured, underinsured,
living in poverty and minority groups. Unlike other FQHC and
independent non-profits, these clinics are solely operated by
NPs.
According to the National Nursing Centers Consortium, there
are at least 250 nurse-managed clinics already operating in
the United States; most are located in the East Coast. Of
these, 10 have been chosen for funding through a federal
expansion initiative. One such clinic, GLIDE Health Services,
is a FQHC located in San Francisco, California and provides
primary and urgent care, preventative services and psychiatric
treatment to an urban population.
Physician Supervision. In many of the nurse-managed clinics,
the physician to NP supervision relationship is quite
flexible. A supervising physician may be present for a very
limited amount of time to perform perfunctory tasks such as
signing off on equipment orders, and reviewing and signing
medical records. The physician may also elect to make
himself/herself available for telephonic consult. For
example, at GLIDE the supervising physician is physically on
site 1-2 days a week to sign off on orders such as wheel
chairs, walkers and commodes and to review medications that
have been prescribed and furnished by NPs. According to
Patricia Dennehy, a NP and director of GLIDE, "Though we value
our MD colleagues and consult with them for complex care
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issues, currently there are administrative barriers to care
delivery and access that are not practical."
Clinical Training Sites. In addition to providing care to
patients, nurse-managed health clinics also play an important
role in health professions education. More than 85 of the
nation's leading nursing schools operate nurse-managed health
clinics that serve as clinical education and practice sites
for nursing students and faculty. Many, like GLIDE, also have
partnerships with other academic programs and provide learning
opportunities for medical, pharmacy, social work, public
health and other students.
e) Full Practice Authority. The American Association of
Nurse Practitioners defines full practice authority as, "The
collection of state practice and licensure laws that allow for
nurse practitioners to evaluate patients, diagnose, order and
interpret diagnostic tests, initiate and manage treatments,
including prescribe medications, under the exclusive licensure
authority of the state board of nursing." Like the changes to
statute proposed in this legislation, under full practice
authority, NPs are still required to meet educational and
practice requirements for licensure, maintain national
certification and remain accountable to the public and the
state board of nursing. Under this model, NPs would continue
to consult and refer patients to other health care providers
according to the patient's needs.
Over the past 50 years, several organizations and research
institutions have examined the feasibility of full practice
authority for NPs. The Institute of Medicine of the National
Academies of Science released a 2010 report titled, The Future
of Nursing: Leading Change, Advancing Health, in which the IOM
wrote, "Remove scope of practice barriers. [NPs] should be
able to practice to the full extent of their education and
training?the current conflicts between what [NPs] can do based
on their education and training and what they may do according
to state federal regulations must be resolved so that they are
better able to provide seamless, affordable and quality care."
A report by the National Governor's Association, The Role of
Nurse Practitioners in Meeting Increased Demand for Primary
Care noted, "In light of research evidence, states might
consider changing scope of practice restrictions and assuring
adequate reimbursement for their services as a way of
encouraging and incentivizing greater NP involvement in the
provision of primary health care."
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Despite these arguments, some physician groups, including the
American Medical Association (AMA) assert that encouraging
full practice authority may put patients' health at risk.
They cite the difference in educational attainment noting that
physicians are required to complete four years of medical
school plus three years of residency compared to the four
years of nursing school and two years of graduate school
required for NPs.
Other States. Many other states have recognized the ability
for NPs to play a more efficient role in the delivery of
health care services and have updated their practice acts to
align with NPs training and education. For example, about one
third of the nation has adopted full practice authority
including: Alaska, Arizona, Colorado, District of Columbia,
Hawaii, Idaho, Iowa, Maine, Montana, Oregon, New Hampshire,
New Mexico, North Dakota, Rhode Island, Vermont, Washington
and Wyoming. The AMA contends that many of the NPs that
practice independently in these states do not deliver care to
underserved areas.
Financial Implications . Over the past 40 years, there have
been a number of studies on the cost-effectiveness of NP
practice (Office of Technology Assessment, 1986; Chenowith,
Martin, Pankowski & Raymond, 2008; Bakerjian, 2008; Chen,
McNeese-Smith, Cowan, Upenieks & Afifi, 2009). Results
overwhelmingly show NPs provide equivalent or improved medical
care at a lower cost than their physician counterparts. Though
the ACA encourages the creation of nurse-managed practices, by
requiring insurers to pay NPs the same rates paid to
physicians for identical services rendered, Medicare will not
provide equal reimbursement. Presently, Medicare pays NPs 85%
of the physician rate for the same services. The Medicare
Payment Advisory Commission, the federal agency that advises
Congress on Medicare issues, found that there was no
analytical foundation for this difference. Despite this fact,
revising payment methodology would require Congress to change
the Medicare law. Additionally, health insurance plans have
significant discretion to determine what services they cover
and which providers they recognize. Not all plans cover NPs.
Further, many managed care plans require enrollees to
designate a primary care provider but do not always recognize
NPs. In fact, a 2009 survey conducted by the National Nursing
Centers Consortium found that nearly half of the major managed
care organizations did not credential NPs as primary care
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providers
( www.healthaffairs.org/healthpolicybriefs/brief.php ). If NPs
were granted full practice authority, state efforts would need
to be undertaken to ensure NPs would be recognized as primary
care providers by insurance companies.
1. Arguments in Support. The United Nurses Associations of
California/ Union of Health Care Professionals supports the bill.
In their letter they indicate, "Independent practice would allow
NPs to choose to see Medi-Cal patients, a decision that is now left
up to the physician they work for. Due to the excellent safety and
efficacy record NPs have earned historically, the Institutes of
Medicine and the National Council of State Boards of Nursing have
recommended full practice for NPs. Currently, 17 states allow NPs
to practice at the full extent of their training and education with
independent practice."
The California Association for Nurse Practitioners supports the
bill. They point out in their letter, "Next year's addition of up
to seven million new health care consumers affected by
implementation of the Affordable Care Act is sure to exacerbate
California's current shortage and uneven distribution of primary
care physicians. SB 491 provides a partial solution to this
dilemma by allowing NPs to play a boarder role in the health care
system. Adoption of the policy changes proposed in this bill would
add California to the growing number of states that already allow
'independent practice' for NPs in a wide range of health care
settings."
The American Association of Retired Persons supports the bill. In
their letter they note, "Decades of evidence demonstrate that
[nurse practitioners] have been providing high quality health care
with positive outcomes equal to the care provided by their
physician counterparts. Consumers will have improved access to
medications, diagnoses and treatments, and referrals to specialists
and therapists with the modernization of California's scope of
practice laws."
The Association of California Healthcare Districts states, "As
health care districts are located in rural areas and have a
difficult time recruiting physicians to their areas, expanding the
scope of practice of Nurse Practitioners would allow patients to
receive continuous preventative and acute care should there be no
access to a physician."
The California Association for Nurse Anesthetists supports the
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bill. In their letter they note, "[Nurse Anesthetists] work
independently of anesthesiologists in 80% of California counties in
a wide variety of practice settings; currently seven rural counties
depend solely on nurse anesthetists?In 2009, Governor Arnold
Schwarzenegger allowed California to "opt-out" of a requirement
that [nurse anesthetists] be supervised by physicians to receive
federal reimbursement. This has allowed our members to provide
safe, high quality care to Californians at affordable rates, while
increasing access to care."
The California Optometric Association believes that this
legislation in necessary to make the promise of the ACA a reality.
Blue Shield of California indicates that the bill will expand the
range of services that these practitioners are able to provide will
improve access and quality of care as they are well trained and
highly educated professionals that are already providing integral
health services.
The California Pharmacists Association wrote a joint letter with
the California Society of Health-System Pharmacists . In it they
write, "CSHP and CPhA believe that it is vital to better utilize
all health care providers consistent with their training and
education to address current workforce shortages. By empowering
nurse practitioners to provide additional services with greater
flexibility, SB 491 is an important part of the equation to meet
health system demand."
Californians for Patient Care also supports the bill. In their
letter they note, "It is widely noted that there are not enough
trained medical professionals to appropriately care for the influx
of new patients. We believe it is important that qualified,
educated and trained nurse practitioners be allowed to practice to
the extent of their licenses to best serve California's patient
population throughout the state."
The National Association of Pediatric Nurse Practitioners state
their support when they write, "With the exception of Nevada,
California is surrounded by states that allow nurse practitioners
full practice authority. We are not asking to expand on what we
are trained to do; we are requesting that required supervision by a
physician be removed since we already operate under professional
standards. This is an unnecessary regulation and time spent
supervising and being supervised limits the amount of time the
nurse practitioner and physician can spend providing direct patient
care."
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4. Support if Amended. The California Association of Physician Groups
supports the bill if amended. They state, "Our concern over full
autonomous practice, as currently stated in this measure, is that
it will lead to increased practice silos in California, competition
with primary care physicians, and increased fragmented delivery of
care."
5. Arguments in Opposition. The California Medical Association (CMA)
opposes the bill and raises several concerns in their letter. They
indicate, "There is no evidence that states that have expanded
scope of practice have experienced improved access to care or lower
levels of underserved patient populations. For example, of the
states that allow independent practice of nurse practitioners, 12
states have a larger underserved population than California." The
CMA also notes, "Current requirements for standardized procedures
are not mere formalities or bureaucratic barriers to care. These
requirements are in place to ensure that patient care includes the
involvement and oversight of a physician who is substantially more
qualified and experienced to oversee patient care." They add,
"Contrary to claims that allowing full independent practice is
consistent with a national trend of state scope of practice
expansions?33 states including Texas, Florida, New York and
Illinois require physician involvement with nurse practitioners.
Of these, 24 require physician involvement?to diagnose, treat and
prescribe." The CMA is also concerned that complaints about care
provided by NPs would be referred to the BRN which would be
responsible for investigation and discipline. They write, "?the
BRN is structured very differently from the MBC and does not have
access to expert physician reviewers who can assess if the care
provided was below or within the community standard of care."
The California Academy of Eye Physicians & Surgeons state their
opposition when they note, "The bills are being promoted such that
they would in some way provide additional access to medical
services for those who will gain coverage under the Affordable Care
Act. With regard to nurse practitioners, it is difficult to
believe that argument is valid. Currently they work under
physician supervision. If they were independent, they would likely
see exactly the same number of patients. The only change would be
that they would see them on their own."
The Union of American Physicians and Dentists also opposes the
bill. They note in their letter, "UAPD/AFSCME embraces the concept
of expanding health care access to residents of the State of
California. However, SB 491 is not the solution. The bill does
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nothing to expand the delivery of quality health care to residents.
Rather, SB 491 stakes out an untested and uncertain health care
delivery system full of potential pitfalls for the patient. The
removal of medical supervision over nurse practitioners has many
shortcomings, including disrupting an effective health care
treatment team."
The Lighthouse for Christ Mission opposes the bill. They believe
physicians, who have many years more training, are far less likely
to miss more rare causes of some diseases, helping to ensure
patients will get the right treatment.
Canvasback Missions indicated similar opposition in their letter
when they note, "As an organization that is keenly interested in
health care and works to serve populations who need access to high
quality health care, we have concerns?NPs who have less training
than physicians?are far less likely to miss rare causes of some
diseases."
The California Society of Anesthesiologists opposes the bill. They
indicate, "Patient safety could be at risk by allowing NP
prescription of drugs, including controlled substances, without the
collaboration of physicians having far more training in diagnosing
underlying diseases and conditions. Further, since excessive
prescribing of controlled substances is seen as a major health
problem, authorizing a new category of direct prescribers is
contrary to the need for stronger oversight and controls."
The California Right to Life Committee, Inc. is also opposed to the
bill. They are concerned that the bill "would be used as a vehicle
for nurses to perform abortions and administer abortifacient
drugs."
6. Oppose Unless Amended. The California Academy of Family Physicians
opposes the bill unless it is amended. They believe legislation
that changes the scope of [NPs] profession as "independent" or
"autonomous" is contrary to what California consumers have come to
expect and need, especially when it comes to patient safety.
The Osteopathic Physicians and Surgeons of California also opposes
the bill unless it is amended. They indicate, "SB 491 is?a
premature response to a genuine problem. OPSC would be happy to
continue a dialogue with Dr. Hernandez, the NPs and other
stakeholders on a more appropriate solution. It is recommended
that SB 491 be held in committee until that dialogue is completed
and consensus is reached on responsible amendments on the measure."
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7. Current Related Legislation. SB 352 (Pavley, 2013) would authorize
a NP, physician assistant or certified nurse-midwife to supervise
medical assistants without a physician present and according to
standardized procedures and protocols created by the physician.
(Note: This bill passed out of Senate Business Professions and
Economic Development (BPED) Committee on April 8, 2013, and is
currently on the Senate floor.)
SB 492 (Hernandez of 2013) Permits an optometrist to diagnose treat
and manage additional conditions with ocular manifestations,
directs the California Board of Optometry to establish educational
and examination requirements and permits optometrists to perform
vaccinations and surgical and non-surgical primary care procedures.
The bill is also up for consideration before the Committee today.
( Note: The bill is up for consideration before the BP&ED Committee
today.)
SB 493 (Hernandez, 2013) authorizes a pharmacist to administer
drugs and biological products that have been ordered by a
prescriber. Expands other functions pharmacists are authorized to
perform, and authorizes pharmacists to order and interpret tests
for the purpose of monitoring and managing the efficacy and
toxicity of drug therapies and to independently initiate and
administer routine vaccinations. Also establishes board
recognition for an advanced practice pharmacist. ( Note: The bill
is up for consideration before the BP&ED Committee today.)
8. Prior Related Legislation. AB 2348 (Mitchell, Chapter 460,
Statutes of 2012) authorized a registered nurse to dispense
specified drugs or devices upon an order issued by a certified
nurse-midwife, nurse practitioner, or physician assistant within
specified clinics. The bill also authorized a registered nurse to
dispense or administer hormonal contraceptives in strict adherence
to specified standardized procedures.
SB 1524 (Hernandez, Chapter 796, Statutes of 2012) deleted the
requirement for at least
6 months duration of supervised experience by a physician before a
nurse-midwife could furnish or order drugs. The bill authorized a
physician and surgeon to determine the extent of the supervision in
connection with the furnishing or ordering of drugs and devices by
a nurse practitioner or certified nurse-midwife.
AB 867 (Nava, Chapter 416, Statutes of 2010) authorized, until July
1, 2018, the California State University to establish a Doctor of
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Nursing Practice degree pilot program at
3 campuses chosen by the Board of Trustees to award the Doctor of
Nursing Practice degree. The bill required the Doctor of Nursing
Practice degree pilot program to be designed to enable
professionals to earn the degree while working full time, train
nurses for advanced practice, and prepare clinical faculty to teach
in postsecondary nursing programs.
SB 809 (Ashburn, 2007) would have deleted the requirement that the
BRN consult with physicians and surgeons in establishing categories
of nurse practitioners. The bill would have revised the educational
requirements for certification as a nurse practitioner and would
have required a nurse practitioner to be certified by a nationally
recognized certifying body approved by the board. The bill would
have allowed a nurse practitioner to prescribe drugs and devices if
he or she has been certified by the board to have satisfactorily
completed at least 6 months of supervised experience in the
prescribing of drugs and devices and if such prescribing is
consistent with his or her education or established clinical
competency, would have deleted the requirement of standardized
procedures and protocols, and would have deleted the requirement of
physician supervision. ( Note : This bill died in Senate BPED
Committee.)
AB 1436 (Hernandez, 2007) would have allowed a nurse practitioner
to perform comprehensive health care services according to his or
her educational preparation. The bill would have authorized a
nurse practitioner to admit and discharge patients from health
facilities, change a treatment regimen, or initiate an emergency
procedure, in collaboration with specified health practitioners.
( Note : This bill was never taken up on the Senate floor.)
AB 1711 (Strickland, Chapter 58, Statutes of 2005) authorized a
registered nurse or licensed pharmacist to administer influenza and
pneumoccocal immunizations without patient-specific orders to
patients age 50 years or older in a skilled nursing facility under
standing orders when they meet federal recommendations and are
approved by the medical director of the skilled nursing facility.
AB 1821 (Cohn, 2004) would have established the Nursing Workforce
Education Investment Act. The act would establish in OSHPD a state
nursing contract program with accredited schools and programs that
educate and train licensed vocational nurses and registered nurses
to increase the supply of nurses in California. ( Note : This bill
was vetoed by the Governor.)
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AB 2226 (Spitzer, Chapter 344, Statutes of 2004) would have
required, after January 1, 2008, an applicant for initial
qualification or certification as a nurse practitioner to meet
specified requirements, including possessing a master's degree in
nursing, a master's degree in a clinical field related to nursing,
or a graduate degree in nursing, and to have satisfactorily
completed a nurse practitioner program approved by the board.
AB 2560 (Montanez, Chapter 205, Statutes of 2004) authorized a
nurse practitioner to furnish drugs or devices under standardized
procedures or protocols when the drugs and devices furnished or
ordered are consistent with the practitioner's educational
preparation or for which clinical competency has been established
and maintained.
SB 111 (Alpert, Chapter 358, Statutes 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.
AB 1545 (Correa, Chapter 914, Statutes of 1999) specified that a
nurse practitioner may not sign for delivery of a complimentary
sample of a dangerous drug or dangerous device; may not direct a
pharmacist to dispense a trade name or generic drug; use a
dispensing device; or hand drugs or dangerous devices to patients
in his or her office or place of practice.
9. Suggested Author's Amendments.
a) In order to clarify the authority NPs have to
delegate tasks to a medical assistant and specify that the
tasks must be within the scope of practice of a medical
assistant, the following amendment should be made:
Amendment . On page 4, line 31, after the word "assistant"
add the following:
" pursuant to standardized procedures and protocols as
developed between the nurse practitioner and medical
assistant and as permitted within the medical assistant
scope of practice. "
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b) In order to clarify the NPs scope of practice should
guide any procedures they perform, the following amendment
should be made:
Amendment . On page 4, line 40, make the following changes:
Strike out the following: " the nurse practitioner's training
and education."
Replace with: " the nurse practitioners scope of practice. "
SUPPORT AND OPPOSITION:
Support:
California Association of Nurse Practitioners
California Association of Nurse Anesthetists
California Optometric Association
Californians for Patient Care
United Nurses Associations of California/ Union of Health Care
Professionals
American Association for Retired Persons
Association of California Healthcare Districts
Blue Shield of California
California Pharmacists Association/ California Society for Health
System Pharmacists
National Association of Pediatric Nurse Practitioners
Western University of Health Sciences
1 nurse practitioner
2 individuals
Support if Amended:
California Association of Physician Groups
Oppose unless amended:
California Academy of Family Physicians
Osteopathic Physicians and Surgeons of California
Opposition:
California Academy of Eye Physicians & Surgeons
California Medical Association
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California Right to Life Committee, Inc.
California Society of Anesthesiologists
Canvasback Missions Inc.
Lighthouse for Christ Mission Eye Center
Union of American Physicians and Dentists
Hundreds of individuals
Consultant: Le Ondra Clark, Ph.D.