Tradeoffs to consider in establishing an occupational restriction: The impact on access to health care services. Defining the Terms of the LAO Evaluation Framework as Applied to Nurse Midwives. https://doi.org/10.2105/ajph.93.6.999. Robust Growth in Earnings Suggests Demand for NurseMidwife Services May Exceed Supply. This is just a dumb idea. Scopeofpractice rules establish the range of services and procedures that a health care provider may perform under their professional license, certification, or otherwise determined competencies. 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. For example, some states set maximum geographic distances from which a physician can supervise a nurse midwife. Mid-level practitioners, also called non-physician practitioners or advanced practice providers, are health care providers who have a defined scope of practice. A significant portion of the remaining 75percent cited reasons related to accessdefined as the ability to have an appropriate and preferred providerfor why they did not use midwife services. This section lays out the main reasons. For example, in Georgia, a physician may enter into a supervisory agreement with up to eight NPs, but only actively supervise . 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. Why should physician assistants and physicians care about laws regulating the number of PAs an MD may supervise? In addition to the abovenoted specialist providers, family practice physicians also regularly provide womens health care services, with a small portion (according to national statistics) regularly attending childbirths. This legislative session, California Governor Gavin Newsom signed AB 890, legislation that expands the existing scope of practice laws for nurse practitioners (NPs). The physician may supervise only one office other than the physician's primary place of practice except that until July 1, 2011, the physician may supervise up to two medical offices other than the physician's primary place of practice if the addresses of the offices are submitted to the board before July 1, 2006. Nurse Midwives Salaries Are Generally Lower Than OBGYNs. DONT DO IT. Survey Data Indicate a Higher Proportion of Women Want Than Receive Midwife Services. The supervising physician and PA/NP/CNM are both enrolled as Medi-Cal providers pursuant to Article 1.3 (commencing with Section 14043) of Chapter 7, Part 3 of https://doi.org/10.1016/j.whi.2017.01.002. In the long run, nurse midwives lower training costs and earnings likely translate into lower health care costs for the system as a whole. This allows, for example, varied levels of direct supervision for lesser and more experienced nurse midwives. Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. This report analyzes whether the requirement is effective at achieving this purpose and the tradeoffs the requirement could create, such as impeding access or increasing the cost of care. The survey found, however, that among mothers who would have preferred to use a midwife, 25percent reported experiencing health problems necessitating referral to a physician rather than a midwife. Figure4 defines the key terms of our framework. (4) The supervising physician shall provide a copy of the signed, written authorization to the nurse practitioner or nurse midwife. The agreement is between one NP on one physician. 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. 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. Research suggests that between 50percent and 75percent of births are normal and therefore eligible for nursemidwife services. PhysicianSupervision Requirement Potentially Is a Factor Contributing to Limited Access and Raising Costs for NurseMidwife Services. NP can obtain full practice prescriptive authority after consulting and collaborating with an NP or physician mentor for 18 months; see MD Statute 8-302(b)(5)(i In California, OBGYNs tend to practice disproportionately in certain regions of the state. Mapping Integration of Midwives across the United States: Impact on Access, Equity, and Outcomes. Edited by Dongmei Li. As discussed above, the research literature amply demonstrates the quality of labor and delivery care provided by nurse midwives in hospital settingsby far the most common setting. One likely reason that nurse midwives salaries are lower is the significantly lower cost of their training. Occupational restrictions may be appropriate when: Consumers would have difficulty observing and/or predicting the quality or safety of a given health care service. I do that now-a-days with my internist wife and her OB/GYN father. It generally involves (1)collaboration in the development and approval of standardized procedures, which advanced practice nurses generally are expected to follow in certain circumstances (such as prescribing medications), and (2)availability for consultation. Theres always an MD designated as on call and the go to person for questions. What we can do for you to make this worth your while is pay you nothing.. 1979. Under California state law, nurse midwives may only practice and deliver health care services under the supervision of a licensed physician. 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. 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. A mid-level practitioner controlled substance license (385/CS) may be issued to a physician assistant (PA) whose supervising physician of record has delegated limited prescriptive authority for controlled substance Schedules II, III, IV, V. The physician is required to include and maintain the guidelines for the delegated Other key factors, such as OBGYNs ability to provide care in complex caseswhich derives from their more extensive trainingalso likely contribute to their higher incomes. All the IGRT codes are considered diagnostic tests subject to the physician supervision requirements in the Code of Federal Regulations (CFR) at 42CFR 410.32(b)(3). Mid-Level Practitioners. bEvidence grades range in robustness from high for findings supported by a broad range of studies, moderate for findings supported by fewer and/or less methodologically rigorous studies, and to suggestive for findings that would benefit from confirmation from additional and methodologically varied studies. 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 . Quality: A summary measure combining (1)patient satisfaction with pregnancy, labor and delivery, and reproductive health care and (2)the consistency of such care with clinical best practice guidelines. What is the scope of practice of a Physician Assistant? Since, in our assessment, the physiciansupervision requirement likely does not significantly improve the safety and quality of care, retaining the physiciansupervision requirement brings tradeoffs without producing any significant, tangible benefits. For example, because the intervention itself is costly and is associated with longer lengths of stay at the hospital, cesarean deliveries are generally between 60percent and 90percent more costly than vaginal deliveries. The potential alternative requirements include the following: The states physiciansupervision requirement for nurse midwives is intended to improve the safety and quality of womens health care. By full scope of practice, we mean delivering advanced practice nursing services, as opposed to the services delivered by a registered nurse as ordered by a physician or other provider. https://doi.org/10.1016/j.whi.2011.06.005. Figure3 summarizes our evaluation framework for assessing occupational restrictions in health care broadly. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. Why not? Labor and delivery is attended at nearby hospitalswhere nurse midwives have admitting privilegesor at freestanding birth centers. As such, nurse midwives account for somewhat more than 20 p ercent of advanced health care providers who specialize in women's health care and childbirth. For freestanding birth center and home births, referral typically will entail transportation to a hospital. https://doi.org/10.1371/journal.pone.0192523. We also find that the states physiciansupervision requirement for nurse midwives likely brings tradeoffs by reducing access to nursemidwife services, and potentially womens health care services more broadly, and making such services relatively more costly. 3. Accordingly, we recommend that the Legislature consider removing the states physiciansupervision requirement for nurse midwives, while adding other alternative safeguards to ensure safety and quality. HospitalBased Labor and Delivery Care by Nurse Midwives Compares Favorably to Care Provided by Physicians. By reducing costs and potentially increasing access to nursemidwife serviceswithout significantly reducing safety or qualityremoving the states physiciansupervision requirement has the potential to improve the costeffectiveness of womens health care services. 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 . For example, this training includes advanced procedures such as cesareans and hysterectomies and advanced treatments for illnesses such as for cancer. 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. This section describes the major practice rules placed on nurse midwives. Previously, we discussed the potential safety and quality impacts of such developments. (Minimum of 5% of the PAs medical records). 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. Your email address will not be published. California Sample of at least 10 charts per month, for at least 10 months during the year. I Physicians can now supervise the number of NPs or PAs they can competently and confidently supervise without a statutory ratio in place. (While OBGYNs extra competencies are critical in complex cases of pregnancy, labor, and delivery, they are not necessarily needed in the case of normal childbirthsthe type of births which nurse midwives are authorized to solely attend.) On the compensation front, only 21 percent of respondents reported salary cuts for physicians, ranging from 5 to 20 percent, with an average of 12.5 percent. Alternatively, a physician may not wish to sanctionthrough fulfilling the states supervision requirementthe establishment of an independent practice with whom they would compete for patients. There is a risk of serious and irrevocable harm when a health care service is performed poorly. Several Provider Types Specialize in Womens Health Care. Resident here. Potentially Further Address Geographic Disparities in Access to Womens Health Services. JavaScript is disabled. The physician's risk and reward are high. Nurse midwives and licensed midwives are authorized to be the exclusive attendant in cases of normal childbirth but are not authorized to be the exclusive attendant of highrisk births, such as those involving twins and those delivered by mechanical or surgical means. Midlevel providers -- nurse practitioners (NPs) and physician assistants (PAs)-- are entering independent practice or working in retail clinics that have no . The following table outlines the number of physician assistants a physician may supervise at one time in states with more restrictive oversight requirements. 2015. No extra time and no compensation, but liability seems minimal given coverage from the federal government. 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. $500 per month per NP/PA in a small hospital group. They must do so, however, in accordance with standardized procedures that are developed and approved in collaboration with their supervising physicians. https://www.ncbi.nlm.nih.gov/pubmed/107372. The last section of this report provides our concluding assessment and includes our recommendations. 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. 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. Answer: Mid-level providers acting under the direct supervision of a medical director or program physician do not require an exemption to perform functions under 42 C.F.R. How do physician supervision laws for PAs in your state compare? State ScopeofPractice Rules Limit Nurse Midwives to Attending Normal Childbirths. Under California law, nurse midwives are authorized to be the exclusive attendant only for normal childbirths. 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. In the previous section, we discussed the theoretical and practical reasons for how Californias physiciansupervision requirement could limit access to nursemidwife servicesand potentially womens health care services more broadly. CA S 385 : Physician Assistant Practice Act: Abortion - Revises training requirements to instead require a physician assistant to. Senate Bill 406 (2013), requires a prescriptive authority agreement be in place between a physician and a PA or APN that has been delegated prescriptive authority. Slightly more than 69 percent of employers have cut back on physician clinical hours, ranging from 5 to 30 percent, with an average of 15 percent. In contrast to California, most other states do not have a physiciansupervision requirement for nurse midwives, and a majority of other states do not even have the requirement for nurse midwives to maintain collaboration agreements with a 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. The Impact of Full Practice Authority for Nurse Practitioners and Other Advanced Practice Registered Nurses in Ohio: Rand.Org. Furthermore, we find that certain other qualityassurance mechanisms could better ensure and improve safety and quality without introducing tradeoffs as significant as the states current physiciansupervision requirement. 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. Third, the ability of nurse midwives to compete with other providers on cost is impeded by the higher costs associated with these payments. https://doi.org/10.1377/hlthaff.17.2.190. However, only 4 NPs can be actively supervised by the physician. Board regulation 263 CMR 5.05 (2) containing the same limitation was deleted by emergency regulation effective May 29, 2013. Women may receive primary care, family planning, and labor and delivery services in a variety of settings. Three types of providers specialize in health care related to childbirth and womens reproductive health. Californias physiciansupervision requirement for nurse midwives is intended to improve the safety and quality of womens health care. In these cases, the payments would compensate physicians for the legitimate costs and risks associated with supervision. (Such payments would not be in the public interest insofar as they only compensate physicians for authorizing the establishment of independent practices with which they would have to compete.). This does not mean that each occasion of service by a nonphysician need also be the occasion of the actual rendition of a (As previously noted, in California, 98percent of nurse midwifeattended births occur at the hospital.) 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. 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. Sctrict supervision laws restrict the growth of medical practices and have negative financial impact for practice owners. Regardless of location, if a physician personally provides the entire service, supervision requirements are not a concern. Nurse Midwives May Furnish Medications in Accordance With Standardized Procedures. If you are . The county and state health departments are exempt from this rule. If it's asked, just say no. For a better experience, please enable JavaScript in your browser before proceeding. 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. Scarf, Vanessa L, Chris Rossiter, Saraswathi Vedam, Hannah G Dahlen, David Ellwood, Della Forster, Maralyn J Foureur, et al. 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. For this reason, the physiciansupervision requirement for nurse midwives raises anticompetitive concerns. 2014. Similarly, women in labor requiring an emergency cesarean section must be referred to a physician. LAO Evaluation Framework for Assessing the States PhysicianSupervision Requirement for Nurse Midwives. On balance, we find that removing the physiciansupervision requirement would have a limited but somewhat uncertain impact on safety and quality outside of hospital settings. . The findings of this report only are intended to apply to nurse midwives, not licensed midwives, who currently are not subject to a physiciansupervision requirement. Consequently, the supervision requirement for nurse midwives does not appear to positively affect safety and quality. 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. 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. The impact on the cost of health care services. 2012. Of the ten states that do specify the number of physicians that a single MD can supervise or collaborate with, the number ranges from two to eight. Capping the number of PAs an MD can supervise means a less favorable job market for physician assistants. I mean I'm just a resident, I was kinda hoping you guys would have our back with this encroachment stuff, but I was also mostly kidding. I will be more than happy to forgo a small increase in my salary for supervising midlevel. c. 112, 9E was amended to eliminate the limitation on the number of physician assistants who could be supervised by a supervising physician. Don't volunteer to give away your power and your profession. These policies and proceduressuch as chart reviews, standardized procedures, and facility licensing or accreditationcould be maintained and potentially improved upon in the absence of physician supervision of nurse midwives. Physician assistants (PAs) are nationally certified, state-licensed advanced practice allied health professionals. 2019. Other studies look at occupational restrictions broadly rather than strictly focusing on whether a state allows nurse midwives to practice without physician supervision or collaboration agreements. 2023, requires California physicians to provide patients with a writt. Note, as well, that supervision requirements apply only to the technical component (the actual test administration . https://doi.org/10.2202/15380637.1589. Which means they are also accountable for the clinical care they provide. Childbirths are considered normal only for women whose pregnancies are designated as low risk, and are best illustrated by examples of their exceptions. "the circumstances and provide written verification of physician availability for consultation, referral, or direct medical intervention in emergencies, and after hours, if indicated." (Ala. Admin. According to Rule 64B8-35.002, F.A.C. R. & Regs. 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