Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. First, utilizing physician assistants rather than hiring additional physicians is a cost-effective way for practice owners to expand services, volume, and ultimately revenue. R. & Regs. Minimum of 104 weeks of supervision. Second, physician control over nursemidwife access to the market through supervision requirements provides a sound theoretical and practical mechanism by which such requirements could limit access to nursemidwife services, and womens health care services overall. Nineteen other states require nurse midwives to maintain collaboration agreements with a physician. We also find evidence of geographic disparities across the state in access to care by OBGYNs. First, we do not find evidence that the safety and quality of maternal and infant health care by nurse midwives is inferior to that of physicians. Most state laws, however, dont follow suit. Tradeoffs to consider in establishing an occupational restriction: The impact on access to health care services. How many Physician Assistants can a physician supervise? 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. Im in a rural area and there are not enough MDs to manage the population. https://doi.org/10.2202/15380637.1589. https://doi.org/10.1016/j.midw.2018.03.024. 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 United States or the jurisdiction in . This focus reflects the fact that such care is a primary focus of nursemidwives services and is the most complex and risky care that they generally provide. I mean I'm just a resident, I was kinda hoping you guys would have our back with this encroachment stuff, but I was also mostly kidding. 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 encounter could then be billed under the physician. Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. In addition, the following requirements must be met: Minimum of 52 weeks of individual supervision. In particular, such restrictions may be appropriate when (1)consumers would have difficulty observing and/or predicting the safety or quality of a given service and (2)there is risk of serious and irrevocable harm when a service is performed poorly. 1992. There also are strong practical reasons to expect that care by nurse midwives is less costly compared to OBGYNs. The IGRT codes assigned to a given level are listed in parentheses. In addition, health systems might interpret the responsibilities and parameters associated with the states physiciansupervision requirement differently. Family practice physicians are trained to deliver a broad range of primary care services, including, but not limited to, womens health care services. Nurse Midwives Salaries Are Generally Lower Than OBGYNs. Midwifeled Care and Obstetricianled Care for Lowrisk Pregnancies: A Cost Comparison.Birth, November. In the office setting, the incident-to guidelines described . Safety: Protection from risk and injury related to pregnancy, labor and delivery, and reproductive health. We believe these other safeguards could be more costeffective than the states physiciansupervision requirement at ensuring safety and quality. Overall, given the evidence that nurse midwives tend to minimize the unnecessary use of labor and delivery interventions, utilizing nurse midwives to a greater extent could increase the costeffectiveness of labor and delivery care. The agreement is between one NP on one physician. Aug 18, 2022. Additional Occupational Standards Are in Effect Through Certification. The survey found, however, that among mothers who would have preferred to use a midwife, 25percent reported experiencing health problems necessitating referral to a physician rather than a midwife. Health care providersprospective or practicingwho wish to perform in certain specialties regularly seek certification from nongovernmental agencies with the intent of demonstrating their proficiency in those specialties or procedures. 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. 2019. the supervision of a physician and surgeon, to determine care, treatment, and surgery by . Lastly, we bring together these components to discuss the potential impact of the states requirement on the safety, quality, accessibility, and costs of womens health care services in California. Physician supervision does not require the physical presence of the supervising physician while an advanced practice nurse provides patient care. I don't think I can get out of it without ruffling a lot of feathers. I do that now-a-days with my internist wife and her OB/GYN father. - - - Maryland No Yes. Since, in our assessment, the physiciansupervision requirement likely does not significantly improve the safety and quality of care, retaining the physiciansupervision requirement brings tradeoffs without producing any significant, tangible benefits. 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. Such interventions, when not medically necessary, can raise the cost of labor and delivery, either because there is an extra charge for the specific intervention or because the interventionparticularly in the case of cesareansresults in a longer length of stay at the hospital. Thus, nurse midwives earn about 60percent of what OBGYNs earn. Greater Variation and Uncertainty in Safety and Quality of Care by Nurse Midwives Outside of the Hospital. 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. 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. Can't wrap my head around this. Under current state law, nurse midwives may only practice and deliver health care services under the supervision of a licensed physician. Johantgen, Meg, Lily Fountain, George Zangaro, Robin Newhouse, Julie StanikHutt, and Kathleen White. The Impact of Full Practice Authority for Nurse Practitioners and Other Advanced Practice Registered Nurses in Ohio: Rand.Org. Examples of complications include labor that is not progressing at a safe speed, or for which the use of medical instruments (such as forceps or a vacuum) is necessary. This Analysis Examines Californias PhysicianSupervision Requirement. But, a delegated MD must be available in some capacity, whether in-person or by phone, to help out should the need arise. Planned OutofHospital Birth and Birth Outcomes. New England Journal of Medicine373(27): 264253. 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. 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. Physician and Resident Communities (MD / DO). K. : The number of persons to be supervised shall be limited to insure that an acceptable standard of medical care is rendered in consideration of the following factors: (a) Risk to patient; (b) Educational preparation, specialty, and experience of the parties to . The remaining five regions of the state have fewer practicing OBGYNs per 1,000 births. As such, the physical presence of a nurse midwifes supervisor is not required under state law during deliveries or other services provided by nurse midwives. (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.). Moreover, on the national level, research shows that states without occupational restrictions on nurse midwives, such as physician oversight, tend to have greater access to nursemidwife services. Perinatal Care and Cost Effectiveness: Changes in Health Expenditures and Birth Outcome Following the Establishment of a NurseMidwife Program.Medical Care17 (5): 491500. Moreover, we find that the requirement likely introduces tradeoffs in terms of decreasing access and raising the cost of care. Nurse Midwives May Only Practice Under the Supervision of a Physician. 2015. Physician assistants (PAs) are nationally certified, state-licensed advanced practice allied health professionals. This legislative session, California Governor Gavin Newsom signed AB 890, legislation that expands the existing scope of practice laws for nurse practitioners (NPs). (CCR 3502) As previously noted, occupational restrictions bring tradeoffs. Therefore, one way safety and quality might be improved would be to add definition and parameters to the states physiciansupervision requirement. (3) The supervising physician shall maintain a written authorization at the supervising physician's primary place of practice. Code 610-X-5-.08 (3)). This research finds that in states with fewer occupational restrictions on nurse midwivesincluding, but not necessarily limited to, physiciansupervision or collaborationagreement requirementsthere are proportionately more nurse midwives practicing and more births are attended by nurse midwives. State ScopeofPractice Rules Limit Nurse Midwives to Attending Normal Childbirths. Under California law, nurse midwives are authorized to be the exclusive attendant only for normal childbirths. PhysicianSupervision Requirement Unlikely to Significantly Improve Safety and Quality. how many midlevels can a physician supervise in california As Figure10 also shows, nurse midwives fill the gaps in womens health care in three of the five regions with relatively few OBGYNs: the Central Coast, San Diego, and the northern and Sierra counties. The state issues distinct licenses for different types of health care providers, including, for example, physicians and surgeons, dentists, and nurses. No extra time and no compensation, but liability seems minimal given coverage from the federal government. Nurse Midwives Comprise an Appreciable Share of the Women's Health Care Workforce in California There are over 2,000 OBGYNs in California, compared to more than 700 n urse midwives and almost 400 l icensed midwives. Patients might obtain fewer services to the extent they or their payers have to pay these higher costs. All allopathic physicians must receive a license from the Board prior to practicing medicine in California. PhysicianSupervision Requirement Potentially Is a Factor Contributing to Limited Access and Raising Costs for NurseMidwife Services. Copyright2022 ThriveAP Inc., All Rights Reserved, limit job opportunities and earning potential, less favorable job market for physician assistants, Finding Your Why with ThriveAP Speaker Steven Wei, EdD, MPH, MS, PA-C, DFAAPA, What is Deprescribing in Practice & How it Optimizes Patient Care, A1C Recommendations for Every Patient Situation, Discussion with ThriveAP Speaker: Jonathon Pouliot, MS, PharmD, BCPS. We recommend that the Legislature consider removing the states physiciansupervision requirement, while adding other safeguards to ensure safety and quality. If I am asked a question or need to examine a patient I do. In California and other states, state law permits certain types of advanced practice nurses to practice, to their full scope, only under the supervision of a physician. Fourth, we provide empirical evidence that access to nursemidwife services appears limited in California. Womens Health Care Providers Include Nurse Midwives. 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. First, as previously discussed, national research shows that states without occupational restrictions such as physician oversight have proportionately more nurse midwives and more births attended by nurse midwives. Medicare requirements; and 5. 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. Practice as a part of a health system (generally defined as a hospital, provider group, or health plan). This research generally finds no association between relatively more stringent occupational restrictions on nurse midwives and improved maternal and infant health outcomes. Thus, while there are five regions in the state with relatively limited access to womens health care services when only counting OBGYNs, just three regions of the state have relatively limited access (by this measure) once nurse midwives are counted as providers. 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. 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. 3. The potential alternative requirements include the following: The states physiciansupervision requirement for nurse midwives is intended to improve the safety and quality of womens health care. The supervising physician must also be able to discharge the chart review and site visit obligations specified by Board rule. Why not? Such safeguards could include requiring nurse midwives to: In an effort to ensure safety and quality, California state law places occupational licensing restrictions on who may provide childbirth and reproductiverelated health care services to women. In exchange for reviewing charts and prescriptions every few months, physicians bill nurse practitioners between $5,000 and $15,000 per year, according to a report by the California Health Care . 1 CMS requirement based on Section 144 of the Public Law 110-275, titled, "MedicareImprovements for Patients and Providers Act As previously discussed, physiciansupervision of nurse midwives is just one of a variety of policies and procedures currently in place with the intention of ensuring and improving the safety and quality of womens health care. We note that, provided the effectiveness (safety and quality) of care remains constant or improves, a reduction in costs necessarily increases its costeffectiveness. This provides further evidence suggesting that demand for nurse midwives exceeds their supply. In California, OBGYNs tend to practice disproportionately in certain regions of the state. For example, the recent high growth in earnings for nurse midwives suggests that demand for their services may exceed supply. A "shared" visit is when the level of service is determined by documentation from both the physician and a midlevel provider for a date of service. The maximum number is determined individually by each type of mid-level practitioner. Specifically, we assess whether this requirement is effective in ensuring and improving the safety and quality of childbirth without unreasonably impeding access or raising costs. (We note that state law is more prescriptive regarding physician supervision of nurse midwives who furnish medication.). Quality: A summary measure combining (1)patient satisfaction with pregnancy, labor and delivery, and reproductive health care and (2)the consistency of such care with clinical best practice guidelines. Potentially Positive Impact on Access to NurseMidwife Services in Hospital Settings. Effective November 4, 2012, M.G.L. But wait, there must be other motives. The type of mid-level provider; 2. 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. State rules establish minimum educational, clinical experience, and other standards in order for individuals to become licensed health care providers. In November 2022, California's nurse practitioner association approved rules that would allow for expanded scope of practice for NPs in the state. 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. Physician Supervision Is Not WellDefined California state law establishes few parameters on what physician supervision of nurse midwives must entail.