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California Nurse Practitioners Lose Battle For Independent Practice, Again

Legislation to allow California’s nurse practitioners more independence in treating patients has fizzled for the year — and it’s not the first time.

A proposed bill to expand the scope of nurse practitioners was scheduled to be heard by an Assembly committee this week, but was pulled by the measure’s author, state Senator Ed Hernandez (D-West Covina), after he determined that it did not have the votes needed to pass.

Expanding the medical role of nurse practitioners has long been opposed by doctors – some say for economic reasons. Proponents of the idea say it can help address the shortage of primary care doctors in the state by making treatment more accessible — and more affordable.

“We have been trying for a really long time … to allow NPs to practice to the fullest extent of their scope and training,” says Donna Emanuele, President for the California Association for Nurse Practitioners.

Under current state law, nurse practitioners can independently provide basic primary care, such as assessing a patient’s health status or diagnosing ailments. But they must follow physician-approved guidelines to prescribe medication, order tests or otherwise manage patients.

Nurse practitioners are among the most highly trained nursing professionals and must have at least a master’s degree. Registered nurses, are only required to hold an associate’s degree at minimum, and they don’t diagnose or prescribe on their own.

Nurse practitioners say they provide quality care that’s comparable to that provided by physicians. They want California lawmakers to allow them to practice without the supervision of a doctor.

‘We continue to hit the same road blocks in terms of some turf wars that I think are unnecessary in today’s age, because there are enough patients to go around,” said Emanuele.

The California Medical Association, which lobbies for the state’s physicians, has vehemently opposed allowing the nurses to treat patients without using standardized medical procedures approved by them.

“Team-based care led by a physician is the safest, most cost-effective way to treat patients,” CMA officials said in a press release after the defeat of a 2013 bill to expand nurse practitioners’ scope of practice.

The California Medical Association did not comment for this story but it did provide a copy of the letter it had filed opposing this year’s measure to lift restrictions on the nurse practitioners.

“[The bill] reverses 40 years of policy that has maintained high quality health care for every Californian by allowing lesser trained practitioners to practice medicine without providing adequate patient protections and medical standards,” the letter said.

A 2010 report by the Institute of Medicine recommended that nurses should be allowed to practice at the full scope of their training, and should achieve higher levels of education.

Since 2013, five states have lifted restrictions on nurse practitioners, raising to 21 the number of states that have expanded nurse practitioners’ legal “scope of practice,” according to the National Council on State Legislatures. The District of Columbia has also done so.

“There is yet to be a study that shows, based on these restrictions, there [are] better primary care outcomes, or better safety or better referrals or anything else,” says Joanne Spetz, associate director of research at Healthforce Center at the University of California at San Francisco, and a professor at the University’s School of Nursing.

Spetz co-authored a recent study that suggests state policies allowing independence for nurse practitioners have resulted in a slight drop in the price of services and a minor increase in overall outpatient, physician and pharmacy costs. The uptick in those costs may be due to expanded patient access and an increase in the volume of services provided, the research suggests.

Nurse practitioners are sometimes paid less than physicians for providing the same health care service, Spetz says. Medicare reimburses nurse practitioners at a lower rate than doctors. The economics of more providers offering the same services may be one reason physicians oppose the idea, says Spetz.

“If you have more competition in the market, the prices will drop, and those dropped prices are great for consumers and patients, but…mean someone’s going to lose money. And that may be a doctor,” says Spetz.

The prospect of lower health care costs compelled business groups to support easing restrictions on nurse practitioners.

“Small businesses continue to really struggle with being able to afford health insurance for themselves and their employees,” says David Chase, California Director of the Small Business Majority, a national policy advocacy group for small businesses. “The ACA has taken a lot of steps to control costs, but we think a lot more needs to be done.”

Hernandez, chairman of the Senate Committee on Health who has championed the nurse practitioner bills during the past two legislative sessions, says he will consider next year whether to reintroduce the proposal.

“We are always searching for solutions to the shortage of primary care providers,” he said.

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