BILL ANALYSIS Ó
AB 1306
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB
1306 (Burke)
As Amended June 30, 2016
Majority vote
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|ASSEMBLY: |78-1 |(June 3, 2015) |SENATE: | 22-9 |(August 30, |
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Original Committee Reference: B. & P.
SUMMARY: Removes the physician supervision requirement for
certified nurse midwives (CNMs), allowing CNMs to manage a full
range of primary gynecological and obstetric health services.
Specifically, this bill:
1)Prohibits a CNM from referring a patient for services if the
CNM has a financial interest in the referral.
2)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).
3)Requires the BRN to create and appoint a Nurse-Midwifery
Advisory Committee (committee) consisting of CNMs in good
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standing with experience in hospital and nonhospital practice
settings, a nurse-midwife educator, two qualified physicians,
as specified, and a consumer of midwifery care.
4)Requires the committee to consist of a majority of
nurse-midwives and to make recommendations to the BRN on all
matters related to nurse-midwifery practice, education,
disciplinary actions, standards of care, and other matters
specified by the BRN, and would require the council to meet
regularly, but at least twice a year.
5)Authorizes a CNM to manage a full range of primary
gynecological and obstetric care services for women from
adolescence beyond menopause, including, but not limited to,
primary health care, gynecologic and family planning services,
preconception care, care during pregnancy, childbirth, and the
postpartum period, immediate care of the newborn, and
treatment of male partners for sexually transmitted
infections, utilizing consultation, collaboration, or referral
to appropriate levels of health care services, as specified.
6)Authorizes a CNM to practice without supervision of a
physician and surgeon in the following settings:
a) A licensed clinic as described in Health and Safety Code
Division 2 Chapter 1 (commencing with Section 1200).
b) A facility as described in Health and Safety Code
Division 2 Chapter 2 (commencing with Section 1250).
c) A facility as described in Health and Safety Code
Division 2 Chapter 2.5 (commencing with Section 1440).
d) A medical group practice, including a professional
medical corporation, a medical partnership, a medical
foundation exempt from licensure pursuant to Health and
Safety Code Section 1206, or another lawfully organized
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group of physicians that delivers, furnishes, or otherwise
arranges for or provides health care services.
e) A licensed alternative birth center, as described in
Health and Safety Code Section 1204, or nationally
accredited birth center.
f) A nursing corporation, as defined in Business and
Professions Code Section 2775.
g) A home setting, except as specified.
7)Prohibits an entity which employs a CNM from not interfering
with, controlling, or otherwise directing the professional
judgment of a CNM, as specified.
8)Makes a CNM practicing without physician and surgeon
supervision subject to all credentialing and quality standards
held by the facility in which the CNM practices. Specifies
that the peer review body shall include CNMs as part of the
peer review body that reviews CNMs. Requires the peer review
body of that facility to impose standards that ensure quality
and patient safety in their facility. Specifies that the
standards shall be approved by the relevant governing body
unless found by a court to be arbitrary and capricious.
9)Provides 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.
10)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 resources of the medical personnel available in the
setting of care, and provides that the practice of
nurse-midwifery emphasizes informed consent, preventive care
and early detection and referral of complications to a
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physician and surgeon.
11)Requires a CNM while practicing in a hospital setting to
collaboratively care for women with more complex health needs.
12)Deletes the requirement that drugs or devices are furnished
or ordered in accordance with standardized procedures and
protocols.
13)Provides 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.
14)Authorizes a CNM to furnish and order drugs or devices in
connection with care rendered in a home.
15)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
that are consistent with nurse-midwifery education
preparation.
16)Deletes the requirement that, in order for a CNM to perform
and repair episiotomies and to repair first-degree and second
degree lacerations of the perineum, the procedures must be
performed pursuant to protocols developed and approved by a
supervising physician and surgeon. Further authorizes a CNM
to perform the procedures in a patient's home.
17)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.
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18)Makes conforming changes.
The Senate amendments:
1)Change the name of the Nurse-Midwifery Advisory Council to the
Nurse-Midwifery Advisory Committee.
2)Change the composition of the committee and changed the
requirements of the committee members.
3)Delete the provisions prohibiting corporations and other
artificial legal entities from practicing mid-wifery.
4)Specify that CNMs must practice consistent with the
Competencies for Basic Midwifery practice promulgated by the
American College of Nurse-Midwives, or its successor national
professional organization, as approved by the BRN.
5)Amend the CNM scope of practice to mean managing "a full range
of primary gynecological and obstetric care" rather than "a
full range of primary health care services."
6)Specify the settings in which a CNM may practice without
physician and surgeon supervision.
7)Further specify the conditions under which a CNM may provide
peripartum care in a home without physician and surgeon
supervision.
8)Provide that the entities under which a CNM might practice may
not interfere with, control, or otherwise direct the
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professional judgment of a CNM.
9)Add the self-referral prohibition.
10)Add additional conforming and technical changes.
FISCAL EFFECT: According to the Senate Appropriations
Committee, pursuant to Senate Rule 28.8, negligible state costs.
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
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
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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 1365 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 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.
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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 gynecological and
obstetric care services for women from adolescence beyond
menopause, including, but not limited to, primary care and
gynecologic and family planning services.
2)A CNM would no longer be required to adhere to standardized
procedures and protocols when:
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,
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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 the
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 [American Congress of Obstetricians
and Gynecologists], 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."
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ARGUMENTS IN OPPOSITION:
The California Medical Association (CMA) opposes the 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
within the scope of gynecology. As such, the author may wish to
amend the 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
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physicians by for-profit and non-profit corporate entities and
government (see Business and Professions Code Section 2400).
Cross Collaboration Between Advisory Councils. This bill would
impact the practice of CNMs. It would also create a Nurse
Midwives Advisory Committee 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.
Analysis Prepared by:
Le Ondra Clark Harvey Ph.D. / B. & P. / (916)
319-3301 FN:
0003867