California, long considered a national trendsetter in health care policy, has a different reputation among mid-level practitioners around the country.
"California is actually on the bottom tier from our perspective," said Tay Kopanos, vice president of state government health policy for the American Association of Nurse Practitioners, based in Austin, Texas.
"California is one of the most restrictive in the country and is the only western state that doesn't allow full and open access to nurse practitioners, with the exception of Utah," Kopanos said. Utah has one relatively small regulatory hurdle, but all other western states allow nurse practitioners to treat patients without first checking with a physician, Kopanos said.
Many states, including California, are working on legislation aimed at changing the way nurse practitioners, physician assistants, pharmacists and other providers do their jobs. Many non-physician providers argue they could and should be doing more for patients than state regulations allow. These efforts are not new, but with Affordable Care Act deadlines looming, they're gaining more attention -- and in some cases more momentum.
"I think there's growing acceptance that something needs to be done and a lot of states are looking at this now with a new sense of urgency," said Stephen Ferrara, executive director of the Nurse Practitioner Association New York State.
"We have a couple bills in the works in New York that are similar to those in California and other states [that] are doing the same thing," Ferrara said. Two bills are in the legislative process in New York, where the first year of the Legislature's two-year session ended in June.
California is one of five states still in active session this summer with scope-of-practice legislation pending. Massachusetts, Minnesota, New Jersey and Pennsylvania also have bills in the works that could change state laws regulating nurse practitioners, pharmacists, physician assistants and other mid-level providers.
In California, four scope-of-practice bills are making their way through the state Legislature, which is in recess until Aug. 12. The last day for each house to pass legislation this year is Sept. 13.
Three bills by Sen. Ed Hernandez (D-West Covina) -- SB 491, SB 492 and SB 493 -- would expand the scope of practice for nurse practitioners, optometrists and pharmacists in California. A bill by Sen. Fran Pavley (D-Agoura Hills) -- SB 352 -- would allow physician assistants and other providers to oversee work by medical assistants.
Stakeholders Surprised California 'Lags Behind'
An online map by the American Association of Nurse Practitioners shows how states fall into one of three categories of nurse practitioner regulations:
- Full practice states, which allow nurse practitioners to evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments (including prescribing medication);
- Reduced practice states, which limit the ability of nurse practitioners to engage in at least one element of nurse practitioner practice. These states require a regulated agreement with a physician or some other outside health discipline in order for nurse practitioners to provide patient care; and
- Restricted practice states, which require supervision, delegation or team management by a physician or some other outside health discipline for nurse practitioners.
The Institute of Medicine and National Council of State Boards of Nursing recommend states adopt the full practice model.
California and 12 other states -- mostly in the South -- fall into the restricted-practice category.
"When I talk to other stakeholder groups around the country, they are all very surprised that California in this particular area lags behind the rest of the nation," Kopanos said. "California was one of the first states to embrace the Affordable Care Act and Medicaid reform and the state has usually been proactive with making the most of resources, so it seems odd to some that California is so restrictive," Kopanos said.
"We're optimistic that legislators in many states -- including California -- will listen to the voice of reason; however we continue to face very stiff opposition in many states," Kopanos said.
Kopanos said nurse practitioners in California have one lobbyist working to get new regulations passed in Sacramento.
"The last time we looked there were 13 lobbyists working to stop that legislation," Kopanos said.
Some of those lobbyists work for the California Medical Association, the state's largest trade group representing physicians.
CMA is opposed to Hernandez' bills seeking to change regulations for nurse practitioners and optometrists and has taken a neutral stance on the bill dealing with pharmacists.
"Our overarching concern in scope-of-practice issues is to make sure that quality of care is not compromised and that all allied health professionals are working to the top of their license," CMA spokesperson Molly Weedn said.
Who Should Lead the Team?
Many states, including California, are moving toward team-based delivery of health care. Part of the legislative jockeying for position in statehouses across the country has to do with who will lead the teams.
The national nurse practitioner organization believes nurse practitioners should be able to lead teams. CMA does not agree.
"I don't know that we're behind the curve on this issue," Weedn said. "We're working on a team-based model of care, and we think teams have to be led by a physician. The notion is to have the person most trained and qualified to be leader of that team. That's not to say the physician is always hands-on, seeing the patient every time. It's not necessary to micro-manage, but we feel strongly that teams should be physician-led," Weedn said.
"Teams need to be centered around the needs of the patient, not the needs of a physician," Kopanos said. "We need to remove the stipulation in law that says a physician still needs to be present to have care delivered."
"In Oregon, a nurse practitioner can manage care completely from diagnosis to prescribing treatment, but step over the border into California and barriers are thrown up that prevent care," Kopanos said. "We are concerned that when legislators begin setting up state-based requirements for team care, they might be shortchanging everyone by requiring a physician to be the head of every team."
"We're not sure that's the best way to do it," Kopanos said. "We can see circumstances in many states from Kentucky to California, where having somebody other than a physician -- maybe a nurse practitioner or maybe some other provider -- heading teams in underserved areas would be best for patients."
"That's what we think should be the driving force behind states' decisions -- what's best for patients," Kopanos said.