Doctors win in dispute with nurses

A physician and a nurse tend to a patient. (Photo: Tyloer Olson, Shutterstock)

Here’s the diagnosis: It was the doctors versus the nurses, and the doctors won – for now.

An effort to allow nurse practitioners limited authority to treat patients without the supervision of a doctor was blocked temporarily in the Assembly amid opposition from physicians, who said the plan would hinder high-quality medical care.

Nurse practitioners are licensed, registered nurses who hold a Master’s degree in nursing or another graduate degree in nursing

The Business and Professions Committee held on to the bill, SB 323 by Senate Health Committee Chair Ed Hernandez, D-Azusa, and the committee plans another hearing next week, just before the July 17 deadline.

The measure’s journey in the Assembly has been difficult: It was voted down in committee on June 30, but Hernandez got permission to bring it back for another vote on Tuesday. Instead, the measure was withdrawn, then amended, then placed back on the committee’s agenda for next week’s hearing. If it stalls again, it might not be heard until 2016 – if then. Hernandez, an optometrist, has carried similar “scope-of-practice” legislation in the past that also has been blocked.

The issue, essentially a turf dispute, is both medical and financial.

Nurse practitioners urged the Legislature to revamp and update the doctors’ current oversight and allow the nurses to conduct some duties, including diagnosis and treatment, without the supervision of a physician. The existing system has been in place for decades, the nurses said, but the Hernandez bill was needed now to help provide health care to millions of new patients triggered by the Affordable Care Act.

“This piece of legislation is good policy, but more importantly, it’s good policy at the right time at the right place for meeting and advancing the healthcare needs of Californians,” said Donna Emanuele, president of the California Association for Nurse Practitioners. The rapid expansion of health coverage to hitherto-uninsured Californians has placed new demands on physicians, and nurse practitioners can help ease that load, she noted.

The proposal “grossly expands the scope of practice for another group of non-physicians.”

Nurse practitioners are licensed, registered nurses who hold a Master’s degree in nursing or another graduate degree in nursing. They work in various healthcare system across the state, including hospitals, organized health systems, family practice, and clinics.

Nurse practitioners are trained in preventive medicine and to use evidence-based outcomes, Emanuele said, not to take the role of physicians. Nurse practitioners assign treatments to patients, and if a patient does not respond normally to that treatment, then a nurse practitioner would refer the patient to a doctor. SB 323 requires a nurse practitioner to refer a patient to a physician if the condition surpasses the nurse’s level of expertise.

“If they need services that are already within my realm,” Emanuele said, “[they] should be able to see me, but if [they] need a physician, then cross that bridge when you get there.”

This is an opportunity for nurse practitioners to update the system of the mid to late 1970s with the evolution of the nurse practitioner’s role, she added. “All of the health professions have evolved over time,” Emanuele said. “And there is times where legislation has not kept up with what [they are] able to capably provide.”

The corporate bar, which has been in place for generations, is meant to prevent doctors from making medical decisions based on profit.

But the California Medical Association and various physician groups are concerned about patient safety, saying SB 323 moves away from team practice.

“We don’t need more independent practice, we need more effective use of highly-integrated teams,” a Sacramento physician with nearly 30 years in practice years testified on Tuesday. “You want a team taking care of you . . . making full use of technologies.”

The CMA said there is no evidence that independent practice for nurse practitioners would lead to greater access to care.

CMA President Luther Cobb said the bill “which would have significantly compromised patient safety. SB 323 would have done nothing to address access to care,” adding that the proposal “grossly expands the scope of practice for another group of non-physicians.”

Hernandez introduced similar legislation two years ago, but it died in the Assembly Appropriations committee.

Hernandez accepted two of the three amendments offered by the Assembly Business and Professions Committee. Most of SB 323’s supporters opposed the third amendment on imposing on what is known as “the corporate bar” on nurse practitioners.

The corporate bar, which has been in place for generations, is meant to prevent doctors from making medical decisions based on profit. With some exceptions, the corporate bar prohibits hospitals from directly hiring doctors. The idea of the corporate bar came from the coal mining days, when the doctor treating the coal miners was hired by the coal mining company.

There should not be any corporate influence in medical decisions, said Assembly Business and Professions Committee Chair Susan Bonilla, D-Concord. Nurse practitioners practicing without physician supervision should adhere to the same provisions that doctors do.

She noted that the committee already passed a bill requiring midwives to adhere to the corporate bar, while a recent court ruling requires optometrists to comply as well.

“It’s about making sure we get there with the best possible way and the best possible policy,” Bonilla said, “by maintaining complete consumer protection.”

The corporate bar was one of several amendments the bill’s opponents asked for, which included giving the Medical Board of California oversight and making sure physicians are working aside nurse practitioners.

“But I didn’t hear that they [CMA] would remove their opposition,” Hernandez said about accepting the corporate bar amendment during Tuesday’s hearing, “so I have to choose, okay, with no commitment to remove their opposition, that I have to lose all my supporters. It doesn’t make any sense for me politically to go down that route.”

SB 323 was defeated four to nine during the June 30 hearing. It was granted reconsideration, then withdrawn from the second hearing.

“It is frustrating,” Emanuele said in a statement on the bill’s failure, “that California continues to lag behind twenty-one other states that currently allow patients direct access to the quality care and services that nurse practitioners provide.”

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