BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 323|
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THIRD READING
Bill No: SB 323
Author: Hernandez (D), et al.
Amended: 4/22/15
Vote: 21
SENATE BUS, PROF. & ECON. DEV. COMMITTEE: 7-0, 4/20/15
AYES: Hill, Block, Galgiani, Hernandez, Jackson, Mendoza,
Wieckowski
NO VOTE RECORDED: Bates, Berryhill
SENATE APPROPRIATIONS COMMITTEE: 5-0, 5/4/15
AYES: Lara, Beall, Hill, Leyva, Mendoza
NO VOTE RECORDED: Bates, Nielsen
SUBJECT: Nurse practitioners: scope of practice.
SOURCE: Author
DIGEST: This bill authorizes a nurse practitioner (NP) who
holds a national certification to practice without physician
supervision in specified settings.
ANALYSIS:
Existing law:
1)Requires that for initial qualification or certification
as a NP, an individual must meet specified requirements
including having a valid and active Registered Nurse (RN)
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license, possess a master's degree in nursing or graduate
degree in nursing and satisfactorily complete a NP
program approved by the Board of Registered Nursing
(BRN). (BPC § 2835.5)
2)Provides that standardized procedures may be implemented
to authorize a NP to do the following: order durable
medical equipment as specified; certify disability after
performance of a physical examination by the NP and
collaboration with a physician and surgeon; and approve,
sign, modify, or add to a plan of treatment or a plan of
care for individuals receiving home health services or
personal care services after consultation with the
treating physician and surgeon. (BPC § 2835.7)
3)Provides that a NP may furnish or order drugs or devices
if specified conditions are met and are done in
accordance with standardized procedures or protocols and
the drugs or devices ordered are consistent with the NPs
educational preparation or for which clinical competency
has been established and maintained. (BPC § 2836.1 (a))
4)Requires one physician to supervise every four
prescribing NPs. (BPC § 2836.1 (e))
This bill:
1)Makes legislative findings and declarations as to the
importance of NPs providing safe and accessible primary care.
2)Authorizes a NP who holds a national certification from a
national certifying body recognized by the BRN (certified NP)
to practice without the supervision of a physician if the
certified NP practices in one of the following settings:
a) A clinic.
b) Specified health facilities, including a general acute
care hospital, acute psychiatric hospital, skilled nursing
facility, intermediate care facility, correctional
treatment center, and hospice facility, as specified.
c) A county medical facility.
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d) An accountable care organization.
e) A group practice, including a professional medical
corporation, another form of corporation controlled by
physicians, a medical partnership, a medical foundation
exempt from licensure, or another lawfully organized group
of physicians that delivers, furnishes, or otherwise
arranges for or provides health care services.
f) A medical group, independent practice association, or
any similar association.
3)Provides that in addition to any other practice authorized in
statute or regulation, a certified NP practicing in specified
settings may do all of the following without physician
supervision, unless collaboration is specified:
a) Order durable medical equipment.
b) Certify disability for purposes of unemployment after
performance of a physical examination by the certified NP
and collaboration, if necessary, with a physician.
c) Approve, sign, modify, or add to a plan of treatment or
plan of care for individuals receiving home health services
or personal care services after consultation, if necessary,
with the treating physician and surgeon.
d) Assess patients, synthesize and analyze data, and apply
principles of health care.
e) Manage the physical and psychosocial health status of
patients.
f) Analyze multiple sources of data, identify a
differential diagnosis, and select, implement, and evaluate
appropriate treatment.
g) Establish a diagnosis by client history, physical
examination, and other criteria, consistent with this
section, for a plan of care.
h) Order, furnish, prescribe, or procure drugs or devices.
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i) Delegate tasks to a medical assistant pursuant to
standardized procedures and protocols developed by the NP
and medical assistant that are within the medical
assistant's scope of practice.
j) Order hospice care, as appropriate.
aa) Order and interpret diagnostic procedures.
bb) Perform additional acts that require education and
training and that are recognized by the nursing profession
as appropriate to be performed by a NP.
4)Requires a certified NP to refer a patient to a physician or
other licensed health care provider if a situation or
condition of the patient is beyond the scope of the education
and training of the NP.
5)Requires a certified NP to maintain professional liability
insurance appropriate for the practice setting.
Background
Nurse practitioner training and educational requirements. A NP
is a registered nurse who possesses additional preparation and
skills in physical diagnosis, psycho-social assessment, and
management of health-illness needs in primary health care, and
who has completed a NP program that conforms to BRN standards.
NP programs are required to include 12 semester units or 18
quarter units of clinical practice. NPs are required to have a
master's degree, and many further pursue a doctorate in nursing.
As of September 2013, the BRN reported 18,541 active, licensed
NPs.
Standardized procedures and protocols. 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. The Medical
Practice Act authorizes physicians to diagnose mental and
physical conditions, to use drugs in or upon human beings, to
sever or penetrate tissue, and to use other methods in the
treatment of diseases, injuries, deformities, or other physical
or mental conditions. As a general rule, the performance of any
of these functions by a NP requires a standardized procedure. A
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NP may perform standardized procedure functions only under the
conditions specified in a health care system's standardized
procedures, and must provide the system with satisfactory
evidence that he or she meets its experience, training, and
education requirements. 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.
Prescribing authority. NPs may furnish drugs by obtaining a
number from the United States Drug Enforcement Agency (DEA) to
prescribe Schedule II-V drugs pursuant to a protocol and
standardized procedures. The DEA considers a NP to be a
"prescriber," but NPs who write prescriptions are considered a
"furnishing" NP under California law. Furnishing is the
delegated authority to write prescriptions, and is done in
accordance with approved standardized procedures and protocols.
Physician supervision is required and the physician must be
available, at least by telephone, at the time the NP examines
the patient. Furnishing NPs are required to be supervised by a
physician, but non-furnishing NPs are not. A physician may
supervise up to four furnishing NPs.
Nurse practitioner as a primary care provider. The Institute of
Medicine (IOM), an independent nonprofit organization which is
part of the National Academy of Sciences, published a report in
2011, in which it concluded that NPs deliver the same quality of
primary care as physicians.
The IOM report acknowledges that some argue NPs should not be
allowed to be independent primary care practitioners because
physicians are more qualified due to their extensive academic
and clinical training, and unique cognitive and technical
skills. However, the IOM report noted that the contention that
NPs are less able than physicians to deliver care that is safe,
effective, and efficient is not supported by research. Further,
NPs are trained to refer out when conditions rise beyond their
competencies and have the ability to coordinate care between
providers.
NPs have been slowly granted practice autonomy in other states
over the last decade. According to information provided by the
American Association of Nurse Practitioners, 21 states allow NPs
to evaluate patients, diagnose, order and interpret diagnostic
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tests, and initiate and manage treatment under the exclusive
license authority of the state board of nursing. Today, NPs
(which make up slightly less than a quarter of all primary care
professionals), together with physicians and physician
assistants, provide most of the primary care in the United
States. The demand for a larger primary care workforce will
grow as access to coverage, service settings, and services
increases under the federal Affordable Care Act (ACA).
Primary care access and Medi-Cal. The ACA was passed in March
2010 to provide quality, affordable healthcare for all Americans
and improve the quality and efficiency of that care. California
was an early adopter of the ACA and has been a leader in
enrolling eligible residents. Primary care providers will be
responsible for health promotion, disease prevention, early
diagnosis, and the coordination of care with other providers for
these new entrants to the market.
Permitting independent practice by NPs will allow greater access
to primary care for Medi-Cal and Medicare populations. Medi-Cal
is the state's Medicaid health insurance program, funded by both
the federal and state government for low-income families and
children, people with disabilities, pregnant women, and seniors.
Medicare is the federal government health insurance program for
seniors and persons with disabilities.
The California HealthCare Foundation reports that presently,
adults with Medi-Cal are nearly twice as likely to report
difficulty getting a doctor appointment than other insured
adults in California. According to the Centers for Medicare and
Medicaid Services, fewer American doctors are treating patients
enrolled in the Medicare health program, reflecting physician
frustration with its payment rates and rules. The number of
doctors who opted out of Medicare last year nearly tripled from
three years earlier. Other doctors are limiting the number of
Medicare patients they treat even if they don't formally opt out
of the system. NPs are limited in their ability to be
reimbursed for care covered by Medi-Cal due to physician
supervision constraints.
NPs in California may currently only treat Medicare patients if
their supervising physician is a Medicare provider. According
to an article in the medical journal Health Affairs, Medicare,
Medicaid, and private insurers typically reimburse NPs at rates
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that are just 75-85% of what they pay physicians for the same
services. NPs generally have less overhead than physicians and
are therefore more likely to work for a lower reimbursement.
Accountability provisions. Presently, supervising physicians
are partially accountable for an NP's practice and a physician's
license is at stake for unprofessional conduct by a supervised
NP. Independence will require that the NP be wholly accountable
for his or her actions, and the liability insurance required in
this bill will help protect consumers in the event of a
malpractice action.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
According to the Senate Appropriations Committee:
One-time costs, likely about $75,000, to update existing
regulations (BRN Fund).
Likely minor ongoing costs for enforcement (BRN Fund). The
BRN indicates that there may be increased need for enforcement
activity under this bill, but that those costs are not
anticipated to be significant.
SUPPORT: (Verified5/5/15)
AARP
Alliance of Catholic Health Care
AltaMed Health Services Corporation
Alzheimer's Association
American Nurses Association\California
Anthem Blue Cross
Association of California Healthcare Districts
Association of California Nurse Leaders
Bay Area Council
Blue Shield of California
California Association for Nurse Practitioners
California Association of Nurse Anesthetists
California Association of Physician Groups
California Association of Public Hospitals and Health Systems
California Commission on Aging
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California Council of Community Mental Health Agencies
California Family Health Council
California Health & Wellness
California Hospital Association
California Naturopathic Doctors Association
California Pharmacists Association
California Primary Care Association
California Senior Legislature
California Society of Health-System Pharmacists
Congress of California Seniors
Johns Hopkins University Division of Occupational and
Environment Medicine
Maxim Healthcare Services, Inc.
MemorialCare Health System
Pacific Clinics
Private Essential Access Community Hospitals
Providence Health & Services
Sharp HealthCare
Small Business Majority
Stanford Health Care
St. Joseph Health
United Nurses Associations of California/Union of Health Care
Professionals
University of California
Western University of Health Sciences
Several individuals
OPPOSITION: (Verified5/5/15)
American Medical Association
American Osteopathic Association
California Academy of Family Physicians
California Chapter of the American College of Cardiology
California Chapter of the American College of Emergency
Physicians
California Medical Association
California Society of Anesthesiologists
California Society of Plastic Surgeons
Union of American Physicians and Dentists
Numerous individuals
ARGUMENTS IN SUPPORT: Supporters of this bill include patient
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and employer representatives, healthcare systems, insurers,
nursing organizations, pharmacists, naturopaths, and academic
institutions. Supporters recognize the extensive training and
certification of NPs ensure patient safety and believe passage
of this bill will increase both healthcare access and provider
participation in Medi-Cal.
The California Association of Physician Groups writes that since
the implementation of ACA, "?California has added 5 million
newly insured patients to the healthcare system. Recently,
newly insured patients tried to find doctors once they had
obtained coverage but found that many practitioners had closed
their practices to new patients ?. California has an aging
primary care physician and osteopathic workforce. Other states
have proven that NPs with full practice authority function well
in that role, and there is a wealth of national studies that
have analyzed the environments in which full practice authority
has been legislated and all have concluded that it is a safe and
effective means to increase access to quality care. While there
is a wealth of studies that support this concept, there is
little or no evidence to refute it."
ARGUMENTS IN OPPOSITION: Opponents are physician organizations
and individuals who are concerned that NPs are insufficiently
qualified to practice without supervision and limiting their
independent practice to specific settings, as defined in the
bill, does not guarantee interdependent practice teams.
The California Chapter of the American College of Cardiology
(CA-ACC) writes, "CA-AAC worries this bill would fracture health
care teams comprised of multiple health care providers working
together to provide coordinated care. Nurse practitioners are
an important part of these health care delivery teams working in
conjunction with supervising physicians. Nurse practitioners
however, do not have sufficient education and training to
examine and diagnose completely independent of physicians and
such a practice puts patients at risk."
Prepared by:Sarah Huchel / B., P. & E.D. / (916) 651-4104
5/6/15 16:49:43
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