BILL ANALYSIS Ó
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|Hearing Date:April 29, 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 RN 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
devices. (BPC § 2836.1(g)(2))
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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 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 that 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
of the implementation of the federal Patient Protection and
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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 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; or
i) Maintain medical malpractice insurance.
6) Specifies that drugs or devices furnished, ordered or prescribed
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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.
Opponents of the ACA turned to the federal courts to challenge
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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
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
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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 nurses may
perform and under what circumstances.
3) State any specific requirements which are to be
followed by NPs in performing particular SPP functions.
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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.
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 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)
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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 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
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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."
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,
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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
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
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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
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
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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."
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."
The California Hospital Association supports the bill if amended.
In their letter they write, "CHA applauds the author's bold
initiative to proactively address California's health care access
needs. While CHA supports the conceptual premises outlined in the
SB 491 provisions, we would like to work with the author and offer
amendments?.to assure NP practice is firmly based within the
boundaries of their education, training and certification and that
quality and patient safety measures are firmly embedded in the
provisions."
5. Arguments in Opposition. The California Medical Association (CMA)
opposes the bill and raises several concerns in their letter. They
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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
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
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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 opposes the
bill. They are concerned that the bill "would be used as a vehicle
for nurses to perform abortions and administer abortifacient
drugs."
The California Psychiatric Association opposes the bill. In their
letter they write, "SB 491 does nothing to assure that in this
independent practice that there is any notification whatsoever to a
patient's physician of additions, deletions or other changes to
psychotropic medications that may have been prescribed by the
physician. SB 491 also opens up the door to a nurse practitioner
diagnosing mental illnesses and then prescribing powerful
anti-psychotics or other psychotropic medications to new patients,
and/or patients without a personal physician."
The California Chapter of the American College of Emergency
Physicians also opposes the bill. They have concerns that nurse
practitioners "do not have sufficient education and training to
examine and diagnose completely independent of physicians and such
a practice puts patients at risk."
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
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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."
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
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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
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
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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.)
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
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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. "
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. "
10. Policy Issue : Should the BRN and MBC collaborate to discuss NPs
proposed
independent prescribing authority? There has been recent attention
paid to the issue of deaths caused by prescription drug overdose
and the connection to physicians who over-prescribe these drugs to
patients. A Los Angeles Times series titled Dying for Relief
highlighted the role of prescription drugs in overdose deaths.
Reporters conducted an analysis of coroners' reports for over 3000
deaths occurring in four counties in Southern California where
toxicology tests found a prescription drug in the deceased's
system. The analysis found that in nearly half of the cases where
prescription drug toxicity was listed as the cause of death, there
was a direct connection to a prescribing physician. Similarly, a
study conducted by the Centers for Disease Control (CDC) found that
in 2010, there were 38,329 deaths resulting from drug overdose,
37,004 deaths in 2009 and 16,849 deaths in 1999. Additionally, the
CDC found that nearly 60 percent of the overdose deaths in 2010
involved pharmaceutical drugs. The attention focused on this issue
has led to questions regarding the role that licensing boards and
other state entities should play when regulating health
professionals who have prescribing authority.
This bill would allow NPs to have independent prescribing
authority. As such, and in the wake of the current scrutiny of
physicians and surgeons who are over-prescribing medications, it is
suggested that the BRN and the MBC collaborate to discuss the
implications of providing NPs with independent prescribing
privileges and the plan for the two boards to work together to
address this issue as it relates to regulating NPs' prescribing
authority.
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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
57 individuals
Support if Amended:
California Association of Physician Groups
California Hospital Association
Oppose unless amended:
California Academy of Family Physicians
Osteopathic Physicians and Surgeons of California
Opposition:
California Academy of Eye Physicians & Surgeons
California Medical Association
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
California Psychiatric Association
American College of Emergency Physicians- California Chapter
Hundreds of individuals
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Consultant: Le Ondra Clark, Ph.D.