State Senate committee takes up bill to expand nurse practitioners' authority

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 Monday marks the first test for a bill that would grant California's nurse practitioners the authority to practice without the oversight of a physician. The measure, facing opposition from the California Medical Association, goes before the State Senate's Business, Professions and Economic Development committee.

The bill, SB 323, represents the second go round for an effort by Senator Ed Hernandez (D-West Covina) to relieve nurse practitioners of the doctor oversight currently required to treat, diagnose and prescribe medication.

Hernandez says the bill is a part of a larger plan to address doctor shortages across the state as the Affordable Care Act has brought 2.5 million newly insured Californians into the healthcare fold.

Only 16 of California’s 58 states counties have the recommended physician-to-patient ratio, he notes.

"We have a great need for primary care providers in predominantly rural and inner city communities," argues Hernandez. "I felt [SB 323] was a good way to address that."

If government is going to mandate "that every single person purchase or have insurance, whether it be through Covered California, large group, their job or through Medi-Cal, then we need to provide that care for those patients," maintains the senator.

The provider shortage is expected to get worse. A recent Association of American Medical Colleges study that found that within the next ten years the U.S. will face a shortage of between 12,000 and 31,000 primary care physicians.

Sen. Hernandez says under his bill, nurse practitioners could operate independently as long as they are affiliated with a medical group. That would include clinics with no doctor if they are part of a larger group.

A nurse practitioner is a registered nurse with a graduate degree in advanced practice nursing.

The California Medical Association, which represents doctors, opposes the bill.

Noting that the bill would allow nurse practitioners to operate "independent of physician supervision, collaboration, or oversight," the Association asserts in a letter to the chair of the business committee that "we are concerned that the changes proposed may undermine the delivery of patient-centered, team-based care in California."

The doctors' group also argues that giving nurse practitioners' enhanced authority would not increase care or cost savings.

CMA spokesman Jason Kinney said patients expect "well trained, fully accountable physicians" to be part of their care.

"Removing the physician from the room is a mistake," he said. "These are critical health decisions and you want these decisions made under the supervision of a qualified physician and to remove the physician from that process is going to reduce the quality of healthcare."

The bill, Kinney argues, does not solve the healthcare access problem in a way that is equitable to communities that need care.
"It's not enough to open the doors, we need to make sure we are providing high quality healthcare for everyone," Kinney said.

Hernandez said he believes the bill would help communities in need because they currently lack access to care and other solutions – like training more doctors – will take much longer to implement. He also said the bill requires accountability, ensures nurse practitioners are working with a larger doctor group and outlines how they will refer patients to doctors and specialists.

The California Association of Nurse Practitioners supports SB 323.  Association President Donna Emanuele says the bill is updating antiquated language in the law and would allow nurse practitioners to use 100 percent of their training, especially in areas where there are few healthcare options.

Emanuele considers the bill a  first step towards gaining complete independence for nurse practitioners, including the ability to open and run their own facilities. They already have that right in 20 states, and several other states allow varying levels of autonomy, according to The Association of Nurse Practitioners.

Sen. Hernandez unsuccessfully introduced a bill in 2013 that sought to give nurse practitioners complete independence, including the right to open their own practices. The Medical Association opposed that bill as well, citing concerns about patient safety.

SB 323 would allow nurse practitioners to do everything they are trained to do now but without the practice agreements that currently give doctors authority to decide how much nurse practitioners can do.

For example, Emanuele says she works in a clinic, an emergency room and an acute care setting, and based on each facility's practice agreement, she has different limits on what kinds of care she can provide.

"Because that barrier is in place patients can’t access the level of care I can provide to them, which impacts their ability to access healthcare services," she maintains. "It delays their ability to get healthcare in a timely and more efficient manner."

Sen. Hernandez stresses that SB 323 is just one part of a larger effort to address the doctor shortage. He says the state needs to train more physicians and increase the number of residencies, as well as place a greater focus on preventative care.