Do nurse practitioners need a supervising physician in california

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Late Tuesday, California Gov. Gavin Newsom signed a bill that will significantly ease restrictions on nurse practitioners (NPs), nurses with advanced degrees who can diagnose symptoms, treat patients and prescribe medicine. Prior to reform, California was one of 22 states that barred NPs from working, or even volunteering in hospitals, unless they were supervised by or collaborated with a physician. 

But under the newly signed AB 890, NPs who have been in practice for at least three years, will finally be able to operate independently, without physician supervision. Once the new law takes effect in 2023, California will become the 16th state to grant NPs with full practice authority following a transition period. Another 13 states let NPs practice independently immediately after becoming licensed. 

“Physician supervision requirements are completely unnecessary and are hurting states’ efforts to respond to Covid-19,” said Institute for Justice Senior Attorney Erica Smith, who submitted testimony in favor of the bill. “Nurse practitioners want to be able to volunteer now, but they are getting caught in red tape.”

Nurse practitioners across the country have struggled to find supervising physicians, either because of limitations in their medical malpractice insurance, or an unwillingness to take on additional responsibilities during this chaotic time. In addition, NPs must often pay physicians thousands of dollars for supervision.

Yet research from numerous organizations across the political spectrum, including the Brookings Institution and the American Enterprise Institute, have found that empowering NPs could have significant benefits for health care efficiency without sacrificing quality of care. Instead, the evidence suggests that restrictions on nurse practitioners serve only to raise prices and protect doctors from competition. 

With many hospitals in desperate need of medical personnel during the Covid-19 pandemic, it may also cost lives. For this reason, multiple organizations and individuals, including the U.S. Secretary of Health and Human Services, have called on states to lift restrictions on NPs during the pandemic.

This article was updated on 10/20/2020 to include a statement by the American Association of Nurse Practitioners.

California has joined the roster of Full Practice Authority (FPA) states, granting nurse practitioners full practice authority. 

 The authority was granted by California’s governor Gavin Newsome, who passed bill AB-890 into legislature earlier this week. The bill was approved on September 29th and the move makes California the 23rd state in the U.S. to offer FPA to its nurse practitioners when it goes into effect in January 2023. 

Other states that grant FPA include Alaska, Arizona, Colorado, Connecticut, District of Columbia, Guam, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Northern Mariana Islands, Oregon, Rhode Island, South Dakota, Vermont, Washington and Wyoming.

What Full Practice Authority Means

If you’re wondering exactly what FPA means, the American Association of Nurse Practitioners (AANP) explains that the designation means that NPs practicing in those states do not have to partner with a physician and do not have oversight by the state’s medical board (like doctors do). FPA sees NPs as fully independent practitioners under their own umbrella--they’re not doctors, so they don’t follow doctor’s rules for oversight, but they can practice independently. 

According to the AANP, data from FPA states show that NPs are more likely to practice in rural and underserved areas and offer quality care with high safety standards. On the other hand, however, states that do not offer FPA are more likely to have “geographic health care disparities, higher chronic disease burden, primary care shortages, higher costs of care and lower standings on national health rankings.”

Along with increased access to care, the AANP also lists these additional benefits to having full practice authority NPs: 

• Streamlined care. Allowing FPA removes the delay in care that can occur when an NP must consult or work with a physician to deliver necessary care. 
• Cost savings. NPs are more cost-effective in general, but FPA also avoids unnecessary service duplication. 
• Upholds patient autonomy. Some patients prefer to work directly with NPs, and may even feel more comfortable sharing health care concerns with primary care NPs. 

In California’s case, the bill outlines exactly how FPA will be granted and run through the California Board of Nursing. It requires the board define the minimum standards necessary for a NP to transition to independent practice, and once that has been met, the NP can perform specific functions that include “ordering, performing, and interpreting diagnostic procedures, certifying disability, and prescribing, administering, dispensing, and furnishing controlled substances.” 

Closing the Provider Gap

As we have seen, one of the leading arguments in favor of FPA NPs is to provide necessary health care to people and areas where primary care physician shortages are common. (Keeping in mind that studies have shown that the quality of care delivered by NPs is equitable, and in some cases, better, than physician-delivered care.) 

In fact, the California Association for Nurse Practitioners (CANP) promoted bill AB-890 specifically as a way to close the primary care provider gap in the state. They shared an infographic that noted that 58.8% of California NPs offered primary care, in comparison to only 16.7% of physicians. 

This, along with the fact that they state more than 11 million Californians live in an area with primary care physician shortages mean that NPs offering full-practice primary care can help meet the primary care needs of many, many people, 

California NPs React

With the bill’s passage, CANP shared the news on their Facebook page, writing: “Thank you Gov. Newsom and Assemblymember Jim Wood for your leadership and action on this important issue. AB 890 will help #ClosetheProviderGap and allow millions of Californians access to the high-quality health care they so desperately needed.”

And both current and future NPs also celebrated the news, speaking to the healthcare disparities they believe granting FPA will allow them to work to solve. 

“As a California nursing student/future NP, I am SO thankful to CANP for the hard work that went into making this vision a reality,” wrote Andy Rohrer, President of the California Nursing Students' Association, with a membership of over 6,000 nursing students who diligently supported this measure, “We see what this means for our future careers, for our patients and the level of care we can provide to them, and the profession of nursing in California. Thank you for paving the way ” 

Meanwhile, veteran NPs also chimed in. “I am so excited!! I've been an NP for 25 years. I gave up on seeing this day. Thank You CANP and Jim Wood!!!,” commented Bonnie Tromello. 

The American Association of Nurse Practitiones (AANP) Responds

The American Association of Nurse Practitioners® (AANP) issued the following statement regarding California Assembly Bill 890 (AB890). The legislation amends practice regulations governing nurse practitioners (NPs) in the state of California.

“AANP does not support AB890 as amended. While NPs across the state worked tirelessly to advocate for a bill that would expand patient access, remove barriers to NP-delivered health care and strengthen provider choice for the residents of California, the final legislation has taken on a flood of problematic amendments that add both significant cost and unnecessary red tape to NP practice in the California health system,” said AANP President Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP. “Further, the final legislation has erected significant anti-competitive barriers for NPs working to increase health care access — all at a time when the state faces escalating health care costs and 7.5 million Californians lack sufficient access to primary care.”

For decades, California has lagged behind other western states in providing patient choice and utilizing its health care workforce to capacity. Under existing state law, California makes it illegal for NPs to provide the full scope of services that their graduate education and clinical training prepared them for, absent a physician “permission slip” or oversight. No other western state creates such practice barriers for NPs or patients seeking NP-delivered care. California’s so-called “solution,” the flawed AB890, would establish a cascading set of new restrictions on NP practice that would maintain California’s position among the most heavily regulated and restrictive in the nation.

“In its current form, AB890 is an untenable solution to the challenges facing California patients seeking health care choice and access. While patients in 22 states and the District of Columbia experience the benefits that come with providing NPs full practice authority, California is moving in the opposite direction, making it harder for NPs to open practices and creating a new, confusing and costly patchwork of regulations. The proposed regulations targeting NP businesses directly undercut the ability of AB890 to close the gap in access and create new points of access to health care. These regulations would also impact the ability of NP practices to hire other NPs, see more patients, and grow their businesses. This would make California less attractive and less competitive to recruit NP primary care practices — one of the key ingredients to increasing rural and underserved health care access,“ said AANP Chief Executive Officer David Hebert, JD. “The legislation has several other shortcomings, and the requirements around a state-based certification exam is just one more example. National board certification exams are the gold standard — not just for NPs, but for dentists, physicians and other health professionals. Creating a unique California exam would be a duplicative and costly process, and it has already been executed by well-established NP national certification boards that are overseen by the National Commission for Certifying Agencies or the American Board of Nursing Specialties. NP national boards are recognized in all other jurisdictions and by the federal government. This is the epitome of unnecessary regulation. The hyperregulation in AB890 and the added costs it would bring would keep health care in California from truly moving forward. In short, AB890 is more problematic than the policy it is trying to solve. While we thank NPs for their efforts and the policymakers who sought to bring full practice authority and more choice to the residents of California, the amendments to AB890 move the state in the wrong direction.” 

AANP will continue to join with policymakers and institutions at the state and federal levels to call for removing barriers to patient access to NP care. In 22 states, the District of Columbia, and two U.S. territories, patients have full and direct access to NPs, strengthening access to primary care. The remaining states maintain barriers that limit patients’ access to care. Eight of the 10 healthiest states have eliminated these outdated regulations and allow NPs to practice to the full extent of their education and training, while the 10 least healthy states all restrict NP practice. 

The American Association of Nurse Practitioners (AANP) is the largest professional membership organization for nurse practitioners (NPs) of all specialties. It represents the interests of the more than 290,000 licensed NPs in the U.S. AANP provides legislative leadership at the local, state, and national levels, advancing health policy; promoting excellence in practice, education, and research; and establishing standards that best serve NPs' patients and other health care consumers. As The Voice of the Nurse Practitioner®, AANP represents the interests of NPs as providers of high-quality, cost-effective, comprehensive, patient-centered health care. To locate an NP in your community, visit npfinder.com. For more information about NPs, visit aanp.org. 

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