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. 









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           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  








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            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  








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            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