Figure7 summarizes our assessment of academic research findings as they pertain to the care provided by nurse midwives and physicians, mostly in hospital settings. The IGRT codes assigned to a given level are listed in parentheses. Enacting policies to increase access to nursemidwife services could increase access to womens health care services, generally maintain safety and quality, and lower costs. The determination is not made on the number of people. 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. Note, as well, that supervision requirements apply only to the technical component (the actual test administration . 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. Altman, Molly R., Sean M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Kenn B. Daratha. Personal supervision: A physician must be in attendance in the room during the procedure's performance. This research generally finds no association between relatively more stringent occupational restrictions on nurse midwives and improved maternal and infant health outcomes. This section turns to California, informed by the national research findings. 2023 State by State Scope of Practice: Physician Assistant. The following bullets give a highlevel summary of how Californias scopeofpractice rules pertain to physicians, nurses, and advanced practice nurses. Therefore, we find that Californias supervision requirement for nurse midwives is unlikely to improve safety and quality for lowrisk pregnancies and births. As described below, physicians can be hesitant to provide statutorily required supervision, or can require compensation to provide such supervision. https://doi.org/10.2105/ajph.93.6.999. This added time and the associated financial commitment come with significant costs for OBGYNs, often in the form of student loans. Moreover, as described in the next section, we identify a number of other qualityassurance mechanisms that are widely utilized in the states health care system that likely play an important role in ensuring the safety and quality of health care services in the state. The supervising physician and PA/NP/CNM are both enrolled as Medi-Cal providers pursuant to Article 1.3 (commencing with Section 14043) of Chapter 7, Part 3 of For example, in Georgia, a physician may enter into a supervisory agreement with up to eight NPs, but only actively supervise . For a better experience, please enable JavaScript in your browser before proceeding. Given these tradeoffs, occupational restrictions should be employed by policymakers with scrutiny and care, and be reassessed as evidence arises regarding impacts on safety, quality, access, and cost. In California, OBGYNs tend to practice disproportionately in certain regions of the state. Third, the ability of nurse midwives to compete with other providers on cost is impeded by the higher costs associated with these payments. PLOSONE13 (2): e0192523. 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. Of the ten states that do specify the number of physicians that a single MD can supervise or collaborate with, the number ranges from two to eight. https://doi.org/10.1016/j.whi.2011.06.005. 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. https://doi.org/10.1056/nejmsa1501738. Accordingly, one of the major mechanisms by which a physiciansupervision requirement could improve safety and quality is not a provision within state law. The supervising physician must also be able to discharge the chart review and site visit obligations specified by Board rule. Minimum of 104 weeks of supervision. Removing Requirement Could Encourage the Establishment of Independent Clinics and Freestanding Birth Centers. 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. However, one reason likely is that births attended by nurse midwives are not always recorded as such (for example, they are recorded as having been attended by a physician). 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. The states physiciansupervision requirement could impede access in three ways. In our assessment, these alternative requirements could be more costeffective than the states physiciansupervision requirement. 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. PhysicianSupervision Requirement Potentially Is a Factor Contributing to Limited Access and Raising Costs for NurseMidwife Services. Which means they are also accountable for the clinical care they provide. California Is Among 23 States to Require Physician Oversight of Nurse Midwives. This means the physician is required to review a certain percentage of an APRN's charts and/or prescribing practices. OBGYNs and nurse midwives overwhelmingly practice in hospitals, while licensed midwives primarily practice outside of hospital settings, such as freestanding birth centers. Bottom line, working with mid-levels carries risks. As licensed clinicians, they must obtain a license in their state of practice before seeing patients. . 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. 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. December 13, 2022. After finishing 36 months of GME, physicians . The physician and midlevel each personally perform a portion of the visit. 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. 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. Effective November 4, 2012, M.G.L. There is a big range state by state of chart . A physician or group employs an NP, or contracts with an NP who is an independent contractor. 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. 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. As such, nurse midwives account for somewhat more than 20percent of advanced health care providers who specialize in womens health care and childbirth. In 39 states, there are limits on the number of physician assistants a physician can supervise or with whom a physician can collaborate. Other qualityassurance mechanisms and practices, in addition to the licensure and certification of professionals, are broadly utilized for ensuring highquality and safe health care. The Federal Trade Commission, in its 2014 report, Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses, voiced this concern, stating that physiciansupervision requirements establish physicians as gatekeepers who control [advanced practice nurses] independent access to the market. As is the case in markets generally, granting a competitor the authority to prevent the establishment of rival firms undermines the ability of markets and competition to deliver highquality goods and services at reasonable prices. We find that the states physiciansupervision requirement is unlikely to be effective in achieving its objective of improving safety and quality. 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. 2018. $500 per month per NP/PA in a small hospital group. The Impact of MidwiferyPromoting Public Policies on Medical Interventions and Health Outcomes.Advances in Economic Analysis & Policy6 (1). Im going to disengage from this thread and enjoy my days off! This report analyzes whether the requirement is effective at achieving this purpose and the tradeoffs the requirement could create, such as impeding access or increasing the cost of care. If I am asked a question or need to examine a patient I do. https://www.ncbi.nlm.nih.gov/pubmed/1635724. Minimum of 13 weeks of individual supervision by an LCSW. There also are strong practical reasons to expect that care by nurse midwives is less costly compared to OBGYNs. (As previously noted, in California, 98percent of nurse midwifeattended births occur at the hospital.) 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. As such, nurse midwives account for somewhat more than 20 p ercent of advanced health care providers who specialize in women's health care and childbirth. Number of Nurse Practitioners That May Be Supervised by One Physician: Under California Business and Professions Code section 2836.1(e), a physician may supervise up to four (4) nurse practitioners (NPs) that furnish drugs or devices. Id love to only have MDs in the practice but theres no way we could serve the community we do without midlevels. Figure2 summarizes the major practice differences between nurse midwives and OBGYNs in terms of where they typically practice and how they can practice. If you are . https://doi.org/10.1371/journal.pone.0192523. This limit is one supervising physician to four advanced practice nurses who furnish medications. Accordingly, we recommend that the Legislature consider removing the states physiciansupervision requirement for nurse midwives, while adding other alternative safeguards to ensure safety and quality. These alternative safety and qualityassurance requirements would be in addition to those that are currently imposed as conditions of licensure and certification to practice as a nurse midwife. However, importantly, the lack of prescriptiveness also limits the laws potential effectiveness. While a variety of provider types assist in childbirth and womens health care services more broadly, several provider types specialize in this domain of care. Your email address will not be published. How Does Provider Supply and Regulation Influence Health Care Markets? 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:. In 2017, nurse midwives were recorded as attending almost 50,000 births in the state, or somewhat more than 10percent of the 470,000 births in the state that year. By Moira K. McGhee. Resident here. The law limits a physician to supervise no more than four PA's, except as provided in Business and Professions Code (BPC) section 3502.5. https://doi.org/10.1016/j.whi.2017.01.002. Their licenses and malpractice insurance covers them. Several research studies explore whether states with less stringent occupational restrictions on nurse midwives experience worse birth outcomes. Tradeoffs to consider in establishing an occupational restriction: The impact on access to health care services. If it's asked, just say no. Given the absence of a physicalpresence requirement, in California and other states, advanced practice nurses may practice far away from their physician supervisors. 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. OBGYNs, on the other hand, must attend 12years of postsecondary education and training, including residency. The law essentially created two new categories of nurse practitioners. Similarly, women in labor requiring an emergency cesarean section must be referred to a physician. Ease of accesshaving sufficient numbers of available health care providers throughout the stateshould be considered in conjunction with the effects on safety and quality. 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. 2003. 8.12. There is no state requirement that nurse midwives practice within the same geographic vicinity as their physician supervisor. Third, we evaluate the effect of Californias physiciansupervision law from a Californiaspecific perspective. 4. 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. 2014. 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