BILL ANALYSIS �
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|SENATE RULES COMMITTEE | SB 491|
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THIRD READING
Bill No: SB 491
Author: Hernandez (D)
Amended: 5/21/13
Vote: 21
SENATE BUSINESS, PROF. & ECON. DEV. COMM. : 6-1, 4/29/13
AYES: Price, Block, Corbett, Galgiani, Hernandez, Hill
NOES: Yee
NO VOTE RECORDED: Emmerson, Padilla, Wyland
SENATE APPROPRIATIONS COMMITTEE : 4-0, 5/13/13
AYES: De Le�n, Hill, Lara, Steinberg
NO VOTE RECORDED: Walters, Gaines, Padilla
SUBJECT : Nurse practitioners
SOURCE : Author
DIGEST : This bill deletes the requirement that nurse
practitioners (NPs) perform certain tasks pursuant to
standardized procedures and/or consultation with a physician or
surgeon and authorizes an NP to perform those tasks
independently. Also requires, after July 1, 2016, that NPs
possess a certificate from a national certifying body in order
to practice.
ANALYSIS :
Existing law:
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1. Establishes the Board of Registered Nursing (BRN), within
the Department of Consumer Affairs, and authorizes the BRN to
license, certify and regulate nurses.
2. Clarifies that there are various and conflicting definitions
of "nurse practitioner" 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.
3. Requires applicants for licensure as an NP to meet specified
educational requirements.
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.
5. Authorizes an NP, pursuant to standardized procedures
created by a physician or surgeon, or in consultation with a
physician or surgeon, to order durable medical equipment;
certify disability claims; and approve, sign, modify or add
information to a plan of treatment for individuals receiving
home health services.
6. Defines the terms "health facility," "furnishing," "drug
order," and "order."
7. Establishes that the furnishing and ordering of drugs or
devices by NPs is done in accordance with the standardized
procedures and protocols (SPPs) developed by the supervising
physician and surgeon, NP and the facility administrator or
designee and shall be consistent with the NP's educational
preparation and/or established and maintained clinical
competency.
8. Indicates a physician and surgeon may determine the extent
of supervision necessary in the furnishing or ordering of
drugs and devices.
9. Permits an NP to furnish or order Schedule II through
Schedule V controlled substances and specifies that a copy of
the SPPs shall be provided upon request to any licensed
pharmacist when there is uncertainty about the NP furnishing
the order.
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10.Indicates that for Schedule II controlled substances, the
SPPs must address the diagnosis of the illness, injury or
condition for which the controlled substance is to be
furnished.
11.Requires that an NP has completed a course in pharmacology
covering the drugs or devices to be furnished or ordered.
12.States that an NP must hold an active furnishing number,
register with the United States Drug Enforcement
Administration (DEA) and take a continuing education course
in Schedule II controlled substances.
13.Specifies the SPPs must list which NPs may furnish or order
drugs or devices.
14.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 SPPs,
approval of the SPPs and availability of the physician and
surgeon to be contacted via telephone at the time of the
patient examination by the NP. Limits the physician and
surgeon to supervise no more than four NPs at one time.
15.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.
This bill:
1. Makes legislative findings and declarations 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 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 an NP must hold a national certification from a national
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certifying body recognized by the BRN.
4. Removes the requirement that NPs must do the following tasks
only if there are SPPs authorized by a physician:
A. Order durable medical equipment.
B. Certify disability claims.
C. Approve, sign, modify, or add information to a
plan of treatment for individuals receiving home health
services.
1. Adds the following to the list of tasks NPs can perform
independently and without SPPs 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. Establish a physical diagnosis, as specified,
consistent with BPC Section 2835.7.
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 NP's knowledge and
experience.
G. Delegate tasks to a medical assistant, pursuant to
SPPs developed by the NP and medical assistant that are
within the medical assistant's scope of practice.
H. Order hospice care.
I. Perform procedures that are necessary and
consistent with the NP's scope of practice, including
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referring a patient if a situation or condition of a
patient is beyond the NP's education, training, or
certification.
1. Requires an NP to maintain professional liability insurance.
2. Specifies that drugs or devices furnished, ordered or
prescribed independently by an NP shall be consistent with
the NP's educational preparation or level of competency.
3. Indicates that an NP shall not furnish, order or prescribe a
dangerous drug without an appropriate examination and a
medical indication except in certain circumstances.
4. Permits NPs to prescribe controlled substances and register
with the DEA.
Background
ACA . On March 23, 2010, President Obama signed the 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
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 v. 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
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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.
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 privacy 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% 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.
NP education, training and scope . The BRN sets the educational
standards for NP certification. An NP is an 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
care regardless of the presence or absence of disease.
An NP does not have an additional scope of practice beyond the
RN's scope and must rely on SPPs for authorization to perform
medical functions which overlap with those conducted by a
physician. 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,
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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, an 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 an 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:
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.
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.
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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.
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.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
According to the Senate Appropriations Committee:
One-time costs, likely about $75,000 to update existing
regulations (Board of Registered Nursing Fund).
Likely minor ongoing costs for enforcement (Board of
Registered Nursing Fund). The BRN indicates that there may
be increased need for enforcement activity under this bill,
but that those costs are not anticipated to be significant.
SUPPORT : (Verified 5/22/13)
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AARP
Association of California Healthcare Districts
Blue Shield of California
C.W. Brower, Inc. (Modesto)
California Association for Nurse Practitioners
California Association of Nurse Anesthetists
California Association of Physician Groups
California Hospital Association
California Nurse-Midwives Association
California Optometric Association
California Pharmacists Association/California Society of
Health-System Pharmacists
Californians for Patient Care
Ceres Department of Public Safety
Indiana State University College of Nursing, Health and Human
Services
Latino Community Roundtable
NAACP
National Asian American Coalition
National Association of Pediatric Nurse Practitioners
United Nurses Associations of California/Union of Health Care
Professionals
University of California
Western University of Health Sciences
OPPOSITION : (Verified 5/22/13)
American Academy of Pediatrics, California
American College of Emergency Physicians - California Chapter
California Academy of Eye Physicians & Surgeons
California Academy of Family Physicians
California Medical Association
California Psychiatric Association
California Right to Life Committee, Inc.
California Society of Anesthesiologists
Canvasback Missions Inc.
Lighthouse for Christ Mission Eye Center
Medical Board of California
Osteopathic Physicians and Surgeons of California
Union of American Physicians and Dentists
ARGUMENTS IN SUPPORT : The author's office indicates that this
bill will establish full practice authority for NPs enabling
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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's office believes this
bill is an answer to the anticipated health workforce shortages
due to the implementation of the ACA 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."
The United Nurses Associations of California/Union of Health
Care Professionals 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 writes, "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 broader 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 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 NPs would allow patients to receive
continuous preventative and acute care should there be no access
to a physician."
Blue Shield of California indicates that this 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 and the California
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Society of Health-System Pharmacists 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."
The National Association of Pediatric Nurse Practitioners
writes, "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."
ARGUMENTS IN OPPOSITION : The California Medical Association
(CMA) indicates, "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 states, "The
bills are being promoted such that they would in some way
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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 California Society of Anesthesiologists indicates, "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 concerned that
the bill "would be used as a vehicle for nurses to perform
abortions and administer abortifacient drugs."
The California Psychiatric Association writes, "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 Academy of Family Physicians believes 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.
MW:ej 5/22/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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