Required fields are marked *. Academic researchers have extensively explored how hospitalbased labor and delivery care by nurse midwives for women with lowrisk pregnancies compares to such care by OBGYNs and other physicians. 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. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. Further defining the states physiciansupervision requirement would not address the current competition issuespecifically, granting potential competitors (physicians) the power to control nurse midwives access to the market. Third, we find empirical evidence that access to nursemidwife servicesand potentially womens health care services overall, at least in certain regions of the stateis limited. Im going to disengage from this thread and enjoy my days off! . 2018. In many cases, physician supervision additionally can involve chart reviews and/or other types of consultation whereby the supervising physician reviews and advises upon advanced practice nurses patient care decisions during and/or after patient treatment. Removing the states physiciansupervision requirement could increase access to nursemidwife services, including in the rural and inland areas of the state that today have relatively more limited access to womens health care services. Major Practice Differences Between Nurse Midwives and OBGYNs, Provide primary care and family planning services, Deliver prenatal, postpartum, and newborn care, Attend births experiencing complicationsa, Deliver with the use of medical instruments. Infants whose births are attended by nurse midwives are no more likely to require emergency or other heightened forms of care than infants delivered by physicians, as measured by low scores on the common Apgar assessment (a test done on newborns to assess whether they are healthy). (We note that state law is more prescriptive regarding physician supervision of nurse midwives who furnish medication.). 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. Geographic Disparities in Access to OBGYNs. 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. Later in the report, we describe how nurse midwives could serve to fill the gaps in access in the more rural and inland regions of the state. 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. Potential to impair rather than improve the quality of health care services. Therefore, one way safety and quality might be improved would be to add definition and parameters to the states physiciansupervision requirement. On Balance, Uncertain but Likely Limited Impact on Safety and Quality Outside of Hospital Settings. The term refers primarily to physician assistants and nurse practitioners. They shared an infographic that noted that 58.8% of California NPs offered primary care, in comparison to only 16.7% of physicians. In 28 states plus the District of Columbia, nurse practitioners can practice much . Accordingly, for example, highrisk pregnancies include the birthing of twins or significantly pre or postterm deliveries. The last section of this report provides our concluding assessment and includes our recommendations. While providing primary care services is within the scope of practice of nurse midwives, the focus of this reportand the research we citeis on the care provided to women and their infants related to pregnancy and childbirth. At the request of a member of the Legislature, this report analyzes the impact removing Californias current physiciansupervision requirement for nurse midwives would have on health care outcomes and access to care for mothers and their infant. of a physician or supervising NP, or while employed by a clinic or hospital with a medical director who is a licensed physician; see ME Statute 32-2102(2-A)(C). cA significant portion of these residency training hours relate to the diagnosis and treatment of conditions outside of the scope of practice of nurse midwives. Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. 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. Providers May Perform Services Within Their Scopes of Practice. This legislative session, California Governor Gavin Newsom signed AB 890, legislation that expands the existing scope of practice laws for nurse practitioners (NPs). Tradeoffs to consider in establishing an occupational restriction: The impact on access to health care services. PhysicianSupervision Requirement Unlikely to Significantly Improve Safety and Quality. The physician's risk and reward are high. 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. Robust Growth in Earnings Suggests Demand for NurseMidwife Services May Exceed Supply. CostEffective: Effectiveness or value in terms of safety, quality, and accessibility of health care in relation to the costs of such care. Effective July 1, 2011 . For example, infant mortality rates and other infant outcomes are comparable for nurse midwives and physicians. 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. State Sets Licensure Standards. Requiring physician supervision of nurse midwives can be appropriate if theory and evidence show: The safety and/or quality of health care provided by nurse midwives appears deficient compared to that of physicians. 0880-6-.02(7-9).) Moreover, this approach would make the tasks associated with supervision more burdensome, potentially making supervision less attractive to physicians, and thereby further impeding nurse midwives ability to practice. The American Academy of Physician Assistants suggests that state laws addressing the supervision of PAs avoid limiting the number of physician assistants that my be supervised by a single MD. https://doi.org/10.1111/birt.12464. Mid-level practitioners include CRNPs, CNMs and PAs. In this section, we describe empirical evidence specific to California that suggests nursemidwife services might be undersupplied relative to the demand for their services, thereby suggesting access to their services could be limited. Mid-Level Practitioners Authorization by State Pursuant to Title 21, Code of Federal Regulations, Section 1300.01(b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the Below are several such mechanisms and practices: There are theoretical and practical reasons to suggest that the states physiciansupervision requirement impedes nurse midwives ability to establish independent practices, as discussed further below. Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. Second, states with physiciansupervision or very similar requirements do not have superior maternal and infant health outcomes. Starting in January, nurse practitioners who have completed 4,600 hours or three years of full-time clinical practice in California can apply for the first category. However, there are always costs. This allows, for example, varied levels of direct supervision for lesser and more experienced nurse midwives. consultation with a supervising physician, approve, sign, modify, or add to a plan of treatment or plan of care. Bureau of Labor Statistics data show that between 2013 and2018 nurse midwives average salaries increased at a faster rate than those for both OBGYNs and health care practitioners generally in California. There are more than 290,000 nurse practitioners in the country, and about 27,000 of them practice in California.. Midwifeled Care and Obstetricianled Care for Lowrisk Pregnancies: A Cost Comparison.Birth, November. Colorado Medical Board (CMB) Rule 400 outlines the rules and regulations regarding the licensure of and practice by PAs. 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). The regulation defines the levels of physician supervision for diagnostic tests as shown below. I dont sign NPs notes. Removing the physiciansupervision requirement for nurse midwives would remove a barriernamely, obtaining a physicians consentthat currently impedes nurse midwives ability to establish womens health clinics or freestanding birth centers, as well as their ability to attend home births. Starting Jan. 1, 2020, DOs and MDs with fewer than 36 months of GME will be required to obtain a postgraduate training license (PTL). This research generally finds no association between relatively more stringent occupational restrictions on nurse midwives and improved maternal and infant health outcomes. We agree with the Federal Trade Commissions finding that physiciansupervision requirements likely impede access and raise costs by giving physicians control over nurse midwives ability to independently deliver services. As with licensure, to obtain certification, providers typically must meet minimum education and/or work experience requirements and pass formal assessments such as a qualification exam. Occupational Restrictions Can Be Appropriate Insofar as They Achieve a Public Purpose Occupational restrictionssuch as licensure, scopeofpractice regulations, and supervision requirementscan be appropriate insofar as they achieve a public purpose without imposing unreasonable tradeoffs. (As previously noted, in California, 98percent of nurse midwifeattended births occur at the hospital.) We recommend that the Legislature consider removing the states physiciansupervision requirement, while adding other safeguards to ensure safety and quality. https://doi.org/10.1016/j.whi.2016.02.003. Your email address will not be published. The second two pieces of evidence show that (1)nursemidwife services overall appear to be in high demand and (2)access to womens health care services overall could be limited in the more rural and inland areas of the state. For example, as shown in Figure10, the Greater Bay Area has nearly three times as many OBGYNs per 1,000 births than the Inland Empireand over 50percent more than the statewide average. Third, we discuss the theoretical and practical reasons for how the states requirement could impede access to and raise costs for nursemidwife services. The states physiciansupervision requirement could impede access in three ways. For freestanding birth center and home births, referral typically will entail transportation to a hospital. Effective November 4, 2012, M.G.L. States With Less Stringent Restrictions on Nurse Midwives Independent Practice Do Not Experience Worse Birth Outcomes. In the absence of a physiciansupervision requirement for nurse midwives, the Legislature might want to consider alternative requirements for nurse midwives that could serve the same intent of ensuring the safety and quality of their services. 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. Several Provider Types Specialize in Womens Health Care. R. & Regs. 4. Childbirths that feature relatively minor lacerations, or for which minor surgical cuts are made to prevent lacerations, are considered normal and are, therefore, within the scope of practice of nurse midwives. 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. Second, we summarize several other qualityassurance mechanisms applicable to the provision of womens health care that are widely utilized or present in the health care sector. 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? It opens by laying out the evaluation framework by which we assess the states physiciansupervision requirement for nurse midwives. States may also place additional terms to guide these relationships. Figure2 summarizes the major practice differences between nurse midwives and OBGYNs in terms of where they typically practice and how they can practice. Physicians Sometimes Ask for Payment in Return for Supervision. State law does not further define the requirements of physician supervision for nurse midwives, except as specifically related to the furnishing (prescribing) of medication, the repair of minor lacerations, and the making of small cuts to prevent lacerations (episiotomies). Authority has been delegated by the supervising physician to provide the covered benefit or service pursuant to their scope of practice. 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. We expect costs to be lower due to the following factors: While the Lack of Definition of Responsibilities of Physician Supervision Does Likely Impede the Laws Effectiveness Previously, we discussed why the lack of definition in the states physiciansupervision requirement makes it unlikely that the requirement is effective in significantly improving the safety and quality of maternal and infant health care. Ratio: On-Site visits required: PA Supervision: Primary Supervising Physician 1:2. 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. 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. This means a physician could have up to 8 mid-level practitioners (4 APRN's and 4 PA's) in a group practice and 6 mid-level practitioners (4 APRN's and 2 PA's) in a solo practice, at any one time. They must do so, however, in accordance with standardized procedures that are developed and approved in collaboration with their supervising physicians. This provides further evidence suggesting that demand for nurse midwives exceeds their supply. For example, one study of 12million births nationwide showed that in states that do not require physician supervision or collaboration agreements, the proportion of all births attended by nurse midwives is nearly 60percent higher than states with such requirements. Potentially Positive Impact on Access to NurseMidwife Services in Hospital Settings. The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates. Obstetrics & Gynecology 126 (4): 71623. Through such practices, nurse midwives can build their own patient bases, with whom they can perform an array of womens health primary care services, and also assist through labor and delivery. Administrator: Hi, we would like to triple your workload and also have you train your replacements since your education is valuable making you too expensive. Figure4 defines the key terms of our framework. In general, occupational restrictions can be an appropriate means to implement the broad public purpose of ensuring and improving the safety and/or quality of a given service. Occupational restrictions may be appropriate when: Consumers would have difficulty observing and/or predicting the quality or safety of a given health care service. Midlevel practitioners are an increasingly important part of how we deliver primary care in North Carolina. 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. Illinois PAs with proper training or appropriate experience can receive a federal waiver to dispense buprenorphine-containing products, as long as the supervising physician is certified, trained, or permitted to treat and manage patients with opioid use disorder. Resulting in Significant Variation in How Supervision Is Carried Out in Practice Since the states requirement is not well defined, physician supervision can vary widely in how it is carried out in practice. The following table outlines the number of physician assistants a physician may supervise at one time in states with more restrictive oversight requirements. 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. 0880-02-.18(7-9) and Tenn. Comp. For nurse midwives, a supervisor must be a physician with a current practice or training in obstetrics. In effect, we have been tasked with analyzing whether a specific occupational licensing requirement for nurse midwivesin this case, the physiciansupervision requirementis meeting its intended safety and quality objectives without significantly decreasing access to health care services (or increasing cost). Track Your Hours monitors all of the supervision requirements for your current status. Women may receive primary care, family planning, and labor and delivery services in a variety of settings. 225 ILCS 95/7.5 The agreement is between one NP on one physician. This limit is one supervising physician to four advanced practice nurses who furnish medications. The practice would much prefer more MDs as well because if youre not supervising others you can see more patients. The following bullets give a highlevel summary of how Californias scopeofpractice rules pertain to physicians, nurses, and advanced practice nurses. Supervising mid-level providers: Good or bad thing? 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. Yang, Y. Tony, Laura B. Attanasio, and Katy B. Kozhimannil. "Immediate availability of the supervising physician to the physician assistant for necessary consultations." "Personal and regular review within 10 days by the supervising physician of the patient records upon which entries are made by the physician assistant." Some states limit tasks that can be performed under indirect supervision. Survey Data Indicate a Higher Proportion of Women Want Than Receive Midwife Services. (4) The supervising physician shall provide a copy of the signed, written authorization to the nurse practitioner or nurse midwife. There is no state requirement that nurse midwives practice within the same geographic vicinity as their physician supervisor. They are obstetricians and gynecologists (OBGYNs), nurse midwives, and licensed midwives. 2015. Californias physiciansupervision requirement for nurse midwives is intended to improve the safety and quality of womens health care. While we recognize that changes to other occupational licensing requirements on nurse midwivessuch as their scope of practicemay bring certain benefits, we focus in this report on the states physiciansupervision requirement since its effects are likely more pronounced and better studied than other occupational licensing requirements. After finishing 36 months of GME, physicians . I am currently the only physician at our site. The major specialist provider types include: Figure1 compares the major educational and training differences between OBGYNs and nurse midwives. 2015. https://www.rand.org/pubs/research_reports/RR848.html. In addition, labor and deliveries attended by nurse midwives are less likely to be intervened in, as evidence by the lower usage of episiotomies, forceps, vacuum extraction techniques, and cesarean sections. Physician assistants must continue . One study we reviewed specifically examines whether physiciansupervision or collaborationagreement requirements are associated with improved birth outcomes. If I am asked a question or need to examine a patient I do. Consistent with the physician assistant title, PAs must practice with physician supervision. Three types of providers specialize in health care related to childbirth and womens reproductive health. Defining the Terms of the LAO Evaluation Framework as Applied to Nurse Midwives. State Scope of Practice Laws, NurseMidwifery Workforce, and Childbirth Procedures and Outcomes.Womens Health Issues26(3):26267. Drawing on national researchwhich, among other things, does not find significant differences in the quality of care between states that do and do not have this requirementwe find that this requirement is unlikely to achieve this purpose. 2014. 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. For example, the states physiciansupervision requirement places no responsibilities on supervising physicians to perform qualityassurance activitiessuch as periodic clinical chart reviewswith their nursemidwife supervisees. 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. 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. In addition, we find that removing the requirement could improve the costeffectiveness of womens health care services by increasing utilization of a less costly but capable provider and potentially lowering the medically unnecessary use of certain costly procedures, such as cesareans. Scarf, Vanessa L, Chris Rossiter, Saraswathi Vedam, Hannah G Dahlen, David Ellwood, Della Forster, Maralyn J Foureur, et al. 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. But, a delegated MD must be available in some capacity, whether in-person or by phone, to help out should the need arise. 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. 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. Im so tired of the argument, well without mid levels we wouldnt have enough providers to see all of the patients.. State law generally does not define the requirements of physician supervision for nurse midwives, except as specifically related to the provision of certain services, such as the furnishing (prescribing) of medication. Their roles vary from state to state, based on the specific statutory provisions of . The Board limits a physician to supervise a total of 360 "full-time equivalent" (FTE) hours per week of mid-level practitioners. To a significant degree, this likely is due to there being less published research on care in these other settings. Yes. Medicare requirements; and 5. The article also mentions how difficult it is to find information about specific cases. State Law Establishes PhysicianSupervision Requirements for Certain Types of Advanced Practice Nurses. These NPs fully understand the care needs and interventions required to help a patient in their health journey, and they can safely practice without physician supervision, Chan said. Such Impediments to Nurse Midwives Ability to Establish Independent Practices Could Impede Access. 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. 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. We believe these other safeguards could be more costeffective than the states physiciansupervision requirement at ensuring safety and quality. R. & Regs. Some scopeofpractice rules are established in state law while others are selfdetermined by individual health care systems and/or professional societiessuch as the American Board of Family Medicine. When the supervision rules were created in the late 1990s, many advanced diagnostic imaging services (MRI, CT, and PET) were in their relative infancy, and the mandate that only physicians could supervise these tests was accepted as appropriate. CMS released Transmittal 205, amending Chapter 11 of the Medicare Claims Processing Manual (Hospice Claims) to provide guidance to hospices on when they can bill for nurse practitioner services.2. 1 CMS requirement based on Section 144 of the Public Law 110-275, titled, "MedicareImprovements for Patients and Providers Act All allopathic physicians must receive a license from the Board prior to practicing medicine in California. Board regulation 263 CMR 5.05 (2) containing the same limitation was deleted by emergency regulation effective May 29, 2013. 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