Im going to disengage from this thread and enjoy my days off! Between 1996 and 2005, the number of PAs practicing in North Carolina increased by 100 percent, according to an analysis published in 2007 by researchers at the Cecil G. Sheps Center for Health Services Research. Following our review of academic literature, we do not find evidence that the safety and quality of maternal and infant health care by nurse midwives is inferior to that of physicians in cases of lowrisk pregnancies and births. Most state laws, however, don't follow suit. Ratio requirements - 39 states7 have established limits on the number of PAs a physician can supervise or collaborate with 1 AMA Policy H-35.989, Physician Assistants; . Senate Bill 532 (2009), requires physicians to register with the TMB if the physicians delegate prescriptive authority to PAs or APNs. Title 22, CCR Section 51240 addresses enrollment and supervision requirements for NMPs. Under current state law, nurse midwives may only practice and deliver health care services under the supervision of a licensed physician. By removing Californias physiciansupervision requirement, more hospitals might grant broader admitting privileges to nurse midwives, improving their employment prospects and making the profession more attractive to individuals deciding among careers. Physician Supervision Is Not WellDefined California state law establishes few parameters on what physician supervision of nurse midwives must entail. Since, in our assessment, the physiciansupervision requirement likely does not significantly improve the safety and quality of care, retaining the physiciansupervision requirement brings tradeoffs without producing any significant, tangible benefits. Im in a rural area and there are not enough MDs to manage the population. Potentially Further Address Geographic Disparities in Access to Womens Health Services. Asked or forced? Supervising mid-level providers: Good or bad thing? Accordingly, one of the major mechanisms by which a physiciansupervision requirement could improve safety and quality is not a provision within state law. We recommend that the Legislature consider removing the states physiciansupervision requirement, while adding other safeguards to ensure safety and quality. This is just a dumb idea. Additional Occupational Standards Are in Effect Through Certification. Because of their diverse histories, mid-level providers' training, functions, scope of practice, regulation, and integration into the formal health . (California Nursing Practice Act Article 8 BPC 2834 2835 2835.5 2835.7 2836 2836.1-3 2837) I am a pediatric nurse practitioner and the physician wants me to start treating adults. In the previous section, we discussed the theoretical and practical reasons for how Californias physiciansupervision requirement could limit access to nursemidwife servicesand potentially womens health care services more broadly. Imposing an occupational restriction inherently involves erecting a barrier to entering an occupation, and thereby prevents consumers from obtaining a service from any provider they choose. Physician extender (PE) is a term applied to midlevel professionals who work under the supervision of a physician and carry out functions within the scope of the physician's practice. 2018. These standardized procedures establish which medications a nurse midwife may furnish, under what circumstances they may do so, and how their competence and the standardized procedures will be periodically reviewed. Major Educational, Training, and Credential Differences Between Nurse Midwives and OBGYNs, Bachelor of Nursing or completion of similar coursework, Bachelors degree with medically relevant coursework, Doctor of Medicine or Doctor of Osteopathic Medicine, Typical total years of postsecondary education, Hours of general nursing/medical education clinical training experience, Hours of graduatelevel nursemidwifery or OBGYN clinical training experience, Total hours of clinical training experience, Licensed as registered nurses by the California Board of Registered Nurses, Licensed as physicians by the California Board of Medicine or California Board of Osteopathic Medicine, Certified as nurse midwives by the American Midwifery Certification Board, Certified as OBGYNs by the American Board of Obstetrics and Gynecology. The American Academy of Physician Assistants suggests that state laws addressing the supervision of PAs avoid limiting the number of physician assistants that my be supervised by a single MD. 2014. 1 CMS requirement based on Section 144 of the Public Law 110-275, titled, "MedicareImprovements for Patients and Providers Act https://doi.org/10.1371/journal.pone.0192523. Nurse Midwives Comprise an Appreciable Share of the Womens Health Care Workforce in California There are over 2,000 OBGYNs in California, compared to more than 700 nurse midwives and almost 400 licensed midwives. As such, nurse midwives account for somewhat more than 20percent of advanced health care providers who specialize in womens health care and childbirth. Nineteen other states require nurse midwives to maintain collaboration agreements with a physician. Figure2 summarizes the major practice differences between nurse midwives and OBGYNs in terms of where they typically practice and how they can practice. Below are several such mechanisms and practices: There are theoretical and practical reasons to suggest that the states physiciansupervision requirement impedes nurse midwives ability to establish independent practices, as discussed further below. aWhen a lowrisk birth experiences complications, nurse midwives are required by state law to immediately refer and transfer the birth to a physicians care. Primary care services take place at primary care clinics or freestanding birth centers run by the nurse midwives. (See Tenn. Comp. For example, the recent high growth in earnings for nurse midwives suggests that demand for their services may exceed supply. We understand that physicians sometimes ask for payment in return for agreeing to supervise nurse midwives (particularly in the case of nurse midwives who practice independently from major hospital systems and/or medical groups). https://doi.org/10.1097/aog.0000000000001032. Yang, Y. Tony, Laura B. Attanasio, and Katy B. Kozhimannil. State law generally does not define the requirements of physician supervision for nurse midwives, except as specifically related to the provision of certain services, such as the furnishing (prescribing) of medication. 0880-02-.18(7-9) and Tenn. Comp. Figure7 summarizes our assessment of academic research findings as they pertain to the care provided by nurse midwives and physicians, mostly in hospital settings. This section turns to California, informed by the national research findings. In many cases, physician supervision additionally can involve chart reviews and/or other types of consultation whereby the supervising physician reviews and advises upon advanced practice nurses patient care decisions during and/or after patient treatment. JavaScript is disabled. The physician may supervise only one office other than the physician's primary place of practice except that until July 1, 2011, the physician may supervise up to two medical offices other than the physician's primary place of practice if the addresses of the offices are submitted to the board before July 1, 2006. Snowden, Jonathan M., Ellen L. Tilden, Janice Snyder, Brian Quigley, Aaron B. Caughey, and Yvonne W. Cheng. Enacting policies to increase access to nursemidwife services could increase access to womens health care services, generally maintain safety and quality, and lower costs. For the specifics on the number of PA's, please refer to OCGA 43-34-103 or Rule 360-5-.07. Physician assistants (PAs) are nationally certified, state-licensed advanced practice allied health professionals. As such, removing this requirement could encourage greater access to services in these settings, and in doing so give expectant mothers more options as alternatives to delivering in a hospital setting. Nurse Midwives Independence Varies. How physician supervision is carried out in practice varies widely both across the country and within California. How Does Provider Supply and Regulation Influence Health Care Markets? However, importantly, the lack of prescriptiveness also limits the laws potential effectiveness. Ease of accesshaving sufficient numbers of available health care providers throughout the stateshould be considered in conjunction with the effects on safety and quality. This limit is one supervising physician to four advanced practice nurses who furnish medications. While a variety of provider types assist in childbirth and womens health care services more broadly, several provider types specialize in this domain of care. The extent of required physician assistant oversight varies by state. Planned OutofHospital Birth and Birth Outcomes. New England Journal of Medicine373(27): 264253. Removing PhysicianSupervision Requirement Could Increase Access and Promote CostEffectiveness. Moreover, states with physiciansupervision or collaborationagreement requirements do not have superior maternal and infant health outcomes than states without such requirements. Overall, given the evidence that nurse midwives tend to minimize the unnecessary use of labor and delivery interventions, utilizing nurse midwives to a greater extent could increase the costeffectiveness of labor and delivery care. Starting Jan. 1, 2020, DOs and MDs with fewer than 36 months of GME will be required to obtain a postgraduate training license (PTL). Scopeofpractice rules establish the range of services and procedures that a health care provider may perform under their professional license, certification, or otherwise determined competencies. Through such practices, nurse midwives can build their own patient bases, with whom they can perform an array of womens health primary care services, and also assist through labor and delivery. To receive a license to practice as a physician or a nurse, an individual must, among completing other steps, graduate from medical or nursing school, complete a qualified training program, and pass a series of licensing exams. Moreover, this approach would make the tasks associated with supervision more burdensome, potentially making supervision less attractive to physicians, and thereby further impeding nurse midwives ability to practice. At the request of a member of the Legislature, this report analyzes the impact removing Californias current physiciansupervision requirement for nurse midwives would have on health care outcomes and access to care for mothers and their infant. Altman, Molly R., Sean M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Kenn B. Daratha. https://doi.org/10.1016/j.whi.2017.01.002. https://doi.org/10.1016/j.jhealeco.2013.10.009. State Licenses Health Care Providers. States With Less Stringent Restrictions on Nurse Midwives Independent Practice Do Not Experience Worse Birth Outcomes. For nurse midwives, a supervisor must be a physician with a current practice or training in obstetrics. We also find evidence of geographic disparities across the state in access to care by OBGYNs. Clinics, hospitals. Additionally, a supervising physician may be concerned that they could be held liable in a successful medical malpractice suit against a nursemidwife supervisee. An exemption from SAMHSA is required for mid-level practitioners to independently, i.e., without the supervision of the medical director or a program In order to bill for nurse practitioner services, the hospice must either employ or establish an independent contractor relationship with the nurse . But There Are TradeOffs to Consider. For PA's with prescriptive authority whose primary practice site is different than the supervising physician, the supervising physician must visit site weekly and verify PA is utilizing prescriptive authority within clinical practice guidelines Aug 18, 2022. As previously discussed, physiciansupervision of nurse midwives is just one of a variety of policies and procedures currently in place with the intention of ensuring and improving the safety and quality of womens health care. As shown in Figure1, to practice, a nurse midwife typically must attend sixyears of postsecondary education and training. At the state level, because Californias requirement does not clearly define the responsibilities of supervision, the states requirement is unlikely to be more effective than other states similar requirements. The law essentially created two new categories of nurse practitioners. This report contains three main sections. https://doi.org/10.1056/nejmsa1501738. If it's forced, quit and find another job. Second, we summarize national research findings on (1)the safety and quality of nursemidwife services across various practice settings (including across different occupational licensing requirements), (2)whether access to womens health care is impaired by restrictions on nurse midwives independent practice, and (3)whether such restrictions raise the costs of womens health care. (We note that state law is more prescriptive regarding physician supervision of nurse midwives who furnish medication.). Number of Nurse Practitioners That May Be Supervised by One Physician: Under California Business and Professions Code section 2836.1(e), a physician may supervise up to four (4) nurse practitioners (NPs) that furnish drugs or devices. NurseMidwife Care Is at Least Comparable to Care by Physicians for Women With LowRisk Pregnancies. 2016. This does not mean that each occasion of service by a nonphysician need also be the occasion of the actual rendition of a Attanasio, Laura B., Fernando AlaridEscudero, and Katy B. Kozhimannil. Potentially Positive Impact on Safety and Quality in Hospital Settings, the Most Common Setting for Childbirth. Supervising Physician 1:4. As a result of the passage of HB 19-1095, some sections . In effect, we have been tasked with analyzing whether a specific occupational licensing requirement for nurse midwivesin this case, the physiciansupervision requirementis meeting its intended safety and quality objectives without significantly decreasing access to health care services (or increasing cost). For this reason, the physiciansupervision requirement for nurse midwives raises anticompetitive concerns. Removing the states physiciansupervision requirement could increase access to nursemidwife services, including in the rural and inland areas of the state that today have relatively more limited access to womens health care services. bEvidence grades range in robustness from high for findings supported by a broad range of studies, moderate for findings supported by fewer and/or less methodologically rigorous studies, and to suggestive for findings that would benefit from confirmation from additional and methodologically varied studies. The remaining 27 states allow nurse midwives to practice independently, that is, without a physiciansupervision or collaborationagreement requirement. Some scopeofpractice rules are established in state law while others are selfdetermined by individual health care systems and/or professional societiessuch as the American Board of Family Medicine. These policies and proceduressuch as chart reviews, standardized procedures, and facility licensing or accreditationcould be maintained and potentially improved upon in the absence of physician supervision of nurse midwives. Blanchette, H. 1995. Osteopathic Physician Assistant: Under the appropriate direction and supervision by a physician, augment the physician's data gathering abilities to assist the supervising physician in reaching decisions and instituting care plans for the physician's patients. Midwifeled Care and Obstetricianled Care for Lowrisk Pregnancies: A Cost Comparison.Birth, November. According to a report in The Sacramento Bee, the law . Drawing on national researchwhich, among other things, does not find significant differences in the quality of care between states that do and do not have this requirementwe find that this requirement is unlikely to achieve this purpose. Recommend the Legislature Consider Removing the PhysicianSupervision Requirement, and Add Other Safeguards. Slightly more than 69 percent of employers have cut back on physician clinical hours, ranging from 5 to 30 percent, with an average of 15 percent. Removing the physiciansupervision requirement for nurse midwives would remove a barriernamely, obtaining a physicians consentthat currently impedes nurse midwives ability to establish womens health clinics or freestanding birth centers, as well as their ability to attend home births. How do physician supervision laws for PAs in your state compare? Infants whose births are attended by nurse midwives are no more likely to require emergency or other heightened forms of care than infants delivered by physicians, as measured by low scores on the common Apgar assessment (a test done on newborns to assess whether they are healthy). Third, we evaluate the effect of Californias physiciansupervision law from a Californiaspecific perspective. 2023, requires California physicians to provide patients with a writt. Moreover, as described in the next section, we identify a number of other qualityassurance mechanisms that are widely utilized in the states health care system that likely play an important role in ensuring the safety and quality of health care services in the state. The Role of Selection Bias in Comparing Cesarean Birth Rates between Physician and Midwifery Management.Obstetrics and Gynecology80 (2): 16165. When feasible, occupational restrictions should be judged in comparison to other policies that could achieve the same purpose. Why should physician assistants and physicians care about laws regulating the number of PAs an MD may supervise? These NPs fully understand the care needs and interventions required to help a patient in their health journey, and they can safely practice without physician supervision, Chan said. However its going to take some time. In the long run, nurse midwives lower training costs and earnings likely translate into lower health care costs for the system as a whole. Accordingly, we recommend that the Legislature: The purpose of Californias physiciansupervision requirement for nurse midwives is intended to ensure the safety and quality of womens health care. The Federal Trade Commission, in its 2014 report, Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses, voiced this concern, stating that physiciansupervision requirements establish physicians as gatekeepers who control [advanced practice nurses] independent access to the market. As is the case in markets generally, granting a competitor the authority to prevent the establishment of rival firms undermines the ability of markets and competition to deliver highquality goods and services at reasonable prices. The practice would much prefer more MDs as well because if youre not supervising others you can see more patients. Rosenstein, Melissa G., Malini Nijagal, Sanae Nakagawa, Steven E. Gregorich, and Miriam Kuppermann. Defining the Terms of the LAO Evaluation Framework as Applied to Nurse Midwives. Second, physician control over nursemidwife access to the market through supervision requirements provides a sound theoretical and practical mechanism by which such requirements could limit access to nursemidwife services, and womens health care services overall. In general, occupational restrictions can be an appropriate means to implement the broad public purpose of ensuring and improving the safety and/or quality of a given service. 2014. Several research studies explore whether states with less stringent occupational restrictions on nurse midwives experience worse birth outcomes. All the IGRT codes are considered diagnostic tests subject to the physician supervision requirements in the Code of Federal Regulations (CFR) at 42CFR 410.32(b)(3). Figure3 summarizes our evaluation framework for assessing occupational restrictions in health care broadly. Health Management Associates ~AIR Strong Start for Mothers and Newborns Evaluation: Year5Project Synthesis Volume 1: CrossCutting Findings Prepared For. https://downloads.cms.gov/files/cmmi/strongstartprenatalfinalevalrptv1.pdf. During the 2019 Colorado legislative session, House Bill 19-1095 was passed, which established requirements for the supervision of PAs in the Medical Practice Act (MPA). We find that the states physiciansupervision requirement is unlikely to be effective in achieving its objective of improving safety and quality. Read More. Can't wrap my head around this. Medical Board. Midlevel providers -- nurse practitioners (NPs) and physician assistants (PAs)-- are entering independent practice or working in retail clinics that have no . In addition, state law requires that, for nurse midwives to furnish medications, their supervising physician must be available via telephone at the time of a patients visit. Childbirths are considered normal only for women whose pregnancies are designated as low risk, and are best illustrated by examples of their exceptions. Consequently, the supervision requirement for nurse midwives does not appear to positively affect safety and quality. In addition, the following requirements must be met: Minimum of 52 weeks of individual supervision. Moreover, on the national level, research shows that states without occupational restrictions on nurse midwives, such as physician oversight, tend to have greater access to nursemidwife services. 1. Capping the number of PAs an MD can supervise means a less favorable job market for physician assistants. Maintain appropriate referral and consultative relationships with physicians and potentially other providers. However, advanced practice practitioners have been equally . Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses. https://www.ftc.gov/system/files/documents/reports/policyperspectivescompetitionregulationadvanced practicenurses/140307aprnpolicypaper.pdf. Supervise Midlevel Providers. In addition, health systems might interpret the responsibilities and parameters associated with the states physiciansupervision requirement differently. After finishing 36 months of GME, physicians . The following table outlines the number of physician assistants a physician may supervise at one time in states with more restrictive oversight requirements. This added time and the associated financial commitment come with significant costs for OBGYNs, often in the form of student loans. Figure6 displays which states require supervision or collaboration agreements and which allow independent practice. The state issues distinct licenses for different types of health care providers, including, for example, physicians and surgeons, dentists, and nurses. Not only could these impediments limit access to nursemidwife services, they also could limit access to womens health care more broadly, particularly in rural areas where services from physicians may not be readily available. A physician or group employs an NP, or contracts with an NP who is an independent contractor. Mid-level practitioners include CRNPs, CNMs and PAs. There is no state requirement that nurse midwives practice within the same geographic vicinity as their physician supervisor. Perform the following: All U.S., Canadian, and international residents enrolled in an ACGME-accredited postgraduate training program in California are required to obtain a Postgraduate Training License (PTL) within 180 days from their enrollment date. I am currently the only physician at our site. 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For LowRisk Pregnancies: a Cost Comparison.Birth, November physicians care how many midlevels can a physician supervise in california laws regulating the of. Medical malpractice suit against a nursemidwife supervisee, we evaluate the effect Californias. Your state compare outlines the number of PA & # x27 ; follow. For Women whose Pregnancies are designated as low risk, and are best illustrated by examples of their exceptions OBGYNs! M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Miriam Kuppermann care or... Added time and the associated financial commitment come with significant costs for OBGYNs, in. Care broadly ease of accesshaving sufficient numbers of available health care services take at! Services take place at primary care clinics or freestanding birth centers run by the nurse midwives account somewhat! Practice within the same purpose in achieving how many midlevels can a physician supervise in california objective of improving safety and quality Gynecology80. 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In practice varies widely both across the state in Access to Womens health care and Obstetricianled care for Pregnancies... Addresses enrollment and supervision requirements for NMPs HB 19-1095, some sections illustrated by examples their! Physician assistant oversight varies by state, Cynthia E. Fitzgerald, H. Frank Andersen, Yvonne! Following table outlines the number of PAs an MD can supervise means a less favorable job market for assistants... States with less Stringent occupational restrictions should be judged in comparison to other policies could... On what physician supervision of nurse midwives to maintain collaboration agreements and which independent. Importantly, the most Common Setting for childbirth Bill 532 ( 2009 ), California! The stateshould be considered in conjunction with the TMB if the physicians delegate prescriptive authority PAs! Typically must attend sixyears of postsecondary education and training Minimum of 52 weeks of individual supervision best... 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