BILL ANALYSIS Ó
SB 323
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Date of Hearing: June 30, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
SB 323(Hernandez) - As Amended June 23, 2015
SENATE VOTE: 25-5
SUBJECT: Nurse practitioners: scope of practice
SUMMARY: Permits Nurse Practitioners (NPs) to practice, without
being supervised by a physician and surgeon, if the NP has met
specified requirements including possessing liability insurance
and national certification.
EXISTING LAW:
1)Establishes the Board of Registered Nursing (BRN), within the
Department of Consumer Affairs (DCA), and authorizes the BRN
to license, certify and regulate nurses. (Business and
Professions Code (BPC) §§ 2701; 2708.1)
2)Clarifies that there are various and conflicting definitions
of "nurse practitioner" and "registered nurse" (RN) that are
used within California and finds the public interest is served
by determining the legitimate and consistent use of the title
"nurse practitioner" established by the BRN. (BPC § 2834)
3)Requires applicants for licensure as a NP to meet specified
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educational requirements including: (BPC § 2835.5)
a) Holding a valid and active registered nursing license;
b) Possessing a Master's degree in nursing, a Master's
degree in a clinical field related to nursing, or a
graduate degree in nursing; and,
c) Completion of a NP program authorized by the BRN.
4)Recognizes the existence of overlapping functions between
physicians and NPs and permits additional sharing of functions
within organized health care systems that provide for
collaboration between physicians and NPs. (BPC § 2725;
Health and Safety Code (HSC) § 1250)
5)Defines "health facility" as any facility, place, or building
that is organized, maintained and operated for the diagnosis,
care, prevention and treatment of physical or mental human
illness including convalescence, rehabilitation, care during
and after pregnancy or for any one or more of these purposes,
for which one or more persons are admitted for a 24-hour stay
or longer. (HSC § 1250)
6)Authorizes a NP to do the following, pursuant to standardized
procedures and protocols (SPPs) created by a physician or
surgeon, or in consultation with a physician or surgeon: (BPC
§ 2835.7)
a) Order durable medical equipment;
b) Certify disability claims; and,
c) Approve, sign, modify or add information to a plan of
treatment for individuals receiving home health services.
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7)Defines "furnishing" as the ordering of a drug or device in
accordance with SPPs or transmitting an order of a supervising
physician and surgeon. (BPC § 2836.1(h))
8)Defines "drug order" or "order" as an order for medication
which is dispensed to or for an ultimate user and issued by a
NP. (BPC § 2836.1(i))
9)Establishes that the furnishing and ordering of drugs or
devices by NPs is done in accordance with the SPP developed by
the supervising physician and surgeon, NP and the facility
administrator or designee and shall be consistent with the NPs
educational preparation and/or established and maintained
clinical competency. (BPC § 2836.1)
10)Indicates a physician and surgeon may determine the extent of
supervision necessary in the furnishing or ordering or drugs
and devices. (BPC § 2836.1(g)(2))
11)Permits a NP to furnish or order Schedule II through Schedule
V controlled substances and specifies that a copy of the SPP
shall be provided upon request to any licensed pharmacist when
there is uncertainty about the NP furnishing the order. (BPC
§ 2836.1(f)(1)(2); HSC §§ 11000; 11055; 11056).
12)Indicates that for Schedule II controlled substances, the SPP
must address the diagnosis of the illness, injury or condition
for which the controlled substance is to be furnished.
(BPC § 2836.1(2))
13)Requires that a NP has completed a course in pharmacology
covering the drugs or devices to be furnished or ordered.
(BPC § 2836.1(g)(1))
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14)States that a NP must hold an active furnishing number,
register with the United States Drug Enforcement
Administration and take a continuing education course in
Schedule II controlled substances. (BPC § 2836.1(3))
15)Specifies that the SPP must list which NPs may furnish or
order drugs or devices. (BPC § 2836.1(c)(1))
16)Requires that the physician and surgeon supervision shall not
be construed to require the physical presence of the
physician, but does include collaboration to create the SPP,
approval of the SPP and availability of the physician and
surgeon to be contacted via telephone at the time of the
patient examination by the NP. (BPC § 2836.1(d))
17)Limits the physician and surgeon to supervise no more than
four NPs at one time.
(BPC § 2836.1(e))
18)Authorizes the BRN to issue a number to NPs who dispense
drugs or devices and revoke, suspend or deny issuance of the
number for incompetence or gross negligence.
(BPC § 2836.2)
THIS BILL:
1)Makes Legislative findings and declarations as to the
importance of NPs providing safe and accessible primary care.
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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;
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; and,
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
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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;
i) Delegate tasks to a medical assistant pursuant to SPPs
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; and,
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) States that it is unlawful for a "certified NP" to refer 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 NP or his or her immediate
family has a financial interest with the person or in the
entity that receives the referral.
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5) Further specifies that the BRN shall review the facts and
circumstances of any conviction and take appropriate
disciplinary action if the "certified NP" has committed
unprofessional conduct and that the BRN may assess fines and
appropriate disciplinary action including the revocation of a
"certified NP's" license.
6) Specifies that a "certified NP" is subject to the peer review
process where a peer review body reviews the basic
qualifications, staff privileges, employment, medical
outcomes or professional conduct of licentiates to make
recommendations for quality improvement and education in
order to do the following:
a) Determine whether a licentiate may practice or continue
to practice in a health care facility, as specified; and,
b) To assess and improve the quality of care rendered in
a health care facility as specified.
7) Requires the BRN to disclose 805 reports, which are the
written reports filed with the BRN, as a result of an action
of a peer review body, within 15 days after any of the
following occur:
a) A "certified NP's" application for staff privileges or
membership is denied or rejected for a medical
disciplinary cause or reason;
b) A "certified NP's" membership, staff privileges, or
employment is terminated or revoked for a medical
disciplinary cause or reason; or,
c) Restrictions are imposed, or voluntarily accepted, on
staff privileges, membership, or employment for
accumulative total of 30 days or more for any 12-month
period, for a medical disciplinary cause or reason.
8)Indicates that if the BRN or licensing agency of another state
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revokes or suspends, without a stay, the license of a
physician and surgeon, a peer review body is not required to
file an 805 report when it takes an action as a result of the
revocation or suspension.
9)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.
10)Requires a "certified NP" to maintain professional liability
insurance appropriate for the practice setting.
FISCAL EFFECT: According to the Senate Appropriations Committee
analysis, this bill will result in one-time costs, likely about
$75,000, to update existing regulations. The bill may also
result in minor ongoing costs for enforcement.
COMMENTS:
Purpose. This bill is sponsored by the author. According to
the author, "Numerous California editorial boards have endorsed
full practice authority for NPs. A 2013 New York Times
editorial stated 'There is plenty of evidence that well-trained
health workers can provide routine service that is every bit as
good or even better than what patients would receive from a
doctor. And because they are paid less than the doctors, they
can save the patient and the healthcare system money.'
Californians deserve access to high quality primary care offered
by a range of safe, efficient, and regulated providers. NPs have
advanced their educational, testing, and certification programs
over the past decade. They've enhanced clinical training, moved
to advanced degrees, and upgraded program accreditation
processes. Other states have recognized advances with NP
practice acts that align with professional competence and
advanced education. But California has not kept pace.
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In California, we have a robust network of providers that are
well-trained, evenly distributed throughout the state, and well
positioned to pay particular attention to underserved areas.
Deploying these professionals in a team-based delivery model
where they work collaboratively with physicians will allow us to
meet the demands placed on our healthcare systems created by a
rapidly aging physician population and expansion of health
insurance coverage."
Background. According to the Association of American Medical
Colleges, by 2015, the nation will face a shortage of 62,100
physicians, 33,100 primary care practitioners and 29,000 other
specialists. Estimates obtained from the Council on Graduate
Medical Education indicate that the number of primary care
physicians actively practicing in California is far below the
state's need. The distribution of these primary care physicians
is also poor. In 2008, there were 69,460 actively practicing
primary care physicians in California, of which only 35 percent
reported they actually practiced primary care. This equates to
63 active primary care physicians per 100,000 persons. However,
according to the CGME, 60 to 80 primary care physicians are
needed per 100,000 persons in order to adequately meet the needs
of the population. When the same metric is applied regionally,
only 16 of California's 58 counties fall within the needed
supply range for primary care physicians. In other words, less
than one third of Californians live in a community where they
have access to adequate health care services. In addition, a
2013 study in Health Affairs found that the proportion of U.S.
medical students choosing careers in primary care dropped from
60 percent in 1998 to approximately 25 percent in 2013. Some
purport that the way to address this shortage is by expanding
the role of NPs and other allied healthcare professionals to
provide primary care services.
NP Education and Training. There are approximately 19,000 NPs
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licensed by the BRN. The BRN sets the educational standards for
NP certification. A NP is a registered nurse (RN) who has
earned a bachelors and postgraduate nursing degree such as a
Master's or Doctorate degree. NPs possess advanced skill in
physical diagnosis, psycho-social assessment and management of
health-illness needs in primary health care, which occurs when a
consumer makes contact with a health care provider who assumes
responsibility and accountability for the continuity of health
care regardless of the presence or absence of disease (Title 16
California Code of Regulations (CCR) §§ 1480(b); 1484).
Examples of primary health care include: physical and mental
assessment, disease prevention and restorative measures,
performance of skin tests and immunization techniques,
withdrawal of blood and authority to initiate emergency
procedures. Data from the Employment Developmental Department
indicates that hospitals are the main employer of NPs.
NP Scope and SPPs. A NP does not have an additional scope of
practice beyond the RNs scope and must rely on SPPs for
authorization to perform medical functions which overlap with
those conducted by a physician (16 CCR § 1485). According to
the BRN, "SPPs are the legal mechanism for registered nurses,
nurse practitioners to perform functions which would otherwise
be considered the practice of medicine." Examples of these
functions include: diagnosing mental and physical conditions,
using drugs in or upon human beings, severing or penetrating the
tissue of human beings and using other methods in the treatment
of diseases, injuries, deformities or other physical or mental
conditions.
SPPs must be developed collaboratively with NPs, physicians and
administration of the organized health care system where they
will be utilized. Because of this interdisciplinary
collaboration, there is accountability on several levels for the
activities to be performed by the NP. Importantly, a NP must
provide the organized health system with satisfactory evidence
that the NP meets the experience, training and/or education
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requirements to perform the functions. If a NP undertakes a
procedure without the competence to do so, such an act may
constitute gross negligence and be subject to discipline by the
BRN.
The BRN and the Medical Board of California (MBC) jointly
promulgated the following guidelines for SPPs: (BRN, 16 CCR §
1474; MBC, 16 CCR § 1379)
"SPPs shall include a written description of the method used in
developing and approving them and any revision thereof. Each
SPP shall:
1)Be in writing, dated and signed by the organized health care
system personnel authorized to approve it.
2)Specify which SPP functions registered nurses may perform and
under what circumstances.
3)State any specific requirements which are to be followed by
NPs in performing particular SPP functions.
4)Specify any experience, training, and/or education
requirements for performance of SPP functions.
5)Establish a method for initial and continuing evaluation of
the competence of those NPs authorized to perform SPP
functions;
6)Provide for a method of maintaining a written record of those
persons authorized to perform SPP functions.
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7)Specify the scope of supervision required for performance of
SPP functions, for example, telephone contact with the
physician.
8)Set forth any specialized circumstances under which the NP is
to immediately communicate with a patient's physician
concerning the patient's condition.
9)State the limitations on settings, if any, in which SPP
functions may be performed.
10)Specify patient record-keeping requirements.
11) Provide for a method of periodic review of the SPP."
Nurse-Managed Health Clinics. Nurse-managed health clinics, of
which many are Federally Qualified Heath Centers (FQHC) and
independent non-profit clinics, are safety net clinics that
provide primary care, health promotion and disease prevention
services to patients who are least likely to receive ongoing
health care. Unlike other FQHC and independent non-profits,
these clinics are solely operated by NPs. The Patient
Protections and Affordable Care Act (ACA) defines a
nurse-managed health clinic as, "?a nurse practice arrangement,
managed by advanced practice nurses, that provides primary care
or wellness services to underserved or vulnerable populations
and that is associated with a school, college, university or
department of nursing, federally qualified health center, or
independent non-profit health or social services agency." (42
U.S.C. § 330A-1 (2010)).
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According to the National Nursing Centers Consortium,
nurse-managed health clinics have doubled in their presence
since 2013. To date, there are 500 nurse-managed health clinics
most of which are located in the East Coast. A small percentage
of these have been chosen for funding through a federal
expansion initiative. One such clinic, GLIDE Health Services,
is a FQHC located in San Francisco, California and provides
primary and urgent care, preventative services and psychiatric
treatment to an urban population.
Physician Supervision. In many of the nurse-managed health
clinics, the physician to NP supervision relationship is quite
flexible. A supervising physician may be present for a very
limited amount of time to perform perfunctory tasks such as
signing off on equipment orders, and reviewing and signing
medical records. The physician may also elect to make
himself/herself available for telephonic consult. For example,
at GLIDE the supervising physician is physically on site 1-2
days a week to sign off on orders such as wheel chairs, walkers
and commodes and to review medications that have been prescribed
and furnished by NPs. According to Patricia Dennehy, a NP and
director of GLIDE, "Though we value our MD colleagues and
consult with them for complex care issues, currently there are
administrative barriers to care delivery and access that are not
practical."
Clinical Training Sites. In addition to providing care to
patients, nurse-managed health clinics also play an important
role in health professions education. More than 85 of the
nation's leading nursing schools operate nurse-managed health
clinics that serve as clinical education and practice sites for
nursing students and faculty. Many, such as GLIDE, have
partnerships with other academic programs and provide learning
opportunities for medical, pharmacy, social work, public health
and other students.
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Full Practice Authority. The American Association of Nurse
Practitioners defines full practice authority as, "The
collection of state practice and licensure laws that allow for
nurse practitioners to evaluate patients, diagnose, order and
interpret diagnostic tests, initiate and manage treatments,
including prescribe medications, under the exclusive licensure
authority of the state board of nursing." Similar to the
changes to statute proposed in this legislation, under full
practice authority, "certified NPs" are still required to meet
educational and practice requirements for licensure, maintain
national certification and remain accountable to the public and
the state board of nursing. Under this model, "certified NPs"
would continue to consult with and refer patients to other
health care providers according to the patient's needs.
Over the past 50 years, several organizations and research
institutions have examined the feasibility of full practice
authority for NPs. The Institute of Medicine of the National
Academies of Science released a 2010 report titled, "The Future
of Nursing: Leading Change, Advancing Health," in which the IOM
wrote, "Remove scope of practice barriers. [NPs] should be able
to practice to the full extent of their education and
training?the current conflicts between what [NPs] can do based
on their education and training and what they may do according
to state federal regulations must be resolved so that they are
better able to provide seamless, affordable and quality care."
In a 2011 report, the IOM noted that three to 14 NPs can be
educated for the same cost as one physician. A report by the
National Governor's Association, "The Role of Nurse
Practitioners in Meeting Increased Demand for Primary Care"
noted, "In light of research evidence, states might consider
changing scope of practice restrictions and assuring adequate
reimbursement for their services as a way of encouraging and
incentivizing greater NP involvement in the provision of primary
health care."
Despite these arguments, some physician groups, including the
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American Medical Association (AMA) assert that granting full
practice authority for NPs may put patients' health at risk.
They cite the difference in educational attainment noting that
physicians are required to complete four years of medical school
plus three years of residency compared to the four years of
nursing school and two years of graduate school required for
NPs. The President of the AMA, Dr. Robert M. Wah, was quoted in
a 2015 New York Times article, "[?nurses practicing
independently] would further compartmentalize and fragment
health care [which should be] collaborative with the physician
at the head of the team."
Financial Implications. Over the past 40 years, there have been
a number of studies on the cost-effectiveness of NP practice.
Results overwhelmingly show NPs provide equivalent or improved
medical care at a lower cost than their physician counterparts.
After insurance reform in Massachusetts, the state demonstrated
that they could gain a cost savings of $4.2 to $8.4 billion,
over a 10 year period, from the increased use of NPs (Eibner, E.
et al. 2009, Controlling Health Care Spending in Massachusetts:
An Analysis of Options. RAND Health).
Though the ACA encourages the creation of nurse-managed
practices, by requiring insurers to pay NPs the same rates paid
to physicians for identical services rendered, Medicare will not
provide equal reimbursement. Presently, Medicare pays NPs 85%
of the physician rate for the same services. The Medicare
Payment Advisory Commission, the federal agency that advises
Congress on Medicare issues, found that there was no analytical
foundation for this difference. Despite this fact, revising
payment methodology would require Congress to change the
Medicare law. A report by the IOM titled "The Future of
Nursing, Leading Change, Advancing Health," recommended that the
Medicare program be expanded to include coverage of advanced
practice registered nurse services just as physician services
are covered. The report also recommended that Medicaid
reimbursement rates for primary care physicians be extended to
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advanced practice registered nurses providing similar primary
care services.
Additionally, health insurance plans have significant discretion
to determine what services they cover and which providers they
recognize. Not all plans cover NPs. Further, many managed care
plans require enrollees to designate a primary care provider but
do not always recognize NPs. In fact, a 2009 survey conducted
by the National Nursing Centers Consortium found that nearly
half of the major managed care organizations did not credential
NPs as primary care providers
(www.healthaffairs.org/healthpolicybriefs/brief.php). If NPs
were granted full practice authority, efforts may need to be
undertaken in order for NPs to be recognized as primary care
providers by insurance companies.
Other States. Many other states have recognized the ability for
NPs to play a more efficient role in the delivery of health care
services and have updated their practice acts to align with NPs
training and education. For example, 20 states have adopted
full practice authority for NPs. The AMA contends that many of
the NPs that practice independently in these states do not
deliver care to underserved areas.
Prior Related Legislation. SB 491 (Hernandez) of 2013, would
have permitted an NP to practice independently after a period of
physician supervision if the NP has national certification and
liability insurance, and authorizes the NP to perform various
other specified tasks related to the practice of nursing without
protocols. NOTE: This bill was held in the Assembly
Appropriations Committee.
ARGUMENTS IN SUPPORT:
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The American Nurses Association/California supports the bill and
writes, "Nurse practitioners play and especially important role
in the implementation of the federal Patient Protection and
Affordable Care Act, which will bring an estimated five million
more Californians into the health care delivery system. As
primary care providers, nurse practitioners provide for greater
access to primary care services in all areas of the state."
The California Association of Physician Groups supports the bill
and writes, "This bill increases the ability to provide access
in meaningful ways to cope with the expansion of the patient
base in California. It modernizes licensure law to reflect the
current reality. It allows Nurse Practitioners to practice to
the full extent of their education and training. Full practice
authority has been proven safe and effective in nineteen other
states."
The California Hospital Association also supports the bill and
writes, "California hospitals have been leaders in transforming
the delivery of health care and preparing for the realities of
ACA. NPs' full practice authority as conceptualized in SB 323
will be a pivotal component of our success in light of current
and projected physician shortages, the much greater time and
cost to train physicians, and expected increased in the demand
for primary care. This is clearly a promising and rational
strategy for increasing the supply of primary care providers for
California."
The United Nurses Associations of California/Union of Health
Care Professionals (UNAC/UHCP) supports this bill and writes,
"NPs full practice authority as conceptualized in SB 323 will be
a pivotal component of our success in light of current and
projected physician shortages, the much greater time and cost to
train physicians, and expected increased in the demand for
primary care. This is a promising strategy for increasing the
supply of primary care providers for California."
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ARGUMENTS IN OPPOSITION:
The American Medical Association opposes the bill. In their
letter they write, "The AMA believes that increased use of
physician-led teams of multidisciplinary health care
professionals will have a positive impact on the nation's
primary care needs. This team-based approach includes
physicians and other clinicians working together, sharing
decisions and information, to achieve improved care, improved
patient health and reduced costs. However, independent practice
and team-based care take health care delivery in two very
different directions. One approach would further
compartmentalize and fragment health care delivery; the other
would foster integration and coordination."
The California Medical Association also opposes the bill and
writes, "The intent language in this bill claims that
independent practice for nurse practitioners will provide for
greater access to primary care services in all areas of the
state. There is no evidence that states that have expanded
scope of practice have experienced improved access to care or
lower levels of underserved patient populations."
The Medical Board of California states in their letter of
opposition, "NPs are well qualified to provide medical care when
practicing under standardized procedures and physician
supervision. The standardized procedures and physician
supervision, collaboration and consultation are in existing law
to ensure that the patient care provided by a NP includes
physician involvement and oversight, as physicians should be
participating in the patient's care in order to ensure consumer
protection?The Board's primary mission is consumer protection
and by expanding the scope of practice for a certified NP and
not requiring any type of physician collaboration, consultation,
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or oversight, patient care and consumer protection could be
compromised."
The Union of American Physicians and Dentists opposes the bill
and writes, "Senate Bill 323 provides no assurances to the
general public, and puts patients at risk. Moreover, Senate
Bill 323 has grave consequences for public sector physicians, as
it would enable state and counties to "supplant" physician
services."
POLICY ISSUES:
1)Practice Settings. This bill would permit "certified NPs" to
practice independently in a variety of settings which span a
continuum of models of care - from team based care models
prevalent in many accountable care organizations, to more
independent models where business share resources as
demonstrated in some independent practice associations. As
such, it is important to clarify that, consistent with the
spirit of the ACA, and in the interest of providing patients
with comprehensive care, this bill is supportive of the
national healthcare movement towards integrated and team-based
healthcare models.
2)Patient Protections. If granted full practice authority, per
the provisions of this bill, "certified NPs" would be required
to adhere to a number of patient protection requirements -
similar to the requirements for physicians who practice
independently. Specifically, this bill would require that a
"certified NP," 1) carry malpractice insurance, 2) adhere to
the anti-kickback and referral laws and 3) be subject to the
same 805 reporting requirements that physicians are subject
to. However, unlike physicians who are subject to the
corporate practice of medicine bar, the NPs would not be
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subject to this provision.
California law prohibits lay individuals, organizations and
corporations from practicing medicine. This prohibition
applies to lay entities and prohibits them from hiring or
employing physicians or other health care practitioners from
interfering with a physician or other health care
practitioner's practice of medicine. It also prohibits most
lay individuals, organizations and corporations from engaging
in the business of providing health care services indirectly
by contracting with health care professionals to render such
services. This prohibition is designed to protect the public
from possible abuses stemming from the commercial exploitation
of the practice of medicine (California Physician's Legal
Handbook, Corporate Practice of Medicine Bar, January, 2015).
According to a 2007 California Research Bureau report titled
"The Corporate Practice of Medicine Doctrine," the employment
status of physicians in California is applied inconsistently
by the application of the doctrine as physicians are exempt
from the doctrine if they work in specific settings including:
professional medical corporations, local hospital districts,
county hospitals, teaching hospitals, non-profit clinics and
non-profit corporations.
Opponents of this bill argue that because the duties of
"certified NPs" are similar to those of a physician and
surgeon, "certified NPs" should be subject to the same
corporate practice of medicine bar. Proponents of the measure
indicate that nurse anesthetists practice independently and
without being subject to the corporate practice of medicine
bar. They also note that in the other four states that have a
corporate practice of medicine bar and permit NPs to practice
without supervision, the NPs are not subject to the corporate
practice of medicine bar.
3)Provision of Healthcare in Rural Settings. The author
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indicates that passage of this legislation will result in
increased access to care. As such, it is important to note
that, according to the Office of Statewide Health Planning and
Development, there are 62 rural hospitals in California that
could benefit from additional healthcare providers.
Additionally, according to the Robert Wood Johnson Foundation,
NPs are the primary care providers most likely to be working
in rural or remote areas. Thus, in context of the amendments
which are outlined below, which may limit the ability of NPs
to exercise full practice authority in rural hospital
settings, the author may wish to consider if the bill should
include provisions permitting NPs to practice without
supervision in rural hospitals.
AMENDMENTS:
1)Based on policy issue number 1, which discusses the national
movement towards integrated and team-based healthcare service
delivery models, the author should amend this measure to
include intent language reflecting this goal.
2)Based on policy issue number 2, pertaining to the corporate
practice of medicine bar, the author should amend this measure
to include the following language to ensure that the same
protections are in place for the practice of "certified NPs."
This should include the same exemptions from the corporate
practice of medicine bar that apply to the practice of
physicians and surgeons in certain settings:
On page 13, line 17, after corporation, insert the following:
(5)A group practice, including a professional medical
corporation, as defined in Section 2406 , another form of
corporation controlled by physicians and surgeons, 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.
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On page 14, after line 27, insert the following:
(e) Corporations and other artificial legal entities shall
have no professional rights, privileges, or powers under this
section, except as provided in Sections 2400, 2401, 2402, and
2403.
REGISTERED SUPPORT:
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
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Blue Shield of California
California Association for Health Services at Home
California Association for Nurse Practitioners
California Association of Nurse Anesthetists, Inc.
California Association of Physician Groups
California Association of Public Hospitals and Health Systems
California Commission on Aging
California Council of Community Mental Health Agencies
California El Camino Real Association of Occupational Health
Nurses
California Family Health Council
California Health & Wellness (CH&W)
California Hospital Association
California Naturopathic Doctors Association
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California Pharmacists Association
California Primary Care Association
California Senior Legislature
California Society of Health-System Pharmacists
California State Association of Occupational Health Nurses
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
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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
REGISTERED OPPOSITION:
American Medical Association
American Osteopathic Association
California Academy of Family Physicians (unless amended)
California Chapter of the American College of Cardiology
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California Chapter of the American College of Emergency
Physicians
California Medical Association
California Orthopaedic Association
California Psychiatric Association
California Society of Anesthesiologists
California Society of Plastic Surgeons
Medical Board of California
Union of American Physicians and Dentists
Over 600 physicians and individuals
Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /
(916) 319-3301
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