I value the contribution that non-physician assistants make and believe that with focused training they can be knowledgeable and assist in patient care but I believe the physician should monitor all such care. The truth is many patients like non-physician assistants because they spend more time with the patient and they are more down to earth but I would not support non- physicians practicing medicine. Nurse practitioners seeing patients without any physician oversight is a road to poor quality medicine. Not to say that they are not good, but there should always be oversight.
The amount of training doctors get vs what non-physicians get is totally different. A physician does 4 yrs medical school then 3-4 yrs of residency . A Physicians assistant does 3 years of school, that’s it! A nurse same thing. In depth training is totally different. So I do not support allowing non-physician to practice medicine without the physician. The physician is much more experienced and more educated and medicine is not always straight forward.
AB 890 SUMMARY:
Requires the Board of Registered Nursing (BRN) to establish a Nurse Practitioner Advisory Committee to advise and make recommendations to the board on all matters relating to nurse practitioners (NPs); authorizes an NP to provide specified services in specified settings, without standardized procedures, if the NP meets additional education, examination, and training requirements; establishes physician consultation, collaboration, and referral requirements; and requires the BRN and the Department of Consumer Affairs to identify or develop an examination that tests for independent practice competency.
The Senate Amendments:
1) Delete the creation of a new Advanced Practice Registered Nursing Board and shift its duties to the BRN and the Nurse Practitioner Advisory Committee.
2) Require the Nurse Practitioner Advisory Committee to advise and make recommendations to the BRN on all matters relating to NPs, including education, appropriate standard of care, disciplinary action, and other matters specified by the BRN.
3) Require the Committee to have four NPs, two physician and surgeons, and one public member.
4) Add additional facilities where NPs may practice without standardized procedures and exempt specified state operated healthcare facilities from the bill.
5) Authorize NPs under the bill to order diagnostic radiologic procedures and utilize the findings and clarify that they may perform or interpret specified clinical laboratory tests.
6) Require NPs under the bill to post a conspicuous notice that discloses that the NP is regulated by the BRN and contains specified BRN complaint and contact information.
7) Delay implementation of independent practice outside of settings where physicians practice and the occupational analysis until Jan 1, 2023.
8) Authorize the BRN to charge a reasonable fee sufficient to cover the cost of issuing the out-of-physician-setting certificate.
9) Require that the NPs practicing outside of the specified healthcare settings where physicians practice consult with a physician, pursuant to individual protocols, under specified circumstances.
10) Require that the NPs practicing outside of the specified healthcare settings where physicians practice to have an identified referral plan specific to the practice area that includes specific referral criteria and addresses specified situations.
11) Include chaptering language related to SB 1237 (Dodd), which is pending Assembly Third Reading as of August 30, 2020.
12) Make other technical, clarifying, and conforming changes. COMMENTS:
Background. An NP is a registered nurse (RN) who has additionally earned a postgraduate nursing degree, such as a Master’s or Doctorate degree, and obtained a certificate from a certifying body. At the state level, the Board of Registered Nursing (BRN) sets the educational standards for NP certification. According to the BRN, an NP is an advanced practice RN who meets BRN education and certification requirements and possesses additional advanced practice educational preparation and skills in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary or acute care.
NP Scope and Standardized Procedures. The RN scope of practice is defined as functions, including basic healthcare, that help people cope with or treat difficulties in daily living that are associated with their actual or potential health or illness problems, and that require a substantial amount of scientific knowledge or technical skill. It includes bedside care, the administration of drugs, skin tests, immunization techniques, the withdrawal of blood, and the observation of patient conditions. Because NPs are RNs for purposes of licensure, their statutory scope of practice is the same.
However, both RNs and NPs may provide additional medical procedures beyond their nursing scope through “standardized procedures.” Standardized procedures establish and outline the procedures nurses may provide beyond the ordinary nursing scope. Standardized procedures are developed nurses, physicians, and the administration of an organized health care system. The BRN and the Medical Board of California have jointly promulgated guidelines for standardized procedures. The guidelines require that standardized procedures take into account the competence of the nurses providing the procedures and include record, referral, and setting requirements, among other guardrails.
As a result of their additional training, NPs tend to perform additional functions through standardized procedures than non-advanced practice RNs. NPs also have specific authorization to furnish controlled substances and medical devices under standardized procedures, except that standardized procedures for Schedules II and III must include patient-specific protocols approved by a treating or supervising physician. According to the BRN’s Criteria for Furnishing Number Utilization by Nurse Practitioners, a “patient-specific protocol… is a protocol contained within the standardized procedures that specifies which categories of patients may be furnished this class of drugs. The protocol may state any other limitations as agreed upon by the NP and the supervising physician, such as the amount of the substance to be furnished, or the criteria for consultation.”
Practice without Standardized Procedures. This bill would additionally authorize an NP, after completing a 3-year transition to practice and passing an examination validated by the Office of Professional Examination Services (OPES) within the Department of Consumer Affairs, to practice without standardized procedures in specified healthcare settings where physicians practice. This authorization would not prohibit standardized procedures or physician supervision, or establish limits on existing healthcare setting operating procedures, but would provide an opportunity for a new baseline scope of practice that does not require standardized procedures.
This bill would not change the regulatory structure for current NPs or those that wish to continue practicing under standardized procedures.
In addition, the bill would further authorize an NP who meets the above requirements and has an additional 3 years of licensed practice to apply for a certificate that allows the NP to practice without standardized procedures in settings where physicians do not practice. The NPs with this certificate would still be required to consult with other healthcare providers and establish physician referral plans. The Senate amendments further outlined specific circumstances were physician consultation is required and situations that must be addressed in the referral plan. They also require that physician consultation must be obtained as specified in individual protocols.
According to the Author:
“As the Legislature and Administration work together to increase coverage, access and affordability to healthcare for all Californian, it is apparent that our current workforce is not equipped to adequately address these goals. Less than half of the 139,000 licenses physicians in California are actively engaged in providing patient care. Of this number, only 32% are primary care physicians. The distribution of physicians also varies greatly by region with the San Joaquin Valley, Inland Empire and rural areas suffering the greatest shortages. While a number of initiatives, including loan forgiveness and expanded residency programs, have focused on improving this situation, we simply cannot train enough interested primary care physicians and need to engage in additional strategies to meet our workforce needs. One of the top recommendations from the California Health Workforce Commission, representing thought leaders from business, health, employment, labor and government, spent a year looking at how to improve California’s ability to meet workforce demands. One of their top recommendations was to allow full practice authority for NPs. This bill aims to accomplish that goal in a measured and reasonable approach.”
Arguments in Support:
A broad coalition of nursing groups, healthcare facilities, and policy groups, support the bill, including the California Association for Nurse Practitioners. Supporters argue that allowing NPs to utilize the full extent of their education and training by granting full practice authority would result in high-quality care, more primary care providers, and cost savings. Supporters argue that research shows NPs provide comparable quality care to physicians, even without physician oversight and that patients managed by an NP have lower rates of hospitalization and ER visits than those managed by physicians. Supporters say that, “Because of the shortage of primary care physicians in rural and underserved areas, NPs are critical to closing the provider gap in our highest-need regions…A 2017 survey found nearly 70% of NPs were accepting new Medi-Cal patients, compared to 55% of primary care physicians. Additionally, 54% of NPs were accepting uninsured patients, compared to 32% of primary care physicians.” Supporters also say that “in order to meet the increased demand for behavioral health services, a sufficient workforce must be in place. [this bill] represents an important strategy, when adopted with other recommendations, to help more Californians receive timely, quality care for their needs.”
Arguments in Opposition:
A coalition of physician groups oppose this bill, generally arguing that NP independent practice would pose a significant risk to patients because NPs do not have the foundations for independent practice, that the bill does not establish clear boundaries for when care should be transferred to a physician, that the bill will not increase access, and create multiple standards of care.
The California Medical Association (CMA) writes in opposition, “[This bill] grants NPs the ability to practice medicine without an equivalent competency review to physicians; diminishing the quality of care for and lowering the standards for licensed individuals practicing medicine in the state.” According to CMA, “While the appearance of this transition of practice is to resemble a residency program, it is not. The ‘transition to practice’ does not have any oversight. No common learning objectives. No criteria for who may provide oversight during the transition. And no competency post ‘transition’ to ensure the [NP] has achieved competency of common learning objectives.” CMA also writes that “the bar on the corporate practice of medicine prohibits lay entities from hiring or employing physicians… The corporate practice of medicine bar is just one of many consumer protections laws, including those related to fraud and abuse, that apply to physicians to ensure that the patient’s best interests are foremost in the practice of medicine. [This bill] must also comply with these important consumer protections.” According to CMA, in states where NPs have been granted the ability to practice independent of physician supervision, NP independence has not resulted in greater numbers of NPs or greater access to care in medically underserved areas. CMA also writes that “[this bill] allows for NPs to practice medicine with no statutory limitations on their scope of practice and without completing the necessary education and training that the Legislature has deemed as essential for physicians to practice medicine safely.”
The Board of Registered Nursing (BRN) is opposed to this bill unless it is amended, writing, “We do not agree that a physician should be included as a member of a nursing committee. We request removal of the language including physicians and surgeons to comprise the Nurse Practitioner Advisory Committee.” FISCAL COMMENTS:
According to the Senate Appropriations Committee:
1) Indeterminate fiscal impact to the Board of Registered Nursing (BRN). Fiscal impacts include covering the cost of new committee members’ per diems, reimbursement for travel costs to participate on the committee, and to establish the standards for the transition to practice in regulations. The BRN reports that workload and costs associated with these activities to be absorbable within existing resources. Other additional costs to the BRN may include the review of applications for out-of-facility certificates and any associated oversight for licensees practicing independently. Fees and assessments from licensees may offset ongoing enforcement and administration costs.
2) Estimated costs of $140,000 every five years for the Office of Professional Examination Services to perform the occupational analysis.
3) Estimated costs up to $25,000 to the Department of Justice (General Fund and Legal Services Revolving Fund) for increased workload to the Civil Law Division and the California Justice Information Services Division to consult with the BRN in establishing minimum standards for NPs and to handle any new caseloads with the expansion of an existing crime.
ASM BUSINESS AND PROFESSIONS: 16-0-4
YES: Low, Bloom, Chiu, Dahle, Eggman, Gipson, Gloria, Grayson, Holden, Irwin, McCarty, Medina, Mullin, Obernolte, Ting, Wood
ABS, ABST OR NV: Brough, Chen, Cunningham, Fong
ASM APPROPRIATIONS: 13-0-5
YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas
ABS, ABST OR NV: Bigelow, Brough, Megan Dahle, Diep, Fong
ASSEMBLY FLOOR: 61-1-18
YES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Chau, Chiu, Chu, Cooley, Cooper, Megan Dahle, Daly, Eggman, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager, Kiley, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Mullin, Muratsuchi, O’Donnell, Obernolte, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Santiago, Smith, Mark Stone, Ting, Waldron, Weber, Wicks, Wood
ABS, ABST OR NV: Arambula, Brough, Cervantes, Chen, Choi, Cunningham, Diep, Flora, Fong, Frazier, Lackey, Mathis, Melendez, Nazarian, Ramos, Reyes, Salas, Rendon
VERSION: August 28, 2020
CONSULTANT: Vincent Chee / B. & P. / (916) 319-3301 FN: 0002669