California Association of Physician Groups

April 6, 2015
Via Fax: (916) 266-9343
The Honorable Jerry Hill
Senate Business, Professions & Economic Development Committee
State Capitol, Rm. 2053
Sacramento, CA 95814
Re: Support - SB 323 (Hernandez) Nurse Practitioners
Dear Chairman Hill:
CAPG represents over 160 accountable physician groups in California and across the
United States that serve 20 million patients. We support policy measures that encourage the
implementation of the Triple Aim – decreased cost, improved patient experience and
development of population health management. We are pleased to support this bill, and we
greatly appreciate the efforts of the author, staff, sponsors and stakeholders.
SB 323 follows the 2013 effort under SB 491, which was also supported by CAPG. SB
323 would increase patient access to care by updating outmoded supervision rules for certain
Nurse Practitioners that qualify under the provisions of the bill. It would accomplish this by
relieving certain NPs from direct physician supervision requirements by giving them “full
practice authority” to provide care within the limits of their training and experience. This bill
does not expand the scope of practice that a Nurse Practitioner can perform under California
Law, i.e. the specific kinds of procedures that they can do. Nurse Practitioners have differing
scopes of practice – based upon their education, level of certification, and specialty training.
Many practice in primary care settings. Others practice in the specialties quite effectively. If
you have been to the Emergency Department recently, you may have been seen by a Nurse
Practitioner instead of a Physician or Osteopath, and you probably received excellent care. If
someone tells you that this bill will permit a Nurse Practitioner to perform brain surgery, he or
she is incorrect. This bill does not expand the legal scope of practice; it changes the supervision
requirement for the level of qualified practice that a particular Nurse Practitioner has reached.
What is “full practice authority?” Under current law, Nurse Practitioners must practice
under the supervision of a physician or osteopath. Does this mean that a physician is standing
by and observing while a Nurse Practitioner is assessing or treating a patient? No. But it does
mean, in practice, that a Nurse Practitioner must find a physician or osteopath willing to enter
into a “collaborative practice agreement” before they can practice anywhere. This limits where
and how they can practice, and in which programs. If a Nurse Practitioner cannot find a
supervising physician in Yreka willing to take Medi-Cal so that she can handle Medi-Cal patients,
the community goes unserved. This actually happened on the eve of the coverage expansion in
California. Nineteen other states have already permitted the same modification, so this
proposal is neither novel nor unproven.
Why is it needed now? Since SB 491 stalled in Assembly Appropriations Committee in
the 2013 Session, California has added 5 million newly insured patients to the healthcare
system. Recently, newly insured patients tried to find doctors once they had obtained coverage
but found that many practitioners had closed their practices to new patients. Care delayed is
care denied, as they say. California has an aging primary care physician and osteopathic
workforce. Other states have proven that Nurse Practitioners with full practice authority
function well in that role, and there is a wealth of national studies that have analyzed the
environments in which full practice authority has been legislated and all have concluded that it
is a safe and effective means to increase access to quality care. While there is a wealth of
studies that support this concept, there is little or no evidence to refute it.
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Does this apply to all Nurse Practitioners? No, only to those who meet the increased
criteria, which include the following:
•
Must be certified by a national certifying body – especially with regard to specialty
practice.
•
Maintains professional liability insurance
•
Must practice within the following settings:
o A clinic, health facility, or county medical facility
o An accountable care organization (defined by the ACA)
o A group medical practice, including a medical corporation, another form of
organization controlled by physicians and surgeons, a medical partnership, a
medical foundation exempt from licensure, or another lawfully organized group
of physicians that delivers, furnishes, or otherwise arranges for or provides
health care services, a medical group, or an independent practice association.
CAPG insisted on the third criteria listed above for a variety of reasons, and Nurse Practitioners
agreed to it during the SB 491 process in 2013, and again with respect to the present bill, SB
323. These practice settings cited in the bill are the places where coordinated patient care is
occurring throughout California. These are the practice settings that submit to tracking and
public reporting of performance measures and patient outcome data that proves safety and
quality. These are the places where the concept of “team based care” is being developed and
evolved. In short, the kinds of places that are advancing increased access to care, quality of
care, and the transparency of outcomes, as well as striving to provide more affordability. CAPG
wanted to ensure that if full practice authority was legislated for Nurse Practitioners that it
wouldn’t result in the creation of another silo of care in a fragmented delivery system. By
requiring that NPs practice in these settings, we are assured that collaboration between all
health professionals will occur. We believe that this provision within the bill will function to
increase the safety of care provided by Nurse Practitioners – and this provision goes over and
above that of any other state that has legislated full practice authority for NPs.
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In conclusion, CAPG member physician groups (which are owned and operated by
physicians) contract with payers (HMOs and PPOs, Medicare and Medi-Cal) to provide access to
health care services. Our members are engaged in the service of providing access to health
care. This bill increases the ability to provide access in meaningful ways to cope with the
expansion of the patient base in California. It modernizes licensure law to reflect the current
reality. It allows Nurse Practitioners to practice to the full extent of their education and
training. Full practice authority has been proven safe and effective in ninetine other states.
Respectfully, we urge your “aye” vote.
Sincerely,
William Barcellona, Esq. MHA
Sr. V.P. Government Affairs
Cc: Senate B,P& ED Committee members
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