BILL ANALYSIS Ó
SENATE COMMITTEE ON
BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT
Senator Jerry Hill, Chair
2015 - 2016 Regular
Bill No: AB 1306 Hearing Date: July 6,
2015
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|Author: |Burke |
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|Version: |July 1, 2015 Click here to enter text. |
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|Urgency: |No |Fiscal: |Yes |
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|Consultant|Sarah Huchel |
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Subject: Healing arts: certified nurse-midwives: scope of
practice
SUMMARY: Removes physician supervision requirements for a Certified
Nurse Midwife (CNM), increases educational requirements,
establishes a Nurse-Midwifery Advisory Council within the Board
of Registered Nursing (BRN), and subjects CNMs to the ban on the
corporate practice of medicine, among other changes.
Existing law:
1)The Nursing Practice Act, provides for the licensure and
regulation of the practice of nursing by the Board of
Registered Nursing (BRN), within the Department of Consumer
Affairs (DCA), and authorizes the BRN to issue a certificate
to practice nurse-midwifery to a person who meets educational
standards established by the BRN or the equivalent of those
educational standards. (Business and Professions Code (BPC)
§§ 2700 et seq.)
2)Authorizes a CNM, under the supervision of a licensed
physician and surgeon, to attend cases of normal childbirth
and to provide prenatal, intrapartum, and postpartum care,
including family-planning care, for the mother, and immediate
care for the newborn. (BPC § 2746.5 (a))
3)Provides that the practice of nurse-midwifery constitutes the
furthering or undertaking by a certified person, under the
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supervision of a licensed physician and surgeon who has
current practice or training in obstetrics, to assist a woman
in childbirth so long as progress meets criteria accepted as
normal. (BPC § 2746.5 (b))
4)States that physician "supervision" shall not be construed to
require the physical presence of the supervising physician.
(BPC § 2746.5 (c))
5)Authorizes a CNM to furnish and order drugs or devices
incidentally to the provision of family planning services,
routine health care or perinatal care, and care rendered
consistently with the CNM's educational preparation in
specified facilities and clinics, and only in accordance with
standardized procedures and protocols, as specified. (BPC §
2746.51 et seq.)
6)Authorizes a CNM to perform and repair episiotomies and to
repair first-degree and second degree lacerations of the
perineum in a licensed acute care hospital and a licensed
alternate birth center, if certain requirements are met,
including, but not limited to, that episiotomies are performed
pursuant to protocols developed and approved by the
supervising physician and surgeon. (BPC § 2746.52)
7)Authorizes the BRN to appoint a Nurse-Midwifery Committee of
qualified physicians and nurses, including, but not limited
to, obstetricians and nurse-midwives, to develop the necessary
standards relating to educational requirements, ratios of
nurse-midwives to supervising physicians, and associated
matters. (BPC § 2746.2)
8)Authorizes a CNM to furnish or order drugs or devices,
including Schedule II-V controlled substances, pursuant to
physician supervision, standardized procedures and protocols,
and other conditions, as specified. (BPC § 2746.51)
9)Prohibits a physician from referring a person for laboratory,
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diagnostic nuclear medicine, radiation oncology, physical
therapy, physical rehabilitation, psychometric testing, home
infusion therapy, or diagnostic imaging goods or services if
the physician or his or her immediate family has a financial
interest with the person or in the entity that receives the
referral. (BPC § 650.01)
10)Requires a physician and surgeon's certificate to practice
medicine. (BPC § 2052)
11)States that corporations and other artificial legal entities
shall have no professional rights, privileges, or powers.
Provides that the Medical Board of California (MBC) may in its
discretion, after such investigation and review of such
documentary evidence as it may require, and under regulations
adopted by it, grant approval of the employment of licensees
on a salary basis by licensed charitable institutions,
foundations, or clinics, if no charge for professional
services rendered patients is made by any such institution,
foundation, or clinic. (BPC § 2400)
12)Establishes exceptions to the ban on the corporate practice
medicine, thereby allowing certain types of facilities to
employ physicians. (BPC § 2401)
13)Establishes the following protections against retaliation for
health care practitioners who advocate for appropriate health
care for their patients pursuant to Wickline v. State of
California (192 Cal. App. 3d 1630):
a) It is the public policy of the State of California that
a health care practitioner be encouraged to advocate for
appropriate health care for his or her patients. For
purposes of this section, "to advocate for appropriate
health care" means to appeal a payer's decision to deny
payment for a service pursuant to the reasonable grievance
or appeal procedure established by a medical group,
independent practice association, preferred provider
organization, foundation, hospital medical staff and
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governing body, or payer, or to protest a decision, policy,
or practice that the health care practitioner, consistent
with that degree of learning and skill ordinarily possessed
by reputable health care practitioners with the same
license or certification and practicing according to the
applicable legal standard of care, reasonably believes
impairs the health care practitioner's ability to provide
appropriate health care to his or her patients.
b) The application and rendering by any individual,
partnership, corporation, or other organization of a
decision to terminate an employment or other contractual
relationship with or otherwise penalize a health care
practitioner principally for advocating for appropriate
health care consistent with that degree of learning and
skill ordinarily possessed by reputable health care
practitioners with the same license or certification and
practicing according to the applicable legal standard of
care violates the public policy of this state.
c) This law shall not be construed to prohibit a payer from
making a determination not to pay for a particular medical
treatment or service, or the services of a type of health
care practitioner, or to prohibit a medical group,
independent practice association, preferred provider
organization, foundation, hospital medical staff, hospital
governing body, or payer from enforcing reasonable peer
review or utilization review protocols or determining
whether a health care practitioner has complied with those
protocols. (BPC § 510)
This bill:
1)Subjects CNMs to the prohibition on referring a person for
laboratory, diagnostic nuclear medicine, radiation oncology,
physical therapy, physical rehabilitation, psychometric
testing, home infusion therapy, or diagnostic imaging goods or
services if the CNM or his or her immediate family has a
financial interest with the person or in the entity that
receives the referral.
2)States that, notwithstanding the prohibition on referrals, a
CNM may refer a person to a licensed alternative birth center
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or to a nationally accredited alternative birth center, among
other facilities.
3)Requires an applicant to acquire an advanced level national
certification by a certifying body that meets standards
established and approved by the BRN for certification as a
nurse midwife.
4)Deletes the authorization for the BRN to appoint a
Nurse-Midwifery Committee, and instead requires the BRN to
create and appoint, with assistance from the MBC, a
Nurse-Midwifery Advisory Council (Council). States that the
Council shall make recommendations to the BRN on all matters
related to nurse-midwifery practice, education, and other
matters as specified by the BRN.
5)Requires the Council to meet regularly, but at least twice a
year.
6)Specifies that the Council shall consist of:
a) Majority of CNMs in good standing with experience in
hospital settings, alternative birth center settings, and
home settings.
b) A nurse-midwife educator who has demonstrated
familiarity with educational standards in the delivery of
maternal-child health care.
c) A consumer of midwifery care.
d) At least two qualified physicians appointed by the MBC,
including an obstetrician that has experience working with
nurse-midwives.
7)Prohibits corporations and other artificial legal entities
from having any professional rights, privileges, or powers.
However, the BRN may in its discretion, after such
investigation and review of such documentary evidence as it
may require, and under regulations adopted by it, grant
approval of the employment of licensees on a salary basis by
licensed charitable institutions, foundations, or clinics, if
no charge for professional services rendered patients is made
by any such institution, foundation, or clinic.
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8)Permits the following entities to employ a CNM and charge for
professional services rendered by a CNM; however, the entity
shall not interfere with, control, or otherwise direct the
professional judgment of a certified nurse-midwife:
a) A nonprofit clinic.
b) A hospital owned and operated by a health care district.
c) A clinic operated primarily for the purpose of medical
education or nursing education by a public or private
nonprofit university medical school, which is approved by
the MBC the Osteopathic Medical Board of California,
provided the CNM holds an academic appointment on the
faculty of the university, including, but not limited to,
the University of California medical schools and hospitals.
d) A licensed alternative birth center, as specified, or a
nationally accredited alternative birth center owned or
operated by a nursing corporation, as specified.
9)Deletes references in current law to supervision by a
physician and surgeon.
10)Authorizes a CNM to manage a full range of primary
gynecological and obstetric care services for women from
adolescence to beyond menopause, consistent with the Core
Competencies for Basic Midwifery practice promulgated by the
American College of Nurse-Midwives, or its successor national
professional organization, as approved by the BRN. These
services include, but are not limited to, primary health care,
gynecologic and family planning services, preconception care,
care during pregnancy, childbirth, and the postpartum period,
and treatment of male partners for sexually transmitted
infections, utilizing consultation, collaboration, or referral
to appropriate levels of health care services, as indicated.
11)Authorizes permissible settings in which a CNM may practice,
including the home, but only when the following conditions
apply:
a) There is the absence of all of the following:
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i) Any preexisting maternal disease or condition likely
to complicate the pregnancy.
ii) Disease arising from the pregnancy likely to cause
significant maternal and/or fetal compromise.
iii) Prior caesarean delivery.
b) There is a singleton fetus.
c) There is cephalic presentation at the onset of labor.
d) The gestational age of the fetus is greater than 370/7
weeks and less than 420/7 completed weeks of pregnancy at
the onset of labor.
e) Labor is spontaneous or induced in an outpatient
setting.
12)States that if a potential CNM client meets the conditions
specified in clauses (b) - (e) above, but fails to meet the
conditions specified in (a) and the woman still desires to be
a client of the CNM, the CNM shall consult with a physician
and surgeon trained in obstetrics and gynecology. A CNM may
assist the woman in pregnancy and childbirth only if a
physician and surgeon trained in obstetrics and gynecology is
consulted and the physician and surgeon who performed the
consultation determines that the risk factors presented by her
disease or condition are not likely to significantly affect
the course of pregnancy and childbirth.
13)States 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 patient and
the resources and medical personnel available in the setting
of care. It also emphasizes informed consent, preventive care,
and early detection and referral of complications to
physicians and surgeons. While practicing in a hospital
setting, the certified nurse-midwife shall collaboratively
care for women with more complex health needs.
14)Requires a CNM to be subject to all credentialing and quality
standards held by the facility in which he or she practices.
The peer review body shall include nurse-midwives as part of
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the peer review body that reviews nurse-midwives. The peer
review body of that facility shall impose standards that
assure quality and patient safety in their facility. The
standards shall be approved by the relevant governing body
unless found by a court to be arbitrary and capricious.
15)Requires any regulations promulgated by a state department
that affect the scope of practice of a CNM to be developed in
consultation with the Council.
16)Deletes references to standardized procedures and protocols
and physician supervision for the furnishing of drugs and
devices by CNMs, except that, in a nonhospital setting, a
Schedule II controlled substance shall be furnished by a CNM
only during labor and delivery and only after a consultation
with a physician and surgeon.
17)Authorizes a CNM to furnish or order drugs or devices related
to the provision of care rendered in a home, as specified.
18)Authorizes a CNM 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
consistent with nurse-midwifery education preparation.
19)Authorizes a CNM to perform and repair episiotomies and to
repair first-degree and second-degree lacerations of the
perineum in a home, as specified.
20)States that a consultative relationship between a CNM and a
physician and surgeon shall not, by itself, provide the basis
for finding a physician and surgeon liable for any act or
omission of the CNM.
21)Makes clarifying and technical amendments.
FISCAL
EFFECT: This bill has been keyed "fiscal" by Legislative
Counsel. According to the Assembly Appropriations Committee
analysis dated May 13, 2015, this bill will result in minor
costs to the BRN Fund for advisory council meetings. The
analysis notes that the potential impact on BRN enforcement
costs resulting from the bill is unclear, but will likely be
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minor, as removing the requirement for supervision does not
significantly change the practice of midwifery.
COMMENTS:
1. Purpose. This bill is sponsored by the California Nurse
Midwives Association . According to the Author's office,
"Approximately 1,200 CNMs are licensed in California by the
BRN to practice midwifery - the care of childbearing women
during pregnancy, labor and birth, and during the postpartum
period. While most states allow CNMs to practice
independently, California is one of only six states that
require physician supervision of CNMs.
"California law requires a CNM to practice under the
supervision of a physician, but specifies that the
supervision requirement shall not be construed to require the
physical presence of the physician. 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-signatures on prescriptions, direct care of the patient,
or evaluation of CNM patients at any point during pregnancy
or well-woman care. In communities without
obstetricians/gynecologists, the supervision requirement
limits access to care for women, even when a CNM is available
to provide care.
"In 2013, the Legislature removed physician supervision of
licensed midwives (LMs) (AB 1308, Bonilla, Chapter 665,
Statutes of 2013). CNMs are required to have a higher level
of education and training than LMs in order to qualify for
licensure (licensed as a registered nurse and graduate of a
Board-approved nurse-midwifery program), and yet are still
subject to physician supervision to practice.
"AB 1306 allows CNMs to practice to the full extent of the
education and training, without physician supervision. The
bill keeps their existing scope of practice in place and
aligns their education and practice requirements with
national standards. In addition, the bill includes consumer
protections to guard against kickbacks and self-referrals, as
well as additional structure for CNMs serving patients in
home and birth center settings."
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2.CNMs. CNMs are advanced practice registered nurses who have
specialized education and training to provide primary care,
prenatal, intrapartum, and postpartum care, including
interconception care and family planning. The nurse -
midwifery certificate also authorizes the CNM to attend cases
of normal childbirth, as well as immediate care for the
newborn. Current law requires CNM be licensed as a registered
nurse and graduate from an approved program in
nurse-midwifery. There are 1,271 CNMs in California.
A CNM may furnish drugs and devices after certification that
he or she has completed at least six months of physician and
surgeon supervised experience in the furnishing of drugs and
devices and a course in pharmacology. "Furnishing" is the
ordering of a drug or device in accordance with standardized
procedure or protocol.
Standardized procedures are defined as 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.
Protocols are a part of standardized procedures and are
designed to describe the steps of medical care for given
patient situations. Protocols are developed in consultation
with a supervising physician. "Supervision" requires
telephonic availability but not the physical presence of the
physician.
This bill would remove the requirements of physician
supervision and largely remove the restrictions on the
independent furnishing of drugs and devices by CNMs.
3.CNMs as Independent Practitioners. According to the U.S.
Library of Medicine, CNMs are well positioned as independent
primary care practitioners. "[CNMs] have improved primary
health care services for women in rural and inner-city areas.
The National Institute of Medicine has recommended that [CNMs]
be given a larger role in delivering women's health care.
"Many studies over the past 20 to 30 years have shown that
[CNMs] can manage most perinatal (including prenatal,
delivery, and postpartum) care. They are also qualified to
deliver most family planning and gynecological needs of women
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of all ages. Some may check and manage common adult illnesses,
as well."
In addition, a 2015 article in the peer-reviewed Journal of
Midwifery & Women's Health, "Midwives as Primary Care
Providers for Women," conclude that "Midwives certified by the
American Midwifery Certification Board are prepared to provide
primary care to women from menarche across the lifespan and to
well newborns to 28 days using consultation, collaboration,
and referral to other providers as needed."
4.Ban on the Corporate Practice of Medicine (CPM). This bill
subjects CNMs to the ban on CPM, which previously has only
been applied to physicians. The corporate practice of
medicine (CPM) is usually referred to in the context of a
prohibition, banning hospitals from employing physicians. The
ban on CPM evolved in the early 20th century when mining
companies had to hire physicians directly to provide care for
their employees in remote areas. However, problems arose when
physicians' loyalty to the mining companies conflicted with
patients' needs. Eventually, physicians, courts, and
legislatures prohibited CPM in an effort to preserve
physicians' autonomy and improve patient care.
Over the years, various state and federal statutes have left
the CPM prohibition substantially weakened and largely
nonsensical. According to a 2007 report issued by the
California Research Bureau, "California's CPM doctrine has
been defined largely through lawsuits and Attorney General
opinions over decades, and then riddled by HMO and other
legislation; its power and meaning are now inconsistent?.
Although some non-profit clinics may employ physicians,
California applies the CPM doctrine to most other entities.
Non-profit associations may employ physicians under specific
circumstances and non-profit corporations may employ
physicians in clinics meeting specific requirements. Teaching
hospitals may employ physicians, but other hospitals,
including most public and non-profit hospitals, may not
employ physicians. Professional medical corporations are
expressly permitted to engage in the practice of medicine,
and may employ physicians. [However, t]hese medical
corporations may operate on a for-profit basis, although the
profit motive was one of the original rationales of the CPM
prohibition." Indeed, the greatest cost pressures typically
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come from health insurers, and not the facilities themselves.
The following entities may currently employ physicians:
A clinic operated primarily of the purpose of
medical education by a public or private nonprofit
university medical school.
A clinic operated by a nonprofit corporation as an
entity organized and operated exclusively for scientific
and charitable purposes.
A narcotic treatment program.
A hospital owned and operated by a health care
district.
A hospital owned and operated by a licensed
charitable organization, that offers only pediatric
subspecialty care, as specified.
California is one of only five remaining states that adhere
to some form of the ban. The American Medical Association,
historically the driving force behind the CPM prohibition, no
longer views physician employment per se as a violation of
medical ethics and has removed the doctrine from its ethical
code.
5. The Changing Healthcare Employment Landscape. California's
ban on CPM is becoming a hindrance to efficiency and the
state's competitiveness in a rapidly changing healthcare
environment. Extending an outdated ban on employment to an
expanding and vital class of health care providers will not
benefit consumers or the professionals themselves. According
to a 2011 survey from the consulting firm Accenture:
"U.S. physicians continue to sell their private practices and
seek employment with healthcare systems, according to a new
survey from Accenture. As physicians migrate from private
practice to larger health systems, the new landscape will
require healthcare information technology (IT), medical
device manufacturers, pharmaceutical companies and payers to
revise their business models and offerings. At the same
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time, hospitals will need to determine how to retain and
recruit the correct mix of physicians, especially in
high-growth service lines, including cardiovascular care,
orthopedics, cancer care and radiology. Patients will
increasingly move to large health systems, as opposed to the
current trend of visiting doctors in private, small practice
settings.
"The rate of independent physicians being employed by health
systems will grow by an annual five percent over three years.
By 2013, less than one-third of physicians are expected to
remain truly independent.
"'Health reform is challenging the entire system to deliver
improved care through insight driven health,' said Kristin
Ficery, senior executive, Accenture Health. 'We see an
increasing number of physicians leaving private practice to
join hospital systems, which will force all stakeholders to
revise and refine their business models, product offerings
and service strategies.'
"According to the survey, physicians are increasingly
attracted to the benefits offered by hospital-based
employment opportunities. These benefits include:
Relief from administrative responsibilities.
Greater access to leading-edge healthcare IT
tools, facilities and equipment.
A more manageable work week.
Stability in a business environment made uncertain
by developments such as payment reforms."
These realities are the same facing CNMs, who are currently
employed by hospitals and other facilities. CNMs would be
unable to continue to realize the benefits of employment
should this measure pass.
1. Health Care Access. The potential impact of the ban on CPM
for CNMs is not only on those currently employed; it will
affect future employment opportunities that will be lost as
the result of it.
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The elimination of the physician supervision requirement for
CNMs, standing on its own, would likely result in the
increased employment by hospitals and clinics of CNMs, given
their versatility: CNMs can provide a wide range of services
in a variety of settings, and hospitals would no longer have
to struggle to find physicians willing to supervise them.
Particularly for rural hospitals and other areas where it is
challenging to attract physicians, employing CNMs would be a
desirable option for expanding hospitals' and clinics'
ability to meet basic community needs.
2. California's CPM Equality Argument. Supporters of the CPM
ban argue that it is necessary for equity in the workforce to
subject any profession that becomes independent of physician
supervision to be subject to the same business constraints as
physicians. This is not a valid argument because the
professions are not on equal footing.
a) Physicians and CNMs have very different practice scopes .
CNMs are advanced practice registered nurses who have
specialized education and training to provide primary care,
prenatal, intrapartum, and postpartum care, including
interconception care and family planning. The nurse -
midwifery certificate also authorizes the CNM to attend
cases of normal childbirth on his or her own
responsibility, as well as immediate care for the newborn.
CNM care includes preventative measures and the detection
of abnormal conditions in mother and child, but CNMs cannot
assist childbirth by any artificial, forcible, or
mechanical means. CNMs are not authorized to perform
surgery, although this bill will allow them to perform and
repair episiotomies and first-degree and second-degree
lacerations of the perineum in a home, as specified.
Obstetrician-gynecologists (OB/GYN) are physicians who possess
special knowledge, skills and professional capability in the
medical and surgical care of the female reproductive system and
associated disorders. OB/GYNs are necessary for abnormal cases
of pregnancy, advanced conditions, and surgeries. Resident
education in obstetrics-gynecology must include four years of
accredited, clinically-oriented graduate medical education,
which must be focused on reproductive health care and ambulatory
primary health care for women, including health maintenance,
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disease prevention, diagnosis, treatment, consultation, and
referral.
There will always be a need for OB/GYNs, and while there will be
some practice overlap, the professions are not, nor will they be
according to the terms of this bill, interchangeable.
b) Physicians still have control of medical staffing
decisions at hospitals and may not have incentives to hire
physician extenders like CNMs .
Current law requires that hospitals have a dual structure - an
administrative governing body, which oversees the hospital
operations, and a medical staff, which provides medical services
and is generally responsible for ensuring that its members
provide appropriate medical care to patients at the hospital.
In order to practice at a hospital, a physician must be granted
privileges by the medical staff. To the extent that CNMs may
provide some overlapping functions with OB/GYNs, hospitals may
prefer to hire some CNMs in addition to OB/GYNs to handle cases
of normal childbirth and provision of primary care. Because this
bill would revoke employment by hospitals by CNMs, CNMs would
have to apply for staff privileges from physicians. Given the
nature of their overlapping scopes, it is likely that medical
staff would be reluctant to replace or supplement OB/GYNs with
CNMs.
1. Additional Means of Protecting Medical Decision Making. In
tandem with the exceptions made to the ban on CPM, California
has enacted legislation sharply limiting actual and potential
corporate control over physicians.
The Knox-Keene Act, which regulates health maintenance
organizations (HMOs), subjects HMOs to the following
requirements:
Capitated payment agreements or shared-risk
arrangements must not be tied to specific medical
decisions.
Health plans must furnish medical services in
a manner providing continuity of care.
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Health plans must provide ready referral to
other providers when good professional practice
requires it.
All services must be readily available, and to
the extent feasible, readily accessible, to all
enrollees.
Health plans must assure that medical
decisions are made by qualified medical providers,
without influence of fiscal or administrative
management.
Multiple sections in California statute and regulation ensure
the primacy of an individual's professional medical
decision-making, including this broad statute contained in
BPC § 501:
"It is the public policy of the State of California that a
health care practitioner be encouraged to advocate for
appropriate health care for his or her patients. For purposes
of this section, 'to advocate for appropriate health care'
means to appeal a payer's decision to deny payment for a
service pursuant to the reasonable grievance or appeal
procedure established by a medical group, independent
practice association, preferred provider organization,
foundation, hospital medical staff and governing body, or
payer, or to protest a decision, policy, or practice that the
health care practitioner, consistent with that degree of
learning and skill ordinarily possessed by reputable health
care practitioners with the same license or certification and
practicing according to the applicable legal standard of
care, reasonably believes impairs the health care
practitioner's ability to provide appropriate health care to
his or her patients."
These and similar provisions make the uneven doctrine of CPM
largely unnecessary.
1. Arguments in Support. Writing in support of the bill, the
California Association of Midwives , Maternal and Child Health
Access (MCHA), Black Women for Wellness , the County of Santa
Cruz Board of Supervisors , South Coast Midwifery & Women's
Healthcare, Inc. , Beach Cities Midwifery & Women's Health
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Care , Beachside Birth Center , the American Association of
Birth Centers , AARP , the California Association of Nurse
Anesthetists , Inland Midwife Service , and the Center on
Reproductive Rights and Justice at the University of
California, Berkley School of Law state, AB 1306 separates
the practice of nurse-midwives from physician practice,
creating an opportunity for expansion of women's health care
services within their current scope of practice. These
organizations state that "California is one of six remaining
states to include physician supervision language, language
which contradicts national and international standards. AB
1306 will not change the high quality of care provided by
nurse-midwives nor the way that nurse-midwives currently
practice. Removing state-mandated supervision would allow
the nurse-midwife to partner collaboratively with physicians,
expanding options beyond working as a physician's employee.
AB 1306 would directly and positively affect the California
health care system by providing for improved physician and
nurse-midwife collaboration and greater innovation in health
care delivery."
The American College of Nurse-Midwives (ACNM) states,
"California nurse-midwives are highly trained providers who
earn graduate degrees and are trained in the disciplines of
midwifery and nursing. AB 1306 would require all
nurse-midwives to pass a national certification examination
to demonstrate mastery of ACNM's core competencies, which
meet or exceed national recommendations for midwifery care,
as a condition of licensure. Safe, quality health care can
best be provided to women and their infants when policymakers
permit CNMs to provide independent midwifery care within
their scope of practice."
The American Nurses Association/California , the California
Association for Nurse Practitioners , the United Nurses
Associations of California/Union of Health Care
Professionals , and the California Nurse Midwife Association
(CNMA) state that a CNM is an advanced practice nurse who is
educated in Master's Degree programs accredited by the
American Commission on Midwifery Education through the US
Department of Education and have a higher level of education
and training than Licensed Midwives. According to these
organizations, "with the increasing number of Californians
insured under Covered California and the Affordable Care Act,
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there is a growing shortage of providers to meet the demand
for primary care services. This bill untethers CNMs from
physician supervision requirements to promote the expansion
of primary health care access for thousands of women. In
addition, the bill eliminated barriers that physicians
encounter from malpractice carriers that prohibit them from
supervising CNMs due to fears of vicarious liability."
2. Arguments in Opposition. The California Hospital
Association , Ridgecrest Regional Hospital , Henry Mayo Newhall
Hospital , San Gorgonio Memorial Hospital , San Benito Health
Care District , Community Hospital of the Monterey Peninsula ,
Lompoc Valley Medical Center , Sutter Health , Sharp
Healthcare , Watsonville Community Hospital , Natividad Medical
Center , St. Helena Hospital Napa Valley , Mammoth Hospital ,
Coalinga Regional Medical Center , Ceders-Sinai , Lodi Health ,
El Camino Hospital , Adventist Health , and Loma Linda
University Health state that their opposition is in response
to the amendment that subjects CNMs to the ban on the
corporate practice of medicine. These organizations state,
"This corporate practice ban would prevent CNMs from being
employed by hospitals, professional corporations, and most
other employers that would like to make CNMs available to
their patient population. The current ban in AB 1306 is more
restrictive than provisions that exist for physicians. This
restriction is an unnecessary and unreasonable barrier for
employment of CNMs and hinders access to care for California
women."
The Medical Board of California has taken an oppose unless
amended position, stating, "This bill does not have the same
clear guidance and restrictions on what types of patients
that [CNMs] can accept and does not clearly delineate when a
patient should be transferred to a physician or require a
physician consult for higher risk patients. Because this
bill does not currently include parameters on independent CNM
practice that would ensure consumer protection, the Board is
opposed to this bill unless it is amended to address these
concerns."
3. Related Legislation This Year. SB 323 (Hernandez) of 2015,
would authorize a nurse practitioner who holds a national
certification to practice without physician supervision in
specified settings. ( Status: This bill is pending
AB 1306 (Burke) Page 19
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reconsideration in the Assembly Business and Professions
Committee).
4. Prior Related Legislation. SB 1308 (Bonilla, Chapter 665,
Statutes of 2013) authorized a midwife to directly obtain
supplies and devices, obtain and administer drugs and
diagnostic tests, order testing and receive reports that are
necessary to his/her practice of midwifery and consistent
with his/her scope of practice; expanded the disclosures
required to be made by a midwife to a prospective client to
include the specific procedures that warrant consultation
with a physician and surgeon; and made other correcting and
conforming changes. This bill included no CPM provisions.
SB 1950 (Figueroa, Chapter 1085, Statutes of 2002) required
the MBC to adopt regulations defining the appropriate
standard of care and level of supervision required for the
practice of midwifery.
SB 1479 (Figueroa, Chapter 303, Statutes of 2000) expanded
the disclosures required to be given by licensed midwives and
also required midwives to register birth certificates for
home births.
SB 350 (Killea, Chapter 1280, Statutes of 1993) enacted the
Licensed Midwifery Practice Act of 1993 to provide for the
licensing and regulation of non-nurse and non-physician
assistant midwives by the MBC.
13.Suggested Amendments.
a) Strike references to the ban on CPM . The ban on CPM has
outlived its usefulness and extending it to another class
of healthcare professionals does not further the interests
of California consumers or CNMs.
On page 14, strike lines 3 -34.
To provide additional protections against any corporate
influence on medical judgment, insert the following on page
16, after line 21:
"(c) No entity in (b) shall interfere with, control, or
otherwise direct the professional judgment of a certified
AB 1306 (Burke) Page 20
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nurse midwife in a manner prohibited by Section 510 or of
any other provision of law."
b) Remove references to the Medical Board of California .
This bill deletes the authorization for the BRN to appoint
a Nurse-Midwifery Committee, and instead requires the BRN
to create and appoint a Nurse-Midwifery Advisory Council,
at least two members of which would be qualified physicians
appointed by the MBC, including an obstetrician that has
experience working with nurse-midwives.
There is no precedent for DCA boards to have appointment
authority over the composition of another board's committee.
BRN is capable of appointing physician members to the Council
proposed in this bill and as such, language referencing a MBC
appointment should be removed.
On page 13, line 36, strike "appointed by the Medical Board
of California"
c) Amendments regarding home birth conditions . The
following language would provide greater semantic clarity
to the circumstances in which a CNM may attend a home
birth.
On page 15, line 39, strike "likely" and add "with the
potential"
On page 15, line 40, add "or birth" after pregnancy.
On page 16, line 1, after "from" add "or during," strike
"likely" and add "with the potential"
On page 16, line 2, strike "significant"
On page 16, line 6, after "is" add "equal to or" and replace
"370/7" with "37/7"
On page 16, line 7, add a space between "42" and "0/7"
SUPPORT AND OPPOSITION:
Support:
AB 1306 (Burke) Page 21
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California Nurse Midwives Association (Sponsor)
AARP
American Association of Birth Centers
American College of Nurse-Midwives
American Nurses Association/California
Beach Cities Midwifery & Women's Health Care
Beachside Birth Center
Black Women for Wellness
California Association of Midwives
California Association of Nurse Anesthetists
California Association for Nurse Practitioners
Center on Reproductive Rights and Justice at the University of
California, Berkley School of Law
County of Santa Cruz Board of Supervisors
Inland Midwife Service
Maternal and Child Health Access
South Coast Midwifery & Women's Healthcare, Inc.
United Nurses Associations of California/Union of Health Care
Professionals
Numerous individuals
Opposition:
Adventist Health
California Hospital Association
Ceders-Sinai
Coalinga Regional Medical Center
Community Hospital of the Monterey Peninsula
El Camino Hospital
Henry Mayo Newhall Hospital
Lodi Health
Loma Linda University Health
Lompoc Valley Medical Center
Mammoth Hospital
Medical Board of California
Natividad Medical Center
Ridgecrest Regional Hospital
San Benito Health Care District
San Gorgonio Memorial Hospital
Sharp Healthcare
St. Helena Hospital Napa Valley
Sutter Health
AB 1306 (Burke) Page 22
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Watsonville Community Hospital
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