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 remaining 27 states allow nurse midwives to practice independently, that is, without a physiciansupervision or collaborationagreement requirement. 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. Nurse midwives are allowed to practice and are active in all 50 states. CrossBarnet, Caitlin, Ian Hill, Lisa Dubay, Brigette Courtot, Sarah Benatar, Bowen Garrett, Fred Blavin, etal. Effective July 1, 2011 . Pursuant to Title 21, Code of Federal Regulations, Section 1300.01 (b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in . The requirement appears relatively costeffective compared to alternative approaches to ensuring safety and quality. HospitalBased Labor and Delivery Care by Nurse Midwives Compares Favorably to Care Provided by Physicians. Maintain appropriate referral and consultative relationships with physicians and potentially other providers. For example, the states physiciansupervision requirement places no responsibilities on supervising physicians to perform qualityassurance activitiessuch as periodic clinical chart reviewswith their nursemidwife supervisees. Practice as a part of a health system (generally defined as a hospital, provider group, or health plan). Removing Californias physiciansupervision requirement reflects one promising avenue to do so. (See BPC, 3502.3, subd. The following bullets give a highlevel summary of how Californias scopeofpractice rules pertain to physicians, nurses, and advanced practice nurses. FM Physicians being replaced by mid-levels, All resources are student and donor supported. There is greater uncertainty regarding the impact on safety and quality that removing the requirement would have on care provided by nurse midwives outside of the hospitalincluding labor and delivery care in nonhospital settings and womens primary care. Nurse Midwives May Only Practice Under the Supervision of a Physician. employment. Mid-level practitioners, also called non-physician practitioners or advanced practice providers, are health care providers who have a defined scope of practice. As noted earlier, we believe this issue might be limiting access to nursemidwife services in the state, and potentially to womens health care services more broadly. Attanasio, Laura B., Fernando AlaridEscudero, and Katy B. Kozhimannil. States With Less Stringent Restrictions on Nurse Midwives Independent Practice Do Not Experience Worse Birth Outcomes. California nurse practitioners (NPs) will be able to practice on their own without physician supervision, after Governor Gavin Newsom signed a law, titled AB 890, opposed by various physician groups. 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). 1. Examples of complications include labor that is not progressing at a safe speed, or for which the use of medical instruments (such as forceps or a vacuum) is necessary. Nurse midwives are required to immediately refer women experiencing complications during childbirth to a physician. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. Those that do not limit the number of PAs an MD can supervise include Alaska, Arkansas, Maine, Massachusetts, Montana, New Mexico, North Carolina, North Dakota, Rhode Island, Tennessee, and Vermont. The findings of this report are not expressly intended to extend to licensed midwives, in large part due to the fact that licensed midwives can already practice without physician supervision under California state law. Requiring physician supervision of nurse midwives can be appropriate if theory and evidence show: The safety and/or quality of health care provided by nurse midwives appears deficient compared to that of physicians. Personal supervision: A physician must be in attendance in the room during the procedure's performance. The last section of this report provides our concluding assessment and includes our recommendations. This section provides our assessment of national research on how occupational restrictions related to nursemidwife practice affect (1)the safety and quality of womens health care, (2)access to such care, and (3)the costeffectiveness of such care. Physician assistants (PAs) are nationally certified, state-licensed advanced practice allied health professionals. The term refers primarily to physician assistants and nurse practitioners. Removing the states physiciansupervision requirement is a means by which the state could increase the number of nurse midwives andparticularly given the constraints on rural hospitals previously discussedaddress geographic disparities in access to womens health care services. (1) The supervisor possesses and maintains a current valid California license as either a marriage and family therapist, licensed clinical social worker, licensed psychologist, or physician who is certified in psychiatry as specified in Section 4980.40 (f) 4980.03 (g) of the Code and has Mid-Level Practitioners Authorization by State Pursuant to Title 21, Code of Federal Regulations, Section 1300.01(b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates. Obstetrics & Gynecology 126 (4): 71623. Such safeguards could include, for example, requiring nurse midwives to maintain appropriate referral and consultative relationships with physicians and requiring that they maintain medical malpractice insurance. Through the licensing of providers, California state law places restrictions on who may provide certain kinds of health care services. 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 To Practice, Nurse Midwives Must Obtain Consent From a Potential Competitor. There are a number of reasons why a physician may choose not to supervise a nurse midwife. This legislative session, California Governor Gavin Newsom signed AB 890, legislation that expands the existing scope of practice laws for nurse practitioners (NPs). The San Joaquin Valley and northern and Sierra regions of the state also have significantly fewer OBGYNs per 1,000 births than the more urban and coastal regions of the state. Patients might obtain fewer services to the extent they or their payers have to pay these higher costs. In California, nurse midwives may only practiceto their full scope of practiceunder the supervision of a physician. 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. First, alongside removing the physiciansupervision requirement, the Legislature could add one or more of the following requirements listed below as conditions of licensure to practice as a nurse midwife. Clinics, hospitals. Planned OutofHospital Birth and Birth Outcomes. New England Journal of Medicine373(27): 264253. 8 Hospital Scope of Practice Medicare COPs Patients may be admitted to a hospital by a I guess my question would be, if a doc is specifically scheduled as on call to supervise and be available for patient care if contacted can they accuracately claim the midlevel is independent? 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. Setting of services provided; 4. Why should physician assistants and physicians care about laws regulating the number of PAs an MD may supervise? The extent of required physician assistant oversight varies by state. - - - Maryland No Yes. There is a risk of serious and irrevocable harm when a health care service is performed poorly. Resident here. This body of research demonstrates that the care provided by nurse midwives during labor and delivery in hospitals is comparable, or in some cases, potentially superior to the care provided by physicians. 2014. Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses. https://www.ftc.gov/system/files/documents/reports/policyperspectivescompetitionregulationadvanced practicenurses/140307aprnpolicypaper.pdf. Nurse Midwives Employ Fewer Costly Labor and Delivery Interventions Than Physicians. However, health care systems, such as hospitals and health insurers, regularly requirefor a broad range of specialtiestheir providers to be certified in order to practice. The Board limits a physician to supervise a total of 360 "full-time equivalent" (FTE) hours per week of mid-level practitioners. 0880-02-.18(7-9) and Tenn. Comp. Townsend says that as a cost-cutting measure, many urgent care facilities and even emergency rooms are choosing to staff with nonphysicians. Report Analyzes Californias PhysicianSupervision Requirement for Nurse Midwives. c. 112, 9E was amended to eliminate the limitation on the number of physician assistants who could be supervised by a supervising physician. Such interventions, when not medically necessary, can raise the cost of labor and delivery, either because there is an extra charge for the specific intervention or because the interventionparticularly in the case of cesareansresults in a longer length of stay at the hospital. This section describes the evaluation framework that we utilize in this report to assess the benefits and tradeoffs of the physiciansupervision requirement for nurse midwives. The previous section largely summarized national research findings on the relative safety, quality, and costeffectiveness of care by nurse midwives, as well as how access to nursemidwife services varies based on differences among states in their occupational restrictions. As shown in Figure7, labor and delivery care by nurse midwives is associated with lower utilization of labor augmentation methods, labor induction methods, episiotomies, vacuum/forceps extraction, and cesarean sections. Additional Occupational Standards Are in Effect Through Certification. DONT DO IT. This Analysis Examines Californias PhysicianSupervision Requirement. Required fields are marked *. (4) The supervising physician shall provide a copy of the signed, written authorization to the nurse practitioner or nurse midwife. Some physician supervisors might regularly interact with their nursemidwife supervisees, while others might collaborate in the initial establishment of their nursemidwife supervisees scope of practice and standardized procedures and have limited subsequent involvement. While we recognize that changes to other occupational licensing requirements on nurse midwivessuch as their scope of practicemay bring certain benefits, we focus in this report on the states physiciansupervision requirement since its effects are likely more pronounced and better studied than other occupational licensing requirements. Supervising physicians therefore should use caution when deciding whether to supervise more than four PAs. Lastly, we bring together these components to discuss the potential impact of the states requirement on the safety, quality, accessibility, and costs of womens health care services in California. This, along with the fact that they state more than 11 million Californians live in an area with primary care physician shortages mean that NPs offering full-practice primary care can help meet the primary care needs of many, many people, The physician's risk and reward are high. Nurse Midwives May Furnish Medications in Accordance With Standardized Procedures. This suggests thatwhen only counting OBGYNsaccess to womens health care services might be limited in certain areas of the state. Examples of such scopeofpractice restrictions include limitations on nurse midwives authority to furnish medication and to practice at a faraway geographic distance from their supervising physician. The Listening to Mothers in California survey showed that 17percent of survey participants (mothers who gave birth in California in 2016) would definitely want to utilize a midwifes services. The Cost of NurseMidwifery Care: Use of Interventions, Resources, and Associated Costs in the Hospital Setting. Womens Health Issues 27 (4): 43440. First, we lay out the evaluation framework we use to analyze this (and potentially other) occupational restrictions. Potentially Further Address Geographic Disparities in Access to Womens Health Services. For example, we understand that some hospitals require physicians to cosign all inpatient admission orders by nurse midwives, whereas other hospitals grant nurse midwives full authority to admit patients. Adding Definition and Parameters to Physician Supervision Does Not Reflect the Best Approach. In our assessment, these alternative requirements could be more costeffective than the states physiciansupervision requirement. Which Limits the Requirements Potential Effectiveness. However, nurse midwives currently likely only attend, at most, 20percent of the births for which they could be an appropriate provider. (Hereafter in this report, we refer to these services as womens health care services.) Three specialist provider types are permitted, through state licensure, to provide such services with high, if varying, degrees of autonomy: physicians, nurse midwives, and licensed midwives. Average physician student loan debt can be as much as four times as high as the average amount for nurse midwives. As a result of the passage of HB 19-1095, some sections . OBGYNs, on the other hand, must attend 12years of postsecondary education and training, including residency. LAO Evaluation Framework for Assessing the States PhysicianSupervision Requirement for Nurse Midwives. Copyright2022 ThriveAP Inc., All Rights Reserved, limit job opportunities and earning potential, less favorable job market for physician assistants, Finding Your Why with ThriveAP Speaker Steven Wei, EdD, MPH, MS, PA-C, DFAAPA, What is Deprescribing in Practice & How it Optimizes Patient Care, A1C Recommendations for Every Patient Situation, Discussion with ThriveAP Speaker: Jonathon Pouliot, MS, PharmD, BCPS. The states physiciansupervision requirement could impede access in three ways. The regulation defines the levels of physician supervision for diagnostic tests as shown below. 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. This allows, for example, varied levels of direct supervision for lesser and more experienced nurse midwives. https://doi.org/10.1097/aog.0000000000001032. Access: Ability of individuals to successfully obtain pregnancy, labor and delivery, and reproductive health care in a timely manner from an appropriate and preferred provider. This section turns to California, informed by the national research findings. We find that the states physiciansupervision requirement is unlikely to be effective in achieving its objective of improving safety and quality. (As previously noted, in California, 98percent of nurse midwifeattended births occur at the hospital.) In the community Im in there are not enough MDs Id love to have another 5 full time mds to work with. Which means they are also accountable for the clinical care they provide. According to Rule 64B8-35.002, F.A.C. Better Outcomes Associated With Nurse Midwives? Consistent with our evaluation framework for occupational restrictions for health care services generally, we view the states restrictions on nursemidwife practice as appropriate insofar as they allow and facilitate access to relatively safe, highquality, and costeffective care. This means a physician could have up to 8 mid-level practitioners (4 APRN's and 4 PA's) in a group practice and 6 mid-level practitioners (4 APRN's and 2 PA's) in a solo practice, at any one time. They're supposed to come to us with questions and such but typically they'll ask whomever is nearest to them at the time . The California Medical Association is concerned that nurse practitioners lack the training to provide adequate care without the supervision of a physician. By Moira K. McGhee. Labor and delivery is attended at nearby hospitalswhere nurse midwives have admitting privilegesor at freestanding birth centers. 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