BILL ANALYSIS Ó SB 491 Page 1 Date of Hearing: August 21, 2013 ASSEMBLY COMMITTEE ON APPROPRIATIONS Mike Gatto, Chair SB 491 (Hernández) - As Amended: August 14, 2013 Policy Committee: Business and Professions Vote: 8-2 Urgency: No State Mandated Local Program: Yes Reimbursable: No SUMMARY This bill allows nurse practitioners (NPs) who meet certain criteria to practice independently of physician supervision (for purposes of this analysis, an "independent NP"). Specifically, this bill: 1)Requires an independent NP to have first practiced under the supervision of a physician for 4,160 hours and be practicing in a clinic, health facility, county medical facility, accountable care organization (ACO), or a group practice. Also requires an independent NP to maintain professional liability insurance appropriate to the practice setting. 2)Requires an independent NP to refer patients to another health care provider if a situation or condition of the patient is beyond the NP's education or training. 3)Establishes the scope of practice for an independent NP, which generally aligns with existing law, regulation, and practice regarding scope of NPs working subject to standardized procedures and protocols. This bill includes the following elements under an independent NP's scope: ordering durable medical equipment, prescribing drugs, establishing diagnoses, referring patients, performing procedures that are consistent with their training, and delegating tasks to medical assistants, among others. 4)Requires the Board of Registered Nursing (BRN) to adopt regulations by July 1, 2015, establishing the means of documenting completion of the new requirements. SB 491 Page 2 FISCAL EFFECT Costs would accrue to the fee-supported Board of Registered Nursing Professions and Vocations Fund. 1)One-time costs as follows: a) Costs to issue regulations and potentially modify existing regulations, and develop verification processes, procedures, and documents, likely exceeding $200,000. b) Costs of around $100,000 over the first two years to certify existing NPs who meet the criteria. BRN projects nearly all NPs would seek the additional independent certification. c) Costs to update IT systems of $20,000. 1)Annual costs of at least $120,000 to BRN for ongoing regulation of independent NPs, including licensing, complaints, and enforcement. 2)Unknown potential costs related to enforcement cases, if it is more workload-intensive for the BRN to establish whether appropriate care was provided according to a nurse's scope of practice, without comparing the treatment with standardized procedures and protocols. Additional expert review may be necessary to establish standard of care, which could raise enforcement costs. 3)The certification process for independent NPs creates additional workload not supported by new fee authority. The independent NP certification process could potentially be combined with a renewal of NP certification to minimize costs, but this bill does create a higher level of ongoing workload with respect to certification. COMMENTS 1)Rationale . This bill seeks to expand the role of NPs consistent with best practices as identified by the Institute of Medicine. The author believes this bill will improve access to care and improve the performance of the health care system. 2)NPs in California . The BRN licenses about 400,000 registered nurses (RNs) in the state, and of these, about 18,000 are SB 491 Page 3 certified as advanced practice RNs, or NPs. NPs are required to have a Master's degree and have additional preparation and skills in physical diagnosis, psycho-social assessment, and management of primary health care needs beyond minimum requirements for RNs. About 12,000 of California's 18,000 NPs also have furnishing numbers issued by the BRN, which allows them to order or furnish drugs and devices to patients using approved standardized procedures. NPs must complete an approved advanced pharmacology course in order to qualify for a furnishing number. Physician supervision is required and the physician must be available, at least by telephonic means, at the time the NP examines the patient. Only furnishing NPs are required to be supervised by a physician. An NP with a furnishing number may obtain a Drug Enforcement Administration (DEA) registration number to order controlled substances as needed for patient care. The NP scope of practice is currently determined by standardized procedures, which are the legal mechanism for NPs to perform functions which would otherwise be considered the practice of medicine. Standardized procedures are policies and protocols developed by a health facility or organized health care system, with input from administrators and health professionals, which establish parameters for medical care. 3)IOM Report . The Institute of Medicine (IOM) of the National Academies recently reviewed nursing education and scope of practice with a focus on the future of nursing. The IOM concluded that advanced practice RNs (NPs in California) should be able to practice to the full extent of their education and training, and recommended states reform scope-of-practice rules to remove restrictions on advanced practice RNs (NPs). The IOM report states, "No studies suggest that advanced practice RNs (NPs) are less able than physicians to deliver care that is safe, effective, and efficient, or that care is better in states with more restrictive scope of practice regulations for advanced practice RNs (NPs). In fact, evidence shows that nurses provide quality care to patients, including preventing medication errors, reducing or eliminating infections, and easing the transition patients make from hospital to home." 4)Recent Amendments . A previous version of this bill also SB 491 Page 4 allowed NPs to practice independently after three years of supervision, without restricting those NPs to practicing in specified clinic or group practice settings. A recent amendment removed this "second pathway" to independent NP certification. Thus, any NP who practiced pursuant to this bill would only be able to do so in the settings specified. 5)Support . Nursing groups; health facilities including the California Primary Care Association, California Hospital Association, and University of California; the California Association of Physician Groups; the BRN; and some labor groups are among numerous supporters of this bill. Supporters believe this bill will increase Californians' access to care, reduce paperwork burdens, and promote high-quality primary health care. 6)Opposition . The California Medical Association, California Association of Family Physicians, Osteopathic Physicians and Surgeons of California, and numerous other physician associations, as well as some labor groups, the Consumer Attorneys of California, believe this bill compromises patient safety. The physician groups emphasize collaborative care provided by a physician-led team is ideal. They indicate requirements for standardized protocols and physician review 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, both in depth and in years of education and training, than a nurse practitioner practicing alone. 7)Related Legislation . SB 492 (Hernandez) and SB 493 (Hernandez) expand scope of practice for optometrists and pharmacists, respectively. SB 492 is pending in Assembly Business and Professions, and SB 493 is pending in this committee. Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081