BILL ANALYSIS Ó
SB 323
Page 1
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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