BILL ANALYSIS                                                                                                                                                                                                    Ó



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          Date of Hearing:  June 28, 2016


                   ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS


                                  Rudy Salas, Chair


                     SB 323(Hernandez) - As Amended July 9, 2015


          SENATE VOTE:  25-5


          NOTE: This bill is being heard on reconsideration having  
          previously failed passage in this committee on June 30, 2015  
          with a 4-9 vote. 


          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  








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            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  
            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,








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             c)   Approve, sign, modify or add information to a plan of  
               treatment for individuals receiving home health services.


          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.  










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          (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))


          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  








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            importance of NPs providing safe and accessible primary care.

         2)Specifies that, in the interest of providing patients with  
            comprehensive care and consistent with the spirit of the  
            federal Patient Protection and Affordable Care Act, the bill  
            is supportive of the national health care movement towards  
            integrated and team-based health care models.

         3)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.

         4)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:









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             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; 

             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.

          5) States that it is unlawful for a "certified NP" to refer a  








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             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. 

          6) 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. 

          7) 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.

          8) 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,








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              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.

         9)Indicates that if the BRN or licensing agency of another state  
            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.

         10)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.

         11)Requires a "certified NP" to maintain professional liability  
            insurance appropriate for the practice setting.

         12)Specifies that settings where NPs practice shall not interfere  
            with, control, or otherwise direct the professional judgment  
            of a nurse practitioner. 

          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  








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          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 have 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. 


          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.  Estimates obtained from the Council on Graduate  
          Medical Education (CGME) 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  








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          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 over 19,000 NPs 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.  









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          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  
          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.









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             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.


             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,  








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          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))


          According to the National Nursing Centers Consortium,  
          nurse-managed health clinics have doubled in their presence  
          since 2013.  To date, there are over 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  
               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  
                                                        







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               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.
          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  








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          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  
          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  








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          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  
          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, at least 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 323 (Hernandez) of 2015, would  
          have permitted a 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  








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          other specified tasks related to the practice of nursing without  
          protocols.  NOTE:  This bill failed passage in the Assembly  
          Committee on Business and Professions and was granted  
          reconsideration. This bill is scheduled to be heard before this  
          committee today.


          SB 491 (Hernandez) of 2013, would have permitted a 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.


          POLICY ISSUES:


         1)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  
            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  








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            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. 


          2) Clinical Experience.  This bill does not require a NP to  
             obtain a certain amount of clinical experience, after  
             becoming a NP, in order to apply to the BRN to become a  
             "certified NP."  However, several other health professions  
             require additional clinical experience in order to receive  
             specialty certification. 
          AMENDMENTS:


          1)Based on policy issue number 1), pertaining to the corporate  
            practice of medicine bar, the author should amend this measure  
            to include the following language to ensure that the same  








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            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.  As such, the  
            following language should be added to Section 2837 of the  
            bill:
            An entity described in subdivision (a) shall not interfere  
            with, control, or otherwise direct the professional judgment  
            of a nurse practitioner functioning pursuant to this section  
            in a manner prohibited by Section 2400 or any other law.   
             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.

           2) Based on policy issue number 2), pertaining to additional  
             clinical experience, the author should amend the bill to  
             require a "certified NP" to complete 3 years of post-graduate  
             clinical practice, under the supervision of a physician and  
             surgeon, before applying to the BRN to become a "certified  
             NP."
             
           REGISTERED SUPPORT:


          AARP


          Alliance of Catholic Health Care


          Association of California Healthcare Districts


          Bay Area Council


          California Association for Health Services at Home










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          California Association of Nurse Anesthetists


          California Association for Nurse Practitioners 


          California Association of Public Hospitals and Health Systems


          California Children's Hospital Association


          California Health Advocates


          California Hospital Association


          California Naturopathic Doctors Association


          California Optometric Association


          Cedars Sinai Medical Center


          Mental Health America


          Planned Parenthood Advocacy Project Los Angeles County


          Planned Parenthood Affiliates of California


          Planned Parenthood Mar Monte










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          Private Essential Access Community Hospitals


          Providence Health & Services Southern California


          SEIU California


          St. Joseph Hoag Health


          Stanford Health Care


          Stanford Health Care- ValleyCare


          University of California


          1 individual





          REGISTERED OPPOSITION:


          American College of Cardiology, California Chapter


          American College of Emergency Physicians, California Chapter


          California Academy of Eye Physicians and Surgeons (unless  
          amended)









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          California Academy of Family Physicians (unless amended)


          California Medical Association


          California Psychiatric Association


          California Society of Plastic Surgeons


          Medical Board of California


          Osteopathic Physicians and Surgeons of California


          Union of American Physicians and Dentists


          Over 400 individuals





          Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /  
          (916) 319-3301

















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