BILL ANALYSIS Ó
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 1306|
|Office of Senate Floor Analyses | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
THIRD READING
Bill No: AB 1306
Author: Burke (D), et al.
Amended: 6/30/16 in Senate
Vote: 21
SENATE BUS., PROF. & ECON. DEV. COMMITTEE: 7-0, 6/27/16
AYES: Hill, Block, Galgiani, Hernandez, Jackson, Mendoza,
Wieckowski
NO VOTE RECORDED: Bates, Gaines
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
ASSEMBLY FLOOR: 78-1, 6/3/15 - See last page for vote
SUBJECT: Healing arts: certified nurse-midwives: scope of
practice
SOURCE: California Nurse Midwives Association
DIGEST: This bill removes physician supervision requirements
for a Certified Nurse Midwife (CNM) as specified, modifies
practice parameters, establishes a Nurse-Midwifery Advisory
Committee (Committee) within the Board of Registered Nursing
(BRN), and protects against retaliation for CNMs who advocate
for appropriate health care for their patients, as specified,
among other changes.
ANALYSIS:
AB 1306
Page 2
Existing law:
1) The Nursing Practice Act provides for the licensure and
regulation of the practice of nursing by the BRN and
authorizes the BRN to issue a certificate to practice
nurse-midwifery to a person who meets educational standards
established by the BRN. (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 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) 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.)
5) 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)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)
AB 1306
Page 3
This bill:
1) Extends protections against retaliation to CNMs who advocate
for patients' appropriate health care.
2) Prohibits CNMs from 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.
3) States that, notwithstanding the prohibition on referrals, a
CNM may refer a person to a licensed alternative birth center
or to a nationally accredited alternative birth center, among
other facilities, if the recipient of the referral does not
compensate the CNM for the patient referral, and any
equipment lease arrangement between the licensee and the
referral recipient complies with specified requirements.
4) 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.
5) Requires the BRN to create the Committee to make
recommendations to the BRN on all matters related to
nurse-midwifery practice, education, and other matters as
specified by the BRN.
6) Requires the Committee to meet regularly, but at least twice
per year.
7) Specifies that the Committee shall consist of:
a) 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.
AB 1306
Page 4
d) At least two qualified physicians, including an
obstetrician that has experience working with
nurse-midwives.
8) 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.
9) Authorizes a CNM to practice without supervision of a
physician and surgeon in the following settings, and
specifies that such entities shall not interfere with,
control, or otherwise direct the professional judgment of a
CNM, as specified:
a) A licensed clinic, as specified.
b) A facility, as specified,
c) A medical group practice, including a professional
medical corporation; a medical partnership; a medical
foundation exempt from licensure, as specified; or another
lawfully organized group of physicians that delivers,
furnishes, or otherwise arranges for or provides health
care services.
d) A licensed alternative birth center, as specified, or
nationally accredited birth center.
e) A nursing corporation, as specified.
f) A home setting.
10)Limits a CNM to attend during a normal, low-risk pregnancy
and childbirth in the home setting when all the following
conditions apply:
a) There is the absence of all of the following:
i) Any preexisting maternal disease or condition
AB 1306
Page 5
creating risks beyond that of a normal, low-risk
pregnancy or birth, as defined in the American College
of Nurse-Midwives' standard-setting documents and any
future changes to those documents.
ii) Disease arising from or during the pregnancy
creating risks beyond that of a normal, low-risk
pregnancy or birth, as defined in the American College
of Nurse-Midwives' standard-setting documents and any
future changes to those documents.
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 37
weeks 0/7 days and less than 42 weeks 0/7 days completed
weeks of pregnancy at the onset of labor.
e) Labor is spontaneous or induced in an outpatient
setting.
11)States that if a potential CNM client meets the conditions
specified in clauses (b) to (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 provide the woman with a
referral for an examination by a physician and surgeon
trained in obstetrics and gynecology. A CNM may assist the
woman in pregnancy and childbirth only if an examination by a
physician and surgeon trained in obstetrics and gynecology is
obtained and, based upon review of the client's medical file,
the CNM determines that the risk factors presented by the
woman's condition do not increase the woman's risk beyond
that of a normal, low-risk pregnancy and birth. The CNM may
continue care of the client during a reasonable interval
between the referral and the initial appointment with the
physician and surgeon.
12)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 CNM shall collaboratively care for women with
more complex health needs.
AB 1306
Page 6
13)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 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.
14)States that the practice of nurse-midwifery does not include
the assisting of childbirth by any forcible or mechanical
means or the performance of a version.
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 Committee.
16)Prohibits any other law from being construed to prohibit a
CNM from furnishing or ordering drugs or devices, including
controlled substances classified in Schedule II, III, IV, or
V under the California Uniform Controlled Substances Act,
when the drugs or devices are furnished or ordered related to
the provision of any of the following:
a) Family planning services.
b) Routine health care or perinatal care.
c) Care rendered, consistent with the CNM's educational
preparation or for which clinical competency has been
established and maintained, to persons within specified
facilities.
d) Care rendered in a home, as specified.
17)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.
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
AB 1306
Page 7
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 nationally accredited birth center and 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.
Background
Certified Nurse Midwives (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 a 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 completing at least
six months of physician 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 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.
CNMs as Independent Practitioners. According to the U.S.
Library of Medicine, CNMs are well positioned as primary care
practitioners. "Many studies over the past 20 to 30 years have
AB 1306
Page 8
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 of
all ages." Echoing this sentiment, the Center for the Health
Professions at the University of California at San Francisco
(UCSF) states that research generally confirms that care
provided by CNMs is at least as safe as that from physicians and
costs less.
However, current laws and regulations hamper the ability of CNMs
to practice to the full extent of their training, limiting their
potential impact. The dean of the UCSF School of Nursing,
Kathleen Dracup, states "Primary care delivery has changed
dramatically in the past 50 years, and for the better; we are
living longer and more comfortably, and [advance practice
nurses] are often the people who have provided the primary care
in partnership with primary care doctors. If regulations around
nurse practitioners and midwives are updated and outdated views
of primary care change, that will provide one very promising
pathway toward effective health care reform."
CNMs have demonstrated an ability to play a key role in the
delivery of primary healthcare to Californians, and this bill
will release them to practice independently, enabling many more
individuals to access needed care.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
SUPPORT: (Verified8/1/16)
California Nurse Midwives Association (source)
AARP
American Association of Birth Centers
American College of Nurse-Midwives
American Nurses Association/California
Association of California Healthcare Districts
Beach Cities Midwifery & Women's Health Care
AB 1306
Page 9
Beachside Birth Center
Black Women for Wellness
California Association for Nurse Practitioners
California Association of Midwives
California Association of Nurse Anesthetists, Inc.
California Hospital Association
Center on Reproductive Rights and Justice at the University of
California, Berkeley School of Law
County of Santa Cruz Board of Supervisors
Inland Midwife Service
Maternal and Child Health Access
Numerous individuals
South Coast Midwifery & Women's Healthcare, Inc.
United Nurses Associations of California/Union of Health Care
Professionals
OPPOSITION: (Verified8/1/16)
California Medical Association
Medical Board of California
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 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, Berkeley School of
Law state that 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, "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
AB 1306
Page 10
care system by providing for improved physician and
nurse-midwife collaboration and greater innovation in health
care delivery."
ARGUMENTS IN OPPOSITION:The California Medical Association (CMA)
writes, "Since February 2015, the CMA has engaged in a
productive stakeholder process with the author and the sponsors
of AB 1306. This process resulted in collaboration and
compromise by all those involved. Even though this bill
reverses decades of California law that ensured high quality
health care through physician supervision of allied health
professionals, CMA adopted a neutral position because the bill
contained provisions that helped ensure that CNMs could only
practice independently in highly integrated settings such as
acute care hospitals and clinics and that independently
practicing CNMs are subject [to] the same patient and consumer
protection laws that apply to practicing physicians. The latest
amendments taken in Senate Business [Professions and Economic
Development] Committee deleted the Corporate Practice of
Medicine (CPM) bar language, which is a key component of these
consumer protection measures.
"?.the CMA believes that AB 1306 will likely result in increased
cost[s] in our healthcare system. A University of Maryland
Division of General Internal Medicine study called, "A
Comparison of resource utilization in nurse practitioners and
physicians, concluded that in a primary care setting, nurse
practitioners may utilize more health care resources than
physicians. The study compared health care resource utilization
for adult patients assigned to a nurse practitioner with that
for patients assigned to a resident or attending physicians.
The reason for the disparity is that lower trained practitioners
are less sure about their initial [diagnoses] and therefore
order more tests and referrals than higher trained physicians."
ASSEMBLY FLOOR: 78-1, 6/3/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle,
Daly, Dodd, Eggman, Frazier, Gallagher, Cristina Garcia,
Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray,
Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones,
Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low,
Maienschein, Mathis, McCarty, Medina, Melendez, Mullin,
AB 1306
Page 11
Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea,
Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago,
Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,
Wilk, Williams, Wood, Atkins
NOES: Beth Gaines
NO VOTE RECORDED: Mayes
Prepared by:Sarah Huchel / B., P. & E.D. / (916) 651-4104
8/3/16 18:06:32
**** END ****