Bringing together our various findings discussed previously, in our assessment, Californias physiciansupervision requirement likely is a factor contributing to limited access to nursemidwife services in the state, and potentially to womens health care services overall. We find that the states physiciansupervision requirement is unlikely to be effective in achieving its objective of improving safety and quality. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. Several Provider Types Specialize in Womens Health Care. Second, we summarize national research findings on (1)the safety and quality of nursemidwife services across various practice settings (including across different occupational licensing requirements), (2)whether access to womens health care is impaired by restrictions on nurse midwives independent practice, and (3)whether such restrictions raise the costs of womens health care. 8.12. DONT DO IT. (1) The supervisor possesses and maintains a current valid California license as either a marriage and family therapist, licensed clinical social worker, licensed psychologist, or physician who is certified in psychiatry as specified in Section 4980.40 (f) 4980.03 (g) of the Code and has Kinda like how in you never document a curbside consult in the medical record. 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:. About Half of States Require Physician Oversight. (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.). Personal supervision: A physician must be in attendance in the room during the procedure's performance. Blanchette, H. 1995. Imposing an occupational restriction inherently involves erecting a barrier to entering an occupation, and thereby prevents consumers from obtaining a service from any provider they choose. If it's asked, just say no. In theory, the payment to physicians could go beyond the costs and risks associated with supervision to reflect a payment being made to allow competitors (nurse midwives) to enter the market and establish independent practices. https://doi.org/10.1016/00029378(95)914242. Which means they are also accountable for the clinical care they provide. Read More. Stange, Kevin. All U.S., Canadian, and international residents enrolled in an ACGME-accredited postgraduate training program in California are required to obtain a Postgraduate Training License (PTL) within 180 days from their enrollment date. In these cases, the payments would compensate physicians for the legitimate costs and risks associated with supervision. In our view, they are likely to be more costeffective than physician supervision since they do not lead to similarly direct anticompetitive effects as does physician supervision. Which Limits the Requirements Potential Effectiveness. This does not mean that each occasion of service by a nonphysician need also be the occasion of the actual rendition of a I Do you have evidence of a lawsuit/board action against an MD in a state with NP independent practice where the NP screwed up but the MD got in some sort of trouble? Additionally, a supervising physician may be concerned that they could be held liable in a successful medical malpractice suit against a nursemidwife supervisee. Im in a rural area and there are not enough MDs to manage the population. Labor and delivery is attended at nearby hospitalswhere nurse midwives have admitting privilegesor at freestanding birth centers. 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. 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. As with other physicians in California, OBGYNs tend to practice disproportionately in certain regions of the state. 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. The states physiciansupervision requirement could impede access in three ways. However its going to take some time. 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. State rules establish minimum educational, clinical experience, and other standards in order for individuals to become licensed health care providers. The following bullets give a highlevel summary of how Californias scopeofpractice rules pertain to physicians, nurses, and advanced practice nurses. The determination is not made on the number of people. The California Medical Association is concerned that nurse practitioners lack the training to provide adequate care without the supervision of a physician. Because these studies examine basic associations (while controlling for certain relevant differences among states, such as demographics and average educational attainment), they do not establish a firm, causal relationship showing whether or not occupational restrictions on nurse midwives improve health outcomes. Figure7 summarizes our assessment of academic research findings as they pertain to the care provided by nurse midwives and physicians, mostly in hospital settings. Potentially Positive Impact on Safety and Quality in Hospital Settings, the Most Common Setting for Childbirth. Perform the following: The practice would much prefer more MDs as well because if youre not supervising others you can see more patients. I guess my question would be, if a doc is specifically scheduled as on call to supervise and be available for patient care if contacted can they accuracately claim the midlevel is independent? A physician could have up to eight (8) mid-level practitioners (4 APRN's and 4 PA's) at one time. Several studies directly compare the costs of care provided by nurse midwives and OBGYNs. They could be imposed as conditions of licensure or as conditions to practice without supervision. https://doi.org/10.1016/j.jhealeco.2013.10.009. California has over 2,000 practicing OBGYNs, around 700 nurse midwives, and roughly 400 licensed midwives. 1992. The Role of Selection Bias in Comparing Cesarean Birth Rates between Physician and Midwifery Management.Obstetrics and Gynecology80 (2): 16165. This is just a dumb idea. Nevertheless, for these latter studies, physiciansupervision requirements are an important component used by researchers to ascertain the extent by which occupational restrictions affect nurse midwives ability to practice independently. (b).) We also find evidence of geographic disparities across the state in access to care by OBGYNs. 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. Minimum of 13 weeks of individual supervision by an LCSW. https://doi.org/10.1111/birt.12464. 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. 2017. four (4) and the maximum of PA's in a solo practice is two (2). The supervising physician must also be able to discharge the chart review and site visit obligations specified by Board rule. California Is Among 23 States to Require Physician Oversight of Nurse Midwives. 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 California, average annual salaries for nurse midwives are $135,000, whereas OBGYNs earn $225,000 annually. As previously noted, occupational restrictions bring tradeoffs. Setting of services provided; 4. Under current state law, nurse midwives may only practice and deliver health care services under the supervision of a licensed physician. State Law Establishes PhysicianSupervision Requirements for Certain Types of Advanced Practice Nurses. Altman, Molly R., Sean M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Kenn B. Daratha. Historically, NPs in California have been required to work under the supervision of a physician a major hurdle in rural communities that attract and retain few doctors, Curtis said. 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. Most state laws, however, dont follow suit. There is no state requirement that nurse midwives practice within the same geographic vicinity as their physician supervisor. Rural hospitals, where we understand nurse midwives have greater challenges finding physiciansupervisors, would no longer face this barrier to employing nurse midwives. They generally entail written agreements between nurse midwives and their collaborating physicians that outline the parameters under which a nurse midwife may practice. Consistent with our evaluation framework for occupational restrictions for health care services generally, we view the states restrictions on nursemidwife practice as appropriate insofar as they allow and facilitate access to relatively safe, highquality, and costeffective care. Second, for nurse midwives who obtain a supervisor, the payments made in exchange for physician supervision likely are passed on to patients and payers as higher costs. 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. Physician assistants (PAs) are nationally certified, state-licensed advanced practice allied health professionals. 2019. 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