It is well-documented that California is facing a shortage of primary care providers. The Californians most affected by these shortfalls are largely low-income, Latino, African American, and Native American and located in rural areas as well as in California’s largest and fastest-growing regions—the Inland Empire, Los Angeles, and the San Joaquin Valley. Newly-proposed legislation aims to address this problem by permitting California’s nurse practitioners to practice under certain conditions without physician supervision.
Assembly Bill 890 was introduced by Assemblymember Jim Wood (D-Santa Rosa), Chair of the Assembly Health Committee, and co-authored by five Assemblymembers and four Senators on both sides of the aisle. Among the co-authors are Cecilia Aguiar-Curry (D-Winters), member of the Assembly Health Committee; Jeff Stone, (R-Temecula) Vice Chair of the Senate Health Committee; and Connie Leyva (D-Chino), member of the Senate Health Committee.
The bill, which amends Section 2837.1 of the Business & Professions Code (a section of The Nursing Practice Act), would expand nurse practitioner education and revise scope of practice regulations so that nurse practitioners could practice without physician supervision after a transitional period of collaboration with a physician or experienced nurse practitioner. Specifically, the bill would authorize a certified nurse practitioner to practice without the supervision of a physician if the nurse practitioner meets specified requirements, including having practiced under the supervision of a physician and surgeon for an unspecified number of hours (to be determined by the Board of Registered Nursing). The bill also would authorize a nurse practitioner to perform additional specified functions, including ordering and interpreting diagnostic procedures, certifying disability, and prescribing, dispensing, and administering controlled substances. Because the bill would expand the scope of a crime (a violation of the Nursing Practice Act is a misdemeanor), the bill would impose a state-mandated local program under the Commission on State Mandates to review and assess alleged violations.
A report by the private-sector California Future Health Workforce Commission1, of which Assemblymember Wood is a member, makes the following statements:
- Full practice authority for nurse practitioners would result in cost savings to Californians from reduced avoidable emergency department stays and hospitalizations, and the lower costs of retail clinic use and primary care.
- Removing scope of practice restrictions would increase the growth rate of nurse practitioner supply by 25 percent. Between 2010 and 2017, California’s NP supply grew 39 percent; with full practice authority, the growth rate would have been 49 percent, and the state would have 1,500 NPs more than it does today.
- If full practice authority is achieved by 2020, there would be nearly 50,000 fewer revisits to emergency departments for ambulatory sensitive conditions, resulting in cost savings of more than $58 million per year.
Currently regulations promulgated by the Board of Registered Nursing under present statutory provisions require nurse practitioners to collaborate with physicians to develop standardized procedures—written authorization to perform certain medical functions not otherwise part of a nurse practitioner’s scope of practice2. There are no requirements in those regulations regarding the physical proximity of the supervising physician to the nurse practitioner—supervision could be done remotely. However, the physician is still legally responsible for the nurse practitioner’s practice, and is expected to determine the appropriate level of supervision, communicate regularly with the nurse practitioner, and oversee quality of care.
Opponents of the bill say nurse practitioners lack the training needed to practice on their own, arguing that online coursework is not as effective as the in-person medical education received by physicians, and that nurse practitioners have fewer hours of actual patient contact than physicians. The bill’s proponents point out that this concern creates a double standard between nurses and physicians because there is a mix of online and in-person programs offered by medical schools, which has been deemed sufficient for a physician and surgeon license.
If this bill passes, California would join 22 other states3 and the District of Columbia in allowing nurse practitioners to practice and prescribe without physician supervision or collaboration, as specified. Doing so, the bill’s proponents state, would not only be cost-effective, but would expand access to care for the state’s most vulnerable populations.
1California Future Health Workforce Commission, Final Report, February 2019
2Title 16, Code of California Regulations, Section 1485 (Scope of Practice).
3Alaska, Arizona, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, South Dakota, Vermont, Washington, and Wyoming.