Doing so can impede competition among service providers and, as a result, potentially raise prices and reduce access to those services. Due to the flexibility of Californias physiciansupervision requirement, described above, we find that Californias requirement is unlikely to be any more effective than other states similar requirements at improving safety and quality. employment. 0880-02-.18(7-9) and Tenn. Comp. Nurse Midwives Employ Fewer Costly Labor and Delivery Interventions Than Physicians. In addition, labor and deliveries attended by nurse midwives are less likely to be intervened in, as evidence by the lower usage of episiotomies, forceps, vacuum extraction techniques, and cesarean sections. The law limits a physician to supervise no more than four PA's, except as provided in Business and Professions Code (BPC) section 3502.5. Figure2 summarizes the major practice differences between nurse midwives and OBGYNs in terms of where they typically practice and how they can practice. Along similar lines, we understand that some health systems require physicians to cosign medication orders, while others do not. Major Practice Differences Between Nurse Midwives and OBGYNs, Provide primary care and family planning services, Deliver prenatal, postpartum, and newborn care, Attend births experiencing complicationsa, Deliver with the use of medical instruments. In our assessment, removing the states physiciansupervision requirement for nurse midwives could improve the safety and quality of labor and delivery care in hospital settings, provided the removal leads to greater utilization of nursemidwife services in these settings. Medical Board. Given these tradeoffs, occupational restrictions should be employed by policymakers with scrutiny and care, and be reassessed as evidence arises regarding impacts on safety, quality, access, and cost. Removing Requirement Could Encourage the Establishment of Independent Clinics and Freestanding Birth Centers. Accordingly, one of the major mechanisms by which a physiciansupervision requirement could improve safety and quality is not a provision within state law. 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. This is just a dumb idea. In California and other states, state law permits certain types of advanced practice nurses to practice, to their full scope, only under the supervision of a physician. 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. Board regulation 263 CMR 5.05 (2) containing the same limitation was deleted by emergency regulation effective May 29, 2013. Required fields are marked *. We also find evidence of geographic disparities across the state in access to care by OBGYNs. Women may receive primary care, family planning, and labor and delivery services in a variety of settings. 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. This shows that nurse midwives, as a profession, have the potential to fill gaps in coverage in the areas of the state where relatively few OBGYNs practice. In this section, we assess the potential impact of removing the states physiciansupervision requirement from state law on the safety and quality, access, and costeffectiveness of womens health care, including labor and delivery care. Comparison of Obstetric Outcome of a PrimaryCare Access Clinic Staffed by Certified NurseMidwives and a Private Practice Group of Obstetricians in the Same Community. AmericanJournal of Obstetrics and Gynecology172 (6): 186468; discussion 186871. As Figure10 also shows, nurse midwives fill the gaps in womens health care in three of the five regions with relatively few OBGYNs: the Central Coast, San Diego, and the northern and Sierra counties. The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates. Obstetrics & Gynecology 126 (4): 71623. - - - Maryland No Yes. 2023 State by State Scope of Practice: Physician Assistant. By Moira K. McGhee. Three types of providers specialize in health care related to childbirth and womens reproductive health. Such interventions, while critical in cases of medical necessity, come with risks and therefore are recommended to be employed only as needed. Academic researchers have extensively explored how hospitalbased labor and delivery care by nurse midwives for women with lowrisk pregnancies compares to such care by OBGYNs and other physicians. For example, as shown in Figure10, the Greater Bay Area has nearly three times as many OBGYNs per 1,000 births than the Inland Empireand over 50percent more than the statewide average. Physician and Resident Communities (MD / DO). The remaining five regions of the state have fewer practicing OBGYNs per 1,000 births. Im in a physician owned practice. We find some evidence that access to nursemidwife services specifically, and womens health care services generally, might be limited in California. Supervision includes, but is not limited to: (1) the continuous availability of direct communication either in person or by electronic communications between the NPP and supervising physician; (2 . As demand for healthcare workers continues to surge . In this section, we analyze the states physiciansupervision requirement for nurse midwives. 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. 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. Edith Ramirez Chairwoman, Julie Brill, Maureen K Ohlhausen, and Joshua D Wright Commissioner. This regulation stipulates the requirements of the Physician-Practitioner Interface Agreement for the various NMP types and also stipulates that they must be enrolled pursuant to Section 51000.30. When feasible, occupational restrictions should be judged in comparison to other policies that could achieve the same purpose. 2014. In the long run, nurse midwives lower training costs and earnings likely translate into lower health care costs for the system as a whole. Potential to impair rather than improve the quality of health care services. LAO Evaluation Framework for Assessing the States PhysicianSupervision Requirement for Nurse Midwives. I dont sign NPs notes. Medicare requirements; and 5. The maximum number is determined individually by each type of mid-level practitioner. A "shared" visit is when the level of service is determined by documentation from both the physician and a midlevel provider for a date of service. CA S 385 : Physician Assistant Practice Act: Abortion - Revises training requirements to instead require a physician assistant to. 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. That risk valuation drives the expectation (if not the absolute need) that all patients evaluated primarily by a mid-level provider also require emergency physician supervision and oversight. https://doi.org/10.1377/hlthaff.17.2.190. 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. 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. This section lays out the main reasons. Read More. The following table outlines the number of physician assistants a physician may supervise at one time in states with more restrictive oversight requirements. 2015. Figure9 shows these trends. Potentially Positive Impact on Safety and Quality in Hospital Settings, the Most Common Setting for Childbirth. https://doi.org/10.1097/aog.0000000000001032. 2012. Mid-Level Practitioners Authorization by State. Nurse Midwives Comprise an Appreciable Share of the Women's Health Care Workforce in California There are over 2,000 OBGYNs in California, compared to more than 700 n urse midwives and almost 400 l icensed midwives. 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). The following bullets briefly describe four settings that specialize in womens health care and detail how physician and nursemidwife services are utilized in similar and different ways across the settings:. Nurse midwives are required to immediately refer women experiencing complications during childbirth to a physician. Rural hospitals, where we understand nurse midwives have greater challenges finding physiciansupervisors, would no longer face this barrier to employing nurse midwives. Following our review of academic literature on the safety and quality of care by nurse midwives, however, we do not find sufficient evidence to justify this occupational restriction for two reasons. Given the absence of a physicalpresence requirement, in California and other states, advanced practice nurses may practice far away from their physician supervisors. Occupational restrictions may be appropriate when: Consumers would have difficulty observing and/or predicting the quality or safety of a given health care service. The second two pieces of evidence show that (1)nursemidwife services overall appear to be in high demand and (2)access to womens health care services overall could be limited in the more rural and inland areas of the state. According to a report in The Sacramento Bee, the law . The Board limits a physician to supervise a total of 360 "full-time equivalent" (FTE) hours per week of mid-level practitioners. We note that since these studies are observational as opposed to experimental in nature, whether fewer occupational restrictions actually cause an increase in the number of practicing nurse midwives, or if other factors explain the identified relationship, is uncertain. First, we discuss the likely impacts on safety and quality of the states physiciansupervision requirement for nurse midwives, given the specifics of the states requirement and how it is implemented in practice. 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. Help Center / How many APRNs can a MD supervise? More than 31,000 California nurse practitioners have been working with minimal supervision in clinical settings under the supervision of physicians for years, sometimes decades. Primary care services take place at primary care clinics or freestanding birth centers run by the nurse midwives. Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Center Program Compared With Traditional PhysicianBased Perinatal Care.American Journal of Public Health93(6): 9991006. Nurse Midwives Salaries Are Generally Lower Than OBGYNs. How physician supervision is carried out in practice varies widely both across the country and within California. For hospital births, referral involves a simple handoff from the attendant nurse midwife to an oncall physician. For example, the states physiciansupervision requirement places no responsibilities on supervising physicians to perform qualityassurance activitiessuch as periodic clinical chart reviewswith their nursemidwife supervisees. State regulations concerning physician supervision of PAs are anything but inconsequential and carry significant implications not only for physician assistants ability to practice but also for the financial stability of medical practices and their ability to deliver patient care. 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. Note, as well, that supervision requirements apply only to the technical component (the actual test administration . Combined individual and/or group. 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. [1] The law brings California in line with over half of the states in the U.S. by permitting NPs to practice independently and to the full extent of their training and education. Specifically, we assess whether this requirement is effective in ensuring and improving the safety and quality of childbirth without unreasonably impeding access or raising costs. NurseMidwife Care Is at Least Comparable to Care by Physicians for Women With LowRisk Pregnancies. We agree with the Federal Trade Commissions finding that physiciansupervision requirements likely impede access and raise costs by giving physicians control over nurse midwives ability to independently deliver services. They shared an infographic that noted that 58.8% of California NPs offered primary care, in comparison to only 16.7% of physicians. 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. Thus, nurse midwives earn about 60percent of what OBGYNs earn. Minimum of 13 weeks of individual supervision by an LCSW. 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. They must do so, however, in accordance with standardized procedures that are developed and approved in collaboration with their supervising physicians. Rosenstein, Melissa G., Malini Nijagal, Sanae Nakagawa, Steven E. Gregorich, and Miriam Kuppermann. While providing primary care services is within the scope of practice of nurse midwives, the focus of this reportand the research we citeis on the care provided to women and their infants related to pregnancy and childbirth. Childbirths that feature relatively minor lacerations, or for which minor surgical cuts are made to prevent lacerations, are considered normal and are, therefore, within the scope of practice of nurse midwives. 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). Some health systems require physicians to cosign medication orders, while others do.. Women with LowRisk Pregnancies Encourage the Establishment of Independent Clinics and Freestanding Birth Centers Group of Obstetricians the... 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