The JAMA Forum: California Dreamin’—The Story of Senate (Scope-of-Practice) Bill 491

Eli Adashi, MD, MSIt was all but impossible to miss the bevy of “scope-of-practice” bills that flooded the California legislature as it faced up to its 2013-2014 session. Introduced by the February 22, 2013, deadline, the Senate Bills (SBs) and Assembly Bills (ABs) in question hardly left a stone unturned. Legislative initiatives promoting the practice autonomy of nurse practitioners (SB 491), optometrists (SB 492), and pharmacists (SB 493) led the way.

Also on the docket were legislative efforts to grant nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs) broader supervisory authority over medical assistants (SB 352). Rounding out the list was the proposed authorization of properly trained NPs, CNMs, and PAs as providers for first-trimester pregnancy termination (AB 154).

Tracing the progression of SB 491 illustrates its contentious course, which is highly emblematic of the ongoing national scope-of-practice feuds between physicians and nonphysician providers. Sponsored by California State Senator Edward P. Hernandez, OD, SB 491 set out to authorize NPs as independent autonomous providers if they completed specific supervised clinical training, attained national certification, and maintained liability insurance. In so doing, SB 491 sought to allow NPs to launch their own “stand-alone clinics” and to practice to the full extent of their education, training, and competence in the absence of physician supervision. Given a favorable hearing at both the Senate Committee on Business, Professions, and Economic Development and the Senate Committee on Appropriation, a lightly amended version of SB 491 moved on to the Assembly Committee on Business, Professions, and Consumer Protection.

It was there that the gloves came off. After a bruising first hearing, SB 491 was voted down, but not before being granted reconsideration and the right to live to fight another day. No more than a week later, SB 491, now significantly amended, narrowly survived a second hearing, albeit at a steep price. Stripped of its “independent practice pathway” provision, SB 491 was no longer in a position to champion NP-managed stand-alone clinics other than in the “collaborative” context of “a hospital, a clinic, or some other medical facilities.” Alive—if on life support—and on its way to the Assembly Committee on Appropriation, SB 491 could see nothing but headwinds before it.

And so it came to pass. SB 491 never quite made it out of the Committee on Appropriation and onto the Assembly floor for a vote. It will be at least 1 year if not 2 years before SB 491 is reintroduced.

Viewed from a national perspective, SB 491 is but one of many state bills seeking to expand the scope of practice of nonphysician providers. According to the National Conference of State Legislatures, a total of 1795 such bills were proposed in 54 states, territories, or the District of Columbia in the course of calendar years 2011 and 2012. Of those, 349 were adopted or enacted into law. This year alone, as of April 1, 178 scope-of-practice bills have been introduced in 38 states and the District of Columbia.

The driving forces behind this mass movement are hardly surprising. Faced with a shrinking supply of primary care physicians and a growing demand for such services, state legislatures from California to Massachusetts are merely doing their level best to address the imbalance. Looming large as well is the Affordable Care Act, now set to enlarge the ranks of the commercially insured and to expand Medicaid coverage. Limited resources and the ever-growing costs of health care have also done their part. Viewed in this light, it would appear unlikely that the national drive to modify the patchwork of scope-of-practice state laws will abate any time soon.

In the eyes of many, SB 491 stands firmly on the side of the angels. Leading this camp is the Institute of Medicine (IOM), the supportive stance of which is articulated in its 2011 report The Future of Nursing: Focus on Scope of Practice. It was the position of the IOM that “now is the time to eliminate the outdated regulations… that limit the ability of nurses to practice to the full extent of their education, training, and competence.” The report further notes that “no studies suggest that advanced practice registered nurses are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope-of-practice regulations.”

A similar position was taken by the National Governors Association (NGA) in its 2012 report The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care. The NGA is on record stating that “states might consider changing scope-of-practice restrictions and assuring adequate reimbursement for their services as a way of encouraging and incentivizing greater NP involvement in the provision of primary health care.” Additional support was offered by the AARP (formerly the American Association of Retired Persons), which, in its Policy Book, called on states to “amend current scope-of-practice laws and regulations to allow nurses… to perform duties for which they have been educated and certified.” All told, these recommendations reaffirm present-day reality, wherein NPs enjoy practice autonomy in 17 states and the District of Columbia.

The above notwithstanding, the forces opposing the relaxation of extant scope-of-practice state statutes remain formidable. In the case of SB 491, the leading state-based opponent proved to be the California Medical Association, which took the position that “allowing nurse practitioners to practice without… physician supervision reduces patient safety and quality of care.” Similar concerns were raised by the California Academy of Family Physicians and the California Society of Anesthesiologists.

At the national level, SB 491 was opposed by the American Academy of Family Physicians, whose 2012 report Primary Care for the 21st Century argued that “substituting NPs for doctors cannot be the answer.… We must not compromise quality for any American and we don’t have to.” Comparable outlooks were enunciated by the American Medical Association, the American Academy of Pediatrics, and the American Osteopathic Association.

Nurse practitioners are thoroughly trained professionals who have earned a master’s level or doctoral degree and who have been certified by the Board of Registered Nursing. Currently about 180 000 strong and growing, NPs constitute a leading element of the national primary care fabric. By many accounts, the national drive to grant greater independence to NPs is here to stay. Continued opposition by “organized medicine” is equally likely. As for SB 491, it will have to wait until “California dreamin’ is becoming a reality.”

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About the author: Eli Y. Adashi, MD, MS (Eli_Adashi@brown.edu) is Professor of Medical Science at the Warren Alpert Medical School of Brown University in Providence, RI. A member of the Institute of Medicine, the Council on Foreign Relations, the Association of American Physicians, and the American Association for the Advancement of Science, Dr Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, and ethics. A former Franklin fellow, Dr Adashi served as a senior advisor on Global Women’s Health to the Secretary of State office of Global Women’s Issues during the Obama Administration.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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