BILL ANALYSIS Ó
AB 1306
Page 1
ASSEMBLY THIRD READING
AB
1306 (Burke)
As Introduced February 27, 2015
Majority vote
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|Committee |Votes |Ayes |Noes |
| | | | |
| | | | |
|----------------+------+--------------------+----------------------|
|Business & |14-0 |Bonilla, Jones, | |
|Professions | |Baker, Bloom, | |
| | |Burke, Chang, Dodd, | |
| | |Eggman, Gatto, | |
| | |Holden, Mullin, | |
| | |Ting, Wilk, Wood | |
| | | | |
|----------------+------+--------------------+----------------------|
|Appropriations |15-2 |Gomez, Bloom, |Bigelow, Wagner |
| | |Bonta, Calderon, | |
| | |Chang, Daly, | |
| | |Eggman, Gallagher, | |
| | |Eduardo Garcia, | |
| | |Holden, Jones, | |
| | |Quirk, Rendon, | |
| | |Weber, Wood | |
| | | | |
| | | | |
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AB 1306
Page 2
SUMMARY: Removes the physician supervision requirement for
certified nurse midwives (CNMs) allowing them to manage a full
range of primary health services, perform peripartum care, provide
emergency care when a physician is not present and perform and
repair episiotomies in all practice settings. Specifically, this
bill:
1)Requires an applicant for a certificate to practice
nurse-midwifery to provide evidence of current advanced level
national certification by a certifying body that meets standards
established and approved by the Board of Registered Nursing
(BRN).
2)Requires the BRN to create and appoint a Nurse-Midwifery
Advisory Council (Council) consisting of CNM in good standing
with experience in hospital and nonhospital practice settings, a
nurse-midwife educator, as specified, and a consumer of
midwifery care.
3)Requires the Council to make recommendations to the board on all
matters related to nurse-midwifery practice, education, and
other matters specified by the board, and would require the
Council to meet regularly, but at least twice a year.
4)Authorizes a certified nurse-midwife to manage a full range of
primary health care services for women from adolescence beyond
menopause, including, but not limited to, gynecologic and family
planning services.
5)Authorizes a certified nurse-midwife to practice in all
settings, including, but not limited to, a home.
6)Declares that the practice of nurse-midwifery within a health
care system provides for consultation, collaboration, or
referral as indicated by the health status of the client and the
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resources of the medical personnel available in the setting of
care, and would provide that the practice of nurse-midwifery
emphasizes informed consent, preventive care and early detection
and referral of complications to a physician and surgeon.
7)Authorizes a certified nurse-midwife to provide peripartum care
in an out-of-hospital setting to low-risk women with
uncomplicated singleton-term pregnancies who are expected to
have uncomplicated birth.
8)Deletes the requirement that drugs or devices are furnished or
ordered in accordance with standardized procedures and
protocols.
9)Authorizes a certified nurse-midwife to furnish and order drugs
or devices in connection with care rendered in a home, and would
authorize a certified nurse-midwife to directly procure supplies
and devices, to order, obtain, and administer drugs and
diagnostic tests, to order laboratory and diagnostic testing,
and to receive reports that are necessary to his or her practice
as a CNM and that are consistent with nurse-midwifery education
preparation.
10)Authorizes a certified nurse-midwife to perform and repair
episiotomies and to repair first-degree and second degree
lacerations of the perineum in a patient's home, and deletes all
requirements that those procedures be performed pursuant to
protocols developed and approved by the supervising physician
and surgeon.
11)Requires a certified nurse-midwife to provide emergency care to
a patient during times when a physician and surgeon is
unavailable.
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12)Indicates that a consultative relationship between a CNM and a
physician and surgeon by itself is not a basis for finding the
physician and surgeon liable for any acts or omissions on the
part of the CNM.
FISCAL EFFECT: According to the Assembly Appropriations
Committee, this bill will result in minor costs to the BRN Fund
for advisory council meetings. Costs for enforcement are unknown,
but estimated to be minor.
COMMENTS:
Purpose. This bill is sponsored by the California Nurse Midwives
Association. According to the author, "AB 1306 creates a level of
parity in the law between [Licensed Midwives] and CNMs by removing
the physician supervision requirements for CNMs, allowing them to
practice independently within their scope of practice. If signed
into law, CNMs will be able to provide a full range of services
for women in all settings, furnish and order prescription drugs,
supplies, and devices, order, obtain, and administer diagnostic
tests, and receive reports.
Most pregnancies and births are completely normal physiologic
events. When permitted to work to the full extent of their
education and experience, CNMs can expertly manage more births in
California. Untethering CNMs from physician supervision
requirements will increase access to primary health care services
for thousands of women in both urban and rural areas."
Background. Midwifery is the care of childrearing women during
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pregnancy, labor and birth and during the postpartum period.
Midwifery services are offered by CNMs, who are regulated by the
BRN and Licensed Midwives (LMs) who are regulated by the Medical
Board of California (MBC). While both CNMs and NMs practice
midwifery, there are differences in their education requirements,
practice settings and supervision requirements.
Education. CNMs are licensed registered nurses with a certificate
to practice midwifery, have acquired additional training in the
field of obstetrics and are certified by the American College of
Nurse Midwives.
LMs have completed a three-year postsecondary education program in
an accredited midwifery school approved by the Medical Board or
via the Challenge Mechanism. The Challenge Mechanism is an
approved midwifery education program which allows students to
obtain credit by examination for previous midwifery education and
clinical experience.
Practice Settings. LMs can practice in home, birth centers and
clinics. CNMs can practice in the same settings, but, unlike LMs,
they can also practice in hospital settings. In 2012, CNMs
attended approximately 8.5% of all births in California - the
majority of which took place in a hospital and 1,365 were in
free-standing birth centers. It is estimated that 90% of all CNM
attended births take place in a hospital setting.
CNM care is a federally mandated Medicaid benefit. According to
the Centers for Disease Control, in 2012, 30% of CNM attended
births in California were Medicaid, 65% were private pay and 2%
were self-pay.
Physician Supervision. In California, LMs are permitted to
practice without the supervision of a physician. However, despite
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the fact that many states allow CNMs to practice independently,
California is one of six states that still requires physician
supervision of CNMs. California law specifies that the
supervision shall not be construed to require the physical
presence of the physician. It also requires that in order for a
CNM to prescribe medication, a physician needs to be
telephonically available.
According to the author, although the supervision requirement
tethers CNMs to practice only where a physician can supervise, it
does not consist of actual oversight of health care delivery,
inspection or review of charts, co-signature on prescriptions,
direct care of the patient or evaluation of CNM patients at any
point during pregnancy or well-woman care.
Changes to CNMs Scope of Practice. If this measure is enacted, a
number of changes to the scope of practice for a CNM and
authorization for a CNMs independent practice would be made.
These include:
1)Management of a full range of primary health care services for
women from adolescence beyond menopause, including, but not
limited to, gynecologic and family planning services.
2)Practice in all settings, including, but not limited to, a home.
3)Authorization to provide peripartum care in an out-of-hospital
setting to low-risk women with uncomplicated singleton-term
pregnancies who are expected to have an uncomplicated birth.
4)A CNM would no longer be required to adhere to standardized
procedures and protocols when:
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a) Furnishing drugs or devices in connection with care
rendered in a home;
b) Procuring supplies and devices;
c) Ordering, obtaining, and administering drugs and
diagnostic tests;
d) Ordering laboratory and diagnostic testing;
e) Receiving reports that are necessary to his or her
practice as a CNM;
f) Performing and repairing episiotomies and to repair
first-degree and second degree lacerations of the perineum in
a patient's home; and,
g) Providing emergency care to a patient during times when a
physician and surgeon is unavailable.
Arguments in Support:
The California Nurse Midwives Association (sponsor) writes in
their letter of support, "AB 1306 provides no new authority for
CNMs than they currently provide. It ensures they can practice as
they currently do without physician supervision? CNM attended
births have documented excellent maternity care outcomes? The
excellent outcomes consistently achieved by nurse-midwives are the
result of the midwifery model of care, not state-mandated
relationships with physicians."
The California Association for Nurse Practitioners supports this
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bill and writes, "With the addition of millions of individuals to
California's healthcare system due to ACA [Affordable Care Act]
implementation, more healthcare providers are crucial to ensure
quality, timely access to care? AB 1306 will assist in addressing
this problem by allowing nurse-midwives to work collaboratively
with physicians to provide women's health care services across the
state, including pregnancy and delivery care."
Access Women's Health Justice, Beach Cities Midwifery & Women's
Health Care, Beachside Birth Center, California Association of
Nurse Anesthetists, Yes2Kollege Education Resources, and the
Women's Community Clinic, all similarly write in their support
letters, "Physician collaboration is and has always been a
hallmark of nurse-midwifery care and AB 1306 will not change that?
According to ACOG, California is facing a workforce shortage of
women's health care providers? AB 1306 will not change the way
that nurse-midwives currently practice and will not change the
high quality of care provided by nurse-midwives."
Arguments in Opposition:
The California Medical Association opposes this bill and writes,
"The CMA believes that AB 1306 allows certified nurse midwives to
independently engage in the practice of medicine and lacks several
important patient protection statutes that include, but are not
limited to: 1) the corporate practice of medicine, 2)
self-referral and anti-kickback prohibitions, 3) standard of care
and 4) prescribing oversight."
Policy Issues for Consideration:
Examination Requirement. As highlighted by the opposition, this
bill would authorize a CNM to work independently, without the
supervision of a physician, and perform primary care services
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including gynecology. As such, the author may wish to amend this
bill to include a requirement for an examination that would take
place at the conclusion of the CNM's residency. This examination
should include criteria similar to the United States Medical
Licensing Examination, Step 3 which medical residents are required
to take in order to show competency in practicing as an
independent and unsupervised medical professional.
Corporate Practice of Medicine (CPM). The CPM is defined as any
involvement of corporations in medicine. The CPM may also be
defined more narrowly, for example, as the employment of a
physician by a lay-controlled corporation that sells the services
of the physician for a profit or provides the physician's services
to its employees free of charge. The CPM now most commonly refers
to the employment of physicians by hospitals, but is also still
used to refer to employment of physicians by for-profit and
non-profit corporate entities and government (see Business and
Professions Code Section 2400).
This bill does not include a provision that prohibits the CPM. As
such, the author should consider amending this bill to include
language that explicitly prohibits the CPM considering that the
provisions of this bill would allow CNMs to act as a primary care
physicians. The addition of this language would serve as an
important patient protection measure.
Cross Collaboration Between Advisory Councils. This bill would
impact the practice of CNMs. It would also create a Nurse
Midwives Advisory Council within the BRN. The MBC has a similar
committee, the MBC Midwifery Advisory Council, which vets issues
germane to the practice of midwifery. As such, it may be fruitful
to require cross collaboration between the two committees as the
practice of midwifery falls within the scope of practice for both
CNMs and LMs.
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Self-referrals. Another patient protection measure that is not
included in this bill is specific language that addresses
self-referrals. California law contains prohibitions against
self-referral in the Physician Ownership and Referral Act of 1993
(PORA) which applies to healthcare licensees. Under PORA, a
"financial interest" includes direct or indirect compensation.
This means that a physician should not have a stock ownership in
the entity to which the physician is referring in order for PORA
to apply (see Business and Professions Code Section 650.01).
The author should include language in this bill that references
these sections of law to ensure that the CNMs financial interests
are not involved in the provision of medical care to patients.
Analysis Prepared by:
Le Ondra Clark Harvey, Ph.D. / B. & P. / (916)
319-3301 FN: 0000414